Carrie Pryce mourned her brother Ian Pryce three times.

The first time was when she learned he had been shot and killed by members of the Toronto Police Service. The second time was when the Special Investigation Unit cleared both the officers of any wrongdoing.

The third time was slower, and took place during the coroner’s inquest into Ian’s death.

“I had a sense a few days into the inquest that there was not going to be any change,” Pryce said.

Coroners’ inquests are called to do two main things: figure out how and why a person died, and whether anything can be done to prevent similar deaths in the future.

But whether these inquests effect any actual change is still in question.

A Toronto Star analysis of coroner’s inquests of police-involved shootings shows the recommendations in the Pryce inquest have been made before — often more than once, some as far back as 15 years ago.

Sometimes, the recommendations get responses from the organizations they’re addressed to. But even then, they reappear in subsequent inquests, raising questions as to whether anything really changes after a coroner’s inquest makes a recommendation.

Advocates say repeated recommendations show a need to revamp the inquest system.

“We either have to fundamentally change what inquests do, or we have to look for another forum,” said Jennifer Chambers, executive director of Empowerment Council, an advocacy group for clients of addictions or mental-illness services, funded through the Centre for Addiction and Mental Health.

“The inquest process itself doesn’t have teeth,” she said.

Inquests are painful events for families of the deceased, and not just at Pryce’s inquest. At the inquest into the death of Jermaine Carby, Carby’s cousin La Tanya Grant said she didn’t expect any of the recommendations made at the inquest to effect change.

“This is just pointless and we’re just going through the motions, because they’re never going to implement these into the police training. There’s no point in making recommendations that are not going to be implemented,” she said.

Often, the odds are stacked against the family from the beginning, according to lawyer Peter Rosenthal. He represented Ian Pryce’s mother during his inquest, and he has represented the families — often mothers — of victims in other inquests. The inquest process can be hard to endure, he said.

“The mother, for example, is not necessarily treated very well by the Special Investigation Unit and the inquest process,” he said.

One of the reasons for that is the imbalance in representation, Rosenthal said. In police matters especially, the police will be represented by several lawyers. One will represent the service, another the Police Services Board, another the chief, and so on. Families are not given automatic representation.

“There’s no funding generally that’s available for the family of the deceased. They have to either come up with a chunk of money for a lawyer or convince a lawyer to do it pro bono,” Rosenthal said.

That’s the first change he would like to see.

“There should be public funding available for a lawyer representing the family and community interest groups,” he said.

That still leaves the problem of unenforced recommendations.

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The main issue, according to Rosenthal, is that recommendations in a coroner’s inquest are not binding on police or any parties involved.

“There’s no way to force them to implement any recommendations, other than pressure from the chief coroner and the public.”

In Pryce’s inquest, several recommendations made had already been accepted or rejected by Toronto Police, from the previous inquest into the deaths of Reyal Jardine Douglas, Sylvia Klibingaitis and Michael Eligon. For example, Pryce’s inquest recommended studying emerging less-lethal technology. The Douglas-Klibingaitis-Eligon inquest recommended studies into conducted-energy weapons, commonly known as Tasers. TPS did not agree with those recommendations, and didn’t implement them.

Pryce’s inquest also recommended formal training in basic negotiations for all police officers. The Douglas-Klibingaitis-Eligon inquest recommended a study on how training “emphasizes communication strategies and de-escalation strategies.” That recommendation was implemented, according to the TPS report in response to the inquest.

Even recommendations that are implemented can be interpreted differently by organizations, or stop being effective after a few years, which may be one reason they reappear, Chambers said. For example, an extra day of training was added for new members of the Toronto police, Chambers said, but there’s still resistance.

“We can train people all we want, but some people are very resistant. You can tell it in the classroom. They’re hostile, they’re resistant, they’re derogatory. A lot of them are appreciative and involved and engaging, but there’s some who aren’t,” she said.

Chambers has her own recommendations. She thinks inquests should be allowed to look at bigger patterns such as the influence of race. In police shootings especially, she said, those bigger patterns need to be looked at.

“Race has never been allowed to be discussed at any inquest I’ve been a part of, because you can never show that race played a factor in the death,” said Chambers.

She also wants community groups to get representation in inquests. Those groups can push conversations that focus on bigger issues such as race and mental health, she said. Already, community groups like Black Lives Matter are having an effect on whether inquests are even called.

“You need the different perspectives public interest groups can bring,” Chambers said.

Pryce is pessimistic about meaningful change happening in the inquest process in the near term. She was happy with the jury’s recommendations, but said the systemic problems that killed her brother are that ones that will prevent any meaningful change.

“He was a black man with a mental health problem. What chance did he stand in society?”