No one needed to explain to Kona Williams, Canada's first Indigenous forensic pathologist, why it was so important for Canada to hold a National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG).

"It's always been in the back of my mind that I'm like four times more likely to end up on my own autopsy table than just about any other woman in the country," said Williams, a coroner with the Ontario Forensic Pathology Service, who is of Cree and Mohawk ancestry.

After reviewing the inquiry's final report, the Sudbury-based coroner said she's disappointed it didn't include recommendations on how to improve provincial systems for death investigation to better meet the needs of Indigenous families.

Williams has worked on autopsies involving missing and murdered Indigenous women, and said too often, Indigenous people receive little information from investigating officials after a family member dies.

"What I hear from them is that there's a serious lack of communication on the part of the death investigation system as a whole, be that with police, the corners, even the forensic pathologists," Williams told Cross Country Checkup.

"Many families were telling me they never even got a cause of death, or they didn't have any idea how to how to find that or to read the reports or to get hold of anybody."

'Missed opportunity'

Williams calls the report a "missed opportunity" because it made scant mention of the role of forensic pathologists in sudden or criminally suspicious deaths of Indigenous women.

"It just speaks to the lack of knowledge and understanding about the death investigation system itself," said Williams.

"There was a lot of focus on the police, on their investigations and their part in it. But we also play quite a big part. And the detail just wasn't there."

Williams said she reached out to the MMIWG commissioners when the inquiry began its work, offering to provide her expertise investigating deaths, from an Indigenous perspective.

Commissioners Qajaq Robinson and Michele Audette prepare to hand the inquiry's final report to Prime Minister Justin Trudeau at a ceremony in Gatineau, Que. (Chantelle Bellrichard/CBC )

She said she never heard back from the commission.

"There wasn't really a push to have us involved," said Williams. "It's a little bit disappointing because you know we [coroners and forensic pathologists] are such a big part of it."

In response to Williams' concerns, the inquiry told Checkup the report dealt with investigations "through the lens of the forensic files" and in testimony of families, pointing to its forensic document project which reviewed 174 cases.

"A number of the issues identified was a lack of resources, particularly in smaller communities and remote areas, where specific investigative tools were not deployed," said commissioner Qajaq Robinson.

"A lot of that forensic type of analysis wasn't available in smaller communities, and that's a serious issue."

Gaps in death investigation systems

Williams said it upsets her to hear Indigenous families describe how they get treated, after an unexpected death, be it criminal or not.

"A lot of our people are not valued. That's disturbing. It shouldn't be like that in this day and age."

A lot of our people are not valued. That's disturbing. It shouldn't be like that in this day and age.​ - Dr. Kona Williams

Williams said the quality of death investigations vary by province and region, and that needs to change.

"I'd like to see a standard across the country of good quality death investigation because we don't have that right now," said Williams.

A standardized system, she said, would ensure that everyone who needs an autopsy gets one and that it would be performed by "good, qualified people."

Indigenous perspective in forensics

As the child of a residential school survivor, Williams said she brings a unique perspective to her work in a morgue, which she undertook hoping to serve Indigenous people.

She ended up in Sudbury because "there's a serious shortage of forensic pathologists in northern Ontario and I figured that's the best place for me right now."

Forensic pathology specifically focuses on determining a cause of death by examining a body.

Chief commissioner Marion Buller, left to right, and commissioners Brian Eyolfson, Qajaq Robinson and Michele Audette prepare the final report to give to the government at the closing ceremony for the National Inquiry into Missing and Murdered Indigenous Women and Girls in Gatineau, Que., on June 3, 2019. (Adrian Wyld/The Canadian Press)

She said she approaches all her cases in the same way.

"I don't discriminate when I do my autopsies," said Williams. "It took me 14 years to get the education to be able to do this job. I make sure that all that experience, all that knowledge and training is applied to every single case."

Williams isn't aware of any other Indigenous forensic pathologists in Canada, but she's pleased to hear there are up-and-coming Indigenous medical students interested in the field.

"This is a huge responsibility. It's a lot of work trying to manage the expectations of both the death investigation system and ... [Indigenous] communities who are happy to see someone like me in a position like this," said Williams.

"I don't want to [still] be the only one in 10 years."

With files from Samantha Lui