Thousands of inquest recommendations intended to save lives have been ignored or rejected by government agencies in Ontario over a 10-year period, a Star analysis shows.

Only a third of some 4,850 recommendations between 2001 and 2011 have been implemented. Another 25 per cent of recommendations “will be” implemented or had an alternative put in place instead.

Critics and families say the chief coroner’s office lacks the resources and authority to follow up with agencies to ensure crucial recommendations are carried out.

“The system is broken. It doesn’t work in its current form,” said Julian Falconer, lawyer for the family of 19-year-old Ashley Smith, who died in a Kitchener prison after tying a ligature around her neck.

Coroner’s inquests are mandatory in deaths of people in custody and are often held for police shooting victims or child wards. They are deeply important to families and to prevent future deaths, advocates say.

But while the coroner’s office has spent $2.8 million on inquests in the past five years — $503,000 in 2012 alone — it does little to track jury recommendations over time and has no authority to enforce them.

The office of the chief coroner asks agencies to follow up in writing one year later on the status of recommendations. But it is optional for agencies to respond, and the coroner does not follow up after the first year.

Interim chief coroner Dr. Dirk Huyer said recommendations are just that — recommendations.

“They’re something for people to consider,” he said. “The jury wouldn’t necessarily have the full understanding ... of how that recommendation would fit into that particular organization’s policies, procedures or approaches.”

Agencies should be responsible for deciding which recommendations to implement because they know best which will be feasible, he said. Huyer’s office has no power under the Coroner’s Act to oversee these decisions.

A jury returned 103 recommendations in an inquest into the death of 5-year-old Jeffrey Baldwin Friday. One of them was for the coroner’s office to hold a press conference in a year to update the public on the status of the recommendations.

Juries have begun to realize their recommendations may never materialize and are trying to enforce accountability, said Falconer.

After the Ashley Smith inquest, the jury called on the Auditor General to review the Correctional Service of Canada’s response to the recommendations. However, a spokesman for the auditor general’s office said the issue is not included in their list of planned audits.

“We cannot address all of the potential audit issues that come to our attention. We consider each request in light of our mandate, the significance of the issue raised, our audit schedule, and our available resources,” said Ghislain Desjardins.

Falconer called this response, first published in a Postmedia News article, “painful.”

“It was devastating for the Smith family to hear in a media interview the auditor-general simply slough off this recommendation,” he said.

For Children and Youth Advocate Irwin Elman, it’s glaringly obvious that recommendations are repeated again and again in child death inquests. He’s calling for a full provincial inquiry into the child protection system.

Elman created a public database — the first of its kind in Canada — to track child custody death inquest recommendations. Privacy legislation forces him to keep secret anything that would identify a child, but the database was one way of holding organizations accountable.

“We want to honour (children) and we want to make sure the province learns from them. It was something we could do, within the limits of our legislation, that would help open up the inquest process,” he said.

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Another inquest that wrapped this week examined the police shootings of three mentally ill people and produced 74 recommendations, including fundamental changes to police training and increased funding to mental health services.

“I don’t want to keep on doing these inquests,” said Peter Rosenthal, lawyer for the family of one of the victims, Michael Eligon. Rosenthal has been counsel in at least “seven or eight” inquests into police-involved deaths.

“My hope is with the very strong recommendations we got in the recent inquest and with the public disgust at what they saw happen to Sammy Yatim, that there will be some real changes, finally,” he said.

The jury also called for the coroner’s office to create a searchable public database to track inquest recommendations. Currently, the office publishes general data in annual reports, but inquest-specific breakdowns are only available upon request.

For some family members, the police-shootings inquest evoked feelings of futility. Anita Wasowicz said outside court Wednesday that she thought a 1999 inquest into the death of Edmond Yu would have fixed the crisis long before her sister Sylvia Klibingaitis was shot in October 2011.

“I thought that was the crisis and tragedy that would have corrected our mental health systems and security and police force systems, to the point where we would not have these types of crises,” she said.

Yu, who suffered from schizophrenia, was shot while wielding a hammer on an empty TTC bus in 1997. An inquest into his death produced 24 recommendations, including some on de-escalation similar to those recommended Wednesday.

Toronto Police deputy chief Michael Federico said the service is required to consider every inquest recommendation and report back to the Toronto Police Services Board. He called the belief that police were not taking action on recommendations a “false and wrong impression.”

“We’ve implemented virtually all of them that have applied in one way or another. The recommendations that are feasible and practical have been implemented,” he said.

But Federico expressed reluctance at some key recommendations made by the jury this week, including that officers should be trained to stop yelling “Drop the knife!” if the person is not responding and try another approach.

“If the person didn’t respond to ‘Drop the knife!’ and they’re still advancing ... suggesting to the person, ‘Let’s sit down and go for a coffee’ might not be feasible,” he said.

The jury in the Yu inquest also called on the coroner’s office to make public the status of the recommendations one year later. But Yu’s sister, Katherine Yu, said that after the first year she felt the recommendations “dropped into the ocean.”

“We use so much money, so much time, even life, to have these kinds of recommendations. But after all this effort, and then it comes to almost nothing ... it’s a waste.”