They were police investigations beset with problems, probes into the deaths of Indigenous people so deficient they must be reopened, according to a highly critical police watchdog report released Wednesday.

Investigators from the Thunder Bay police had “misguided” approaches to some cases. They reached “premature conclusions” about how someone died. Inexperienced officers were “thrust into a lead investigator role.” Forensic specialists failed to “fulfil basic requirements.”

This, according to the detailed report released by the Office of the Independent Police Review Director (OIPRD), coming after a two-year systemic review of how the Thunder Bay police force handled more than three dozen sudden death investigations since 2009, and a select few dating back to 2000.

At least nine investigations were “so problematic” they should be reopened, according to police review director Gerry McNeilly — including four deaths of Indigenous youth that were the subject of a recent coroner’s inquest. Due to the poor quality of the initial investigations, McNeilly said he could not be confident the probes were “accurately concluded or categorized.”

Unveiling the report in Thunder Bay Wednesday, McNeilly said the deaths the OIPRD probed “were too often handled differently because the deceased was Indigenous.”

Below, a look at the nine cases McNeilly recommended be reopened — and what he says went wrong. The report does not identify the victims in those cases, but acknowledges some of the names may already be in the public domain. It instead uses initials, which are not connected to the actual names. The Star put names to six of the cases, based on previous reporting.

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Christina Gliddy, March 2016

Gliddy, a 28-year-old Indigenous woman, was found “near death” by a railroad bridge, her pants pulled part-way down. She died in hospital. Staff noted she had scrapes and bruising on her body. The cause of death was recorded as hypothermia.

It was, according to the OIPRD, a “textbook case to treat as a suspicious death unless and until a thorough investigation showed otherwise.”

Instead, “police quickly latched onto the finding of hypothermia, disregarding the evidence that compelled further investigation,” the report said — including the possibility, given her state of undress, fresh head injuries and bruises and abrasions, she had been sexually assaulted.

A central issue, the report found, was the failure to thoroughly investigate an unnamed man who was with Gliddy on the night she died. The man was interviewed, but it was not clear to OIPRD investigators in what capacity, namely whether he was a suspect. “Very few questions” were asked of him in a recorded interview, the report notes.

The OIPRD identified other concerns about Gliddy’s death probe, including “haphazard” collection of exhibits and photographs from the scene and a failure to interview key witnesses.

“Investigators should have focused on how (Gliddy) came to be unconscious, whether anyone else’s actions contributed to her death — and more specifically, whether she was sexually assaulted,” the report states.

A senior officer who investigated Gliddy’s death, and who was interviewed by the OIPRD, said in hindsight, police could have done more ... The case closed earlier than it should have in the circumstances.”

“C.D.,” February 2014

“C.D.” was an 18-year-old Indigenous woman who was in a common-law relationship with a male who was nearly 50. A man called 911 and reported his girlfriend had tried to hang herself but was still alive. She was later pronounced dead and an autopsy determined the cause of death was “ligature hanging,” according to the report.

During the initial police investigation, it was determined the 911 caller gave a false identity, and the boyfriend, who was unco-operative, later disappeared.

The police investigation “was deficient in several critical areas, leaving important questions unanswered which could affect the ultimate conclusions in the case,” according to the report. That included that no formal statements were taken and none of the woman’s acquaintances were interviewed.

Major problems were identified with the forensic work. The report also questioned how the coroner’s investigative statement could conclude the woman’s boyfriend found her and “cut her down” when photographic evidence suggested the belt had not been cut.

The OIPRD report also notes the “coroner briefly attended the scene” and it appeared “he declared the death to be non-suspicious before he had even examined the body at the hospital and before the autopsy had been performed.”

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Marie Lynette Spence, April 2016

Police were called in to investigate after a woman’s body was found in a wooded area. The woman’s pants were partially pulled down. According to police, the supervising coroner did not think the death was suspicious.

Days later, an autopsy ruled the cause of death as hypothermia “in a woman with ketoacidosis and acute ethanol intoxication.” The autopsy report notes 34 recent injuries to her head, neck, torso and more.

The OIPRD investigation found multiple problems with the police probe, including that the discovery of her body in a state of partial undress should have compelled “police to treat this as a suspicious death unless and until foul play could reasonably be excluded.”

Errors were also made in part due to confusion about who was the primary investigator — police or the coroner. The death “was only one of a number of cases in which the coroner made decisions better made by, or in consultation with, criminal investigators.” As a result, there were issues maintaining the scene, and Spence’s body was moved though it is not known by whom, or why.

“G.H.,” March 2015

A passerby called police after finding the body of a 20-year-old man, G.H., in the snow, the report said. Firefighters confirmed the death, and according to police advised them the deceased “had possibly been in a fight.”

The cause of death was listed as “hypothermia,” with other conditions noted, including “elevated blood ethanol concentration.”

The OIPRD raised the alarm about a number of factors, including that no criminal investigators attended the scene while the body was there. Instead, the coroner ordered the removal of the body “before investigators had even arrived at the scene.”

There was also insufficient questioning of a witness, who “was never asked the most rudimentary questions about his knowledge,” the report said. The report raised concerns about some officers’ basic police knowledge, saying it was evident at least two investigators on this file failed to have a complete understanding of how the deceased’s injuries had to be considered.

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“I.J,” March 2017

The body of a 57-year-old Indigenous woman was discovered by a passerby on the icy pavement. She had “a clump of hair gripped in her hand” and “fresh abrasions and cuts.” She had been released from hospital less than two days before, after police brought her there under the provisions of the Mental Health Act.

A forensic pathologist determined her cause of death was “hypothermia and ethanol intoxication in a woman with a left ankle fracture.”

Problems were identified with the initial actions taken by police, including that the crime seen depicted in photographs “was not accurately or completely captured by attending officers describing the scene, including the investigators.”

That the woman’s belongings were scattered and her money holder was open should have “required that this matter be dealt with as a suspicious death and that foul play not be discounted without a thorough investigation.”

Jethro Anderson, October 2000

Anderson, 15, was reported missing to police by his aunt on Oct. 29, 2000, but according to the records obtained by the OIPRD, there was no police activity before Nov. 3, 2000.

According to the report, police were told volunteers would be conducting a ground search along the Kaministiquia River because he was known to hang out there, and there was concern he may have fallen into the river. Anderson’s body was found Nov. 12 in the river. A coroner was contacted and observed bruising to his left cheek and an abrasion. Later, the coroner reported the cause of death was “asphyxia due to drowning.”

The OIPRD described the police probe as “wholly inadequate.” That included that, despite being told by multiple sources Anderson had been assaulted before his death, “no sustained or serious criminal investigation followed.”

A review of the file “compels the conclusion that (Anderson’s) death did not get the attention it deserved. It also invites consideration as to whether this is explained by his personal circumstances, Indigenous status or both. At the very least, the poor quality of the investigation had the effect of undervaluing his life.”

Curran Strang, September 2005

Strang, 18, was reported missing Sept. 22, 2005, but according to the report, there is no indication police acted before Sept. 24. Strang’s body was located Sept. 26 in the river, about four metres from shore. He was face down and had no shirt or socks on.

The coroner attended the scene and ordered an autopsy. The OIPRD report states Strang’s lungs were full of water and the cause of his death was “consistent with drowning and acute alcohol intoxication.”

The OIPRD found problems with the investigation, including that injuries found on Strang’s body were not investigated by the pathologist. The report states police were “not in a position, based on the very limited investigation conducted, to rule out foul play in this death.”

“In some of these cases, the passage of time may make re-investigation difficult. The point of recommending re-investigation is to reflect that in these cases, the original investigations were so incomplete or inadequate to prevent the ruling out of foul play or third party contributions to the deaths,” according to the report.

Kyle Morrisseau, November 2009

Morrisseau, 17, was reported missing Oct. 28, 2009, after a school counsellor reported he hadn’t been at school for two days. His body was found in the river on Nov. 10, was removed from the water and the coroner was called. An autopsy report stated the cause of death was “asphyxiation due to drowning associated with alcohol intoxication.” There were abrasions on his shins.

The OIPRD’s investigation found there were “many leads developed during the missing persons investigation which were not followed up on,” and many investigative steps that would be expected in a suspicious death probe were not taken, according to the report. “As such, TBPS is not in a position to rule out foul play in this death,” it states.

Jordan Wabasse, February 2011

Wabasse, 15, was reported missing on Feb. 8, 2011. His body was not found until May 10, 2011, when boaters spotted it floating in the river. The coroner attended the scene and an autopsy concluded the cause of death was “cold water drowning,” with contributing factors being “alcohol use, cold ambient temperature,” according to the report. A pathologist stated “in the absence of any other evidence, there is no reason to suspect foul play.”

The OIPRD identified problems with the investigation, including that despite receiving information that Wabasse may have been mistakenly targeted for drug debts, it was concluded there was “no reason to suspect foul play.”

“There were several leads to follow up on and individuals to interview who may have had direct knowledge of this matter. This was not pursued,” reads the report.

“There is compelling evidence that (Wabasse) may have been a victim of a crime,” the report says.