Open this photo in gallery Maxine Skunk's face is reflected in a photo of her with her sister, Joyce Wassaykeesic, who, along with three others, died in a house fire in 2014 in Mishkeegogamang First Nation. The family did not receive word from the coroner about what happened until two years after the fire. David Jackson/The Globe and Mail

From a window in her single-storey home on the Mishkeegogamang First Nation, Maxine Skunk could see the ashen ruin of the house where her sister, her two little nieces and her nephew had lived only days before. The deadly fire, which started long after midnight on a frigid day in February, 2014, was mostly out. Little was left of the aging, prefab structure, except charred timber and twisted metal.

But, in the place where the bedroom had been, something was still smouldering.

Ms. Skunk says the bodies of her 30-year-old sister, Joyce Wassaykeesic; Joyce’s daughters, six-year-old Serenity and three-year-old Kiralyn; and Ms. Skunk’s 21-year-old nephew, Nathan Wassaykeesic, were left in the home for four days after the blaze. For most of that time, they lay open to the sky. When snow began to fall, maintenance workers from the reserve covered them with a makeshift tent.

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The coroner’s office was called, but no coroner ever came. Instead, fire and police investigators and the community itself were left to take on the coroner’s duties of protecting and preserving the integrity of the remains as they awaited a forensic anthropologist – an expert in the identification of human bones – to arrive in the community of about 900 people, a five-hour drive northwest of Thunder Bay.

“When I woke up every morning for four days after the fire, it was really surreal,” Ms. Skunk, the owner of a small store and gas station, said in an interview in Mishkeegogamang’s spartan band-council meeting room. “When everything else was kind of cooled down, you could tell where they were because it was still smoking there for four days.”

When a death occurs by murder, fire, suicide or accident in Ontario, a coroner is supposed to attend the scene – and speak for the dead. Coroners confirm the identification of the deceased and help determine how, when and where they died. They often provide vital information to police officers investigating crimes and to public-health officials working to prevent deaths.

Coroners may interview family members, neighbours, doctors and emergency responders and access hospital records to determine what led to a person’s death. Their investigations are crucial to identifying mortality trends and to making recommendations to prevent similar fatalities. Coroners may also call for a public inquiry to further examine what happened.

But in Northern Ontario’s First Nation communities, scant few coroners have set foot for more than a decade. They have failed to turn up for scores of fire deaths and for dozens of teen suicides – not even for some murders. Their absence has increased the burden on police and deepened the anguish of families.

Dirk Huyer, the Chief Coroner of Ontario, recognizes the situation is unacceptable: In February, he told The Globe and Mail that the system must change. And, when a woman and four children died in May in a fire in the community of Kitchenuhmaykoosib Inninuwug, a full team of medical, forensic and coroner personnel arrived the next day.

But that scale of response is highly unusual. And it followed on the heels of a court case brought by the parents of a four-year-old First Nations boy, Brody Meekis, who say they were “failed” by Ontario’s coroners; and in the wake of scrutiny, as well, from media outlets, including The Globe and Mail.

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“It’s evolution,” Dr. Huyer says, of the team that was sent to Kitchenuhmaykoosib Inninuwug, in a follow-up interview with The Globe in May. “I wasn’t happy with what happened in Mishkeegogamang.”

The fire there, however, typified how, in the vast majority of sudden deaths in the First Nations reserves of Northern Ontario, the appearance of coroners is anything but a certainty.

The Mishkeegogamang fire “is an absolute tragic example of how the absence of a coroner can seriously and dramatically compound the suffering for family and community,” says lawyer Julian Falconer, who was involved in the recent court case on behalf of the Meekis family.

Mr. Falconer says the current regime is not only discriminatory; it also places undue burden on the Nishnawbe Aski Police Service (NAPS), which must do the work of coroners. (The NAPS serves 35 First Nations communities in a jurisdiction that includes two-thirds of Ontario.) In turn, he added, public-safety issues have not been identified as quickly as they could have been.

And then there is the issue of respect for the dead, and for those left behind. “Structures could have been built, steps could have been taken, to properly protect the dignity of the deceased and to respect the feelings and grief of family and community members,” Mr. Falconer says.

Mishkeegogamang, he adds, “is a perfect example of why you have a coroner in charge of a scene.”







Open this photo in gallery Ontario Justice Stephen Goudge is shown in 2008, the year he issued a landmark report on the role of coroners after an inquiry into the misconduct of pathologist Dr. Charles Smith. J.P. Moczulski/The Globe and Mail

Eleven years ago, following his public inquiry into the pediatric forensic pathology system in Ontario, Justice Stephen Goudge said that the first role of the coroner is to attend to the scene of deaths.

Every province has its own system for handling deaths and its own set of qualifications for those who officially pronounce that someone has died, identify the deceased and determine the time and the cause of their demise. Only Ontario and Prince Edward Island rely solely on doctors to handle deaths, most of whom perform the job as a sideline.

In addition to the basic declaration of death, they are supposed to obtain information that could prove helpful to a pathologist conducting an autopsy, communicate with family and community members about what is happening to the bodies, and detect systemic issues and disease trends that may prevent similar deaths.

For those reasons, Justice Goudge wrote in his 2008 report, “the coroner’s presence is said to be critical when the apparent means of death is homicide or suicide, though it also remains ‘extremely important’ for the investigations of apparent or natural deaths.” Yet, he found, Ontario coroners were simply not attending deaths in remote communities.

Although Justice Goudge wrote that “the status quo is not acceptable,” it has continued apace. Investigating coroners in Ontario are paid $450 for handling a case, plus $185 an hour and expenses if they have to fly to a remote community; an investigation that requires a day or two of travel is well remunerated.

But Dr. Huyer acknowledges that it is “rare” for a coroner to go to a Northern reserve, even when Ontario’s guidelines for death investigations deem attendance to be absolutely necessary – such as in the case of suicides and the deaths of children. “It’s not right,” he says.

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Open this photo in gallery Dr. Dirk Huyer, Ontario's chief coroner, acknowledges that changes to the province's system for handling deaths are needed to properly serve First Nations communities. Galit Rodan/The Canadian Press

In Toronto, Ottawa and a handful of other large Ontario cities, there are dedicated coroners. In the rest of the province, including Thunder Bay and reserves to the north, a dispatch unit is called and one of several part-time coroners is assigned to the case. Being practising doctors, they inevitably have other things on the go. “Sometimes families and communities and investigators are waiting for a period of time,” Dr. Huyer concedes.

In urban areas, including Thunder Bay, they almost always turn up. On remote First Nations, they often don’t.

Dr. Huyer sees a better way. In laying out his proposal to The Globe, he outlines a plan that would train local people in Indigenous communities to act as coroner liaisons who would have a direct knowledge of the work that coroners do, as well as an understanding of the local community and customs. They would contact the coroner’s office when a death occurs, act as the eyes and ears of the coroner, and keep the families of the deceased abreast of developments. “The liaison will be able to stand with the family and help them to interpret the system,” Dr. Huyer says.

Although he says that setting up such a system is a priority for him, and that he has received positive feedback from First Nations leaders in multiple discussions, he has yet to determine the costs involved, or to present the idea to the Ontario government.

What needs to happen now, says the chief coroner, is to put pen to paper.

There are issues in Thunder Bay, too. A review by Ontario’s Office of the Independent Police Review Director, which found racism at an “institutional level” within the Thunder Bay Police Service, also uncovered serious problems with the relationship between the police and coroners, including lack of co-ordination and information sharing. As a result, the police watchdog noted in December, some death investigations had been prematurely closed and evidence lost before a full understanding of what had happened to the deceased. The Chief Coroner is working with Thunder Bay police to address these issues.

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Open this photo in gallery The grave site of Brody Meekis on the Sandy Lake First Nation in Northern Ontario, shown in 2015. The four-year-old boy died of strep throat. Fred Lum/The Globe and Mail

Dr. Huyer was one of the defendants in the case that was brought by the family of Brody Meekis against Wojciech Aniol, the assigned investigating coroner; Michael Wilson, the regional supervising coroner; and the province of Ontario. Brody died of strep throat in May, 2014, on the Sandy Lake First Nation, 600 kilometres north of Thunder Bay. Strep is rarely fatal in Canada; yet, no coroner went to Sandy Lake after Brody’s death.

Afterward, neither Dr. Aniol nor Dr. Wilson kept the Meekis family abreast of the coroner’s investigation, their lawsuit alleged.

Brody’s parents argued, in the suit fought by Mr. Falconer, that the coroners’ omissions amounted to “malfeasance in public office.” They also contended that the coroners failed in their obligation to provide a high-quality investigation that could be used to prevent similar deaths.

But Justice John Fregeau of the Ontario Superior Court of Justice disagreed. Earlier this spring, he ruled that the Ontario Coroners Act leaves it to the individual coroner to decide how an investigation will be conducted. And, even though Ontario’s guidelines for death investigations dictate that a coroner “should” go to the scene, that is up to the coroner’s discretion, he ruled. In addition, he said, it is left to the coroner to determine how much communication happens with the family of the deceased.

But Dr. Huyer says that what is prescribed by law does not encompass the full extent of what is expected of coroners. "The important thing is that the family has lost their loved one; they deserve to know the information about what happened.”

That, in turn, takes time and dedication on the part of the coroner involved.

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Murray Trussler, who retired as chief of staff at the James Bay General Hospital in Moosonee in 2010, worked as a coroner in Northern Ontario from 2006 to 2010. He remembers the large number of suicides in First Nations communities: In 2011, the suicide rate for First Nations men between the ages of 15 and 24 was five times that of their non-Indigenous counterparts. The number of fire deaths on First Nations is 10 times that in the rest of Canada.

“I can’t speak for all coroners, but I always went, every time, to the scene of the investigation. That’s really what you had to do,” Dr. Trussler said in a telephone interview from B.C., where he now lives. For example, he explains, a death may look like a suicide, but a coroner can’t make that determination until he investigates. “Just because somebody has a noose around their neck doesn’t mean they committed suicide. It could be murder.”

And yet, in many cases, the arrival of a coroner is anything but a given. Derek Snider, the deputy chief of NAPS, has been with the force since 2002. “We’ve had youth suicides, house fires with adults and children perishing, and I have worked in the crime unit with NAPS and have been up to many of the investigations myself,” he says. “I can’t remember a coroner attending.”

Notes Mr. Snider, “It has a huge impact on our officers … You feel like the weight of the world is on your shoulders. You have to deal with families. You have to be the securer of scenes. You have to deal with the nurses. You have to wait for the medical records or the coroners’ warrants to come through.”

What’s more, the officers, who work alone or in pairs on a First Nation, are sometimes called to an emergency in another part of the community, just as they are trying to sort out the scene of a death.

“It’s overwhelming,” Mr. Snider says.

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Open this photo in gallery In the days after her sister's house went up in flames, Ms. Skunk says there was no one to explain why the bodies inside were not moved. 'We were in the dark all the time,' she says. David Jackson/The Globe and Mail

Ms. Skunk woke in the early hours of Feb. 13, 2014, to a banging on her front door. It was a niece who had been staying in the home of Ms. Wassaykeesic. She had smelled smoke and jumped out a window to escape.

“She was screaming ‘There’s a fire, they’re in there. The girls are in there,’ ” Ms. Skunk recalls

She threw on a jacket over her pajamas and ran to her sister’s house just a few hundred metres away. Smoke was billowing from the structure. People who got there before she did said her nephew emerged alive but that he ran back in to save the others.

A few minutes later, the house was fully ablaze.

Ms. Skunk says she told herself that her sister and girls had somehow gotten out of the burning house. But she returned home to find that Ms. Wassaykeesic had “left a message on my phone. It was a faint ‘help.’ And in the background, you can hear the flames. It sounded like wind.”

For the next four days, with no coroner on scene in Mishkeegogamang, there was no one to explain to Ms. Skunk why the bodies were not being moved. “We were in the dark all the time,” she says.

Although he says he cannot speak to the specifics of the Mishkeegogamang case, Dr. Huyer says it is “very fair and very appropriate and very understandable” that someone would question why a coroner was not on hand to insist that the bodies be covered. He added that “the four-day part is something that is, frankly, very distressing to me and, over all, from a systems point of view, very disappointing.”

The bodies of the four victims were eventually gathered and sent to Toronto for autopsies. They were returned to the community a little over a week later.

Then, there was silence, says Ms. Skunk. No one from the coroner’s office called or wrote to say what the autopsies had revealed. “It was very difficult to get information. They gave us a bit of a hard time,” she says, adding that her elderly mother, who could not speak English, was especially frustrated and distraught.

But Connie Gray-McKay, who was the chief of Mishkeegogamang on the night of the fire, kept demanding answers. And eventually, two years after that February night, Dr. Wilson, the regional supervising coroner (who referred The Globe’s questions to Dr. Huyer) arrived in Mishkeegogamang to tell the family what he knew.

Dr. Huyer said that fire marshals sometimes take a long time to do their analysis, which can delay coroners’ reports. But, he said, a two-year wait is far beyond the norm.

Ms. Skunk says that Dr. Wilson told her that Nathan Wassaykeesic died with large amounts of soot in his lungs. There was also soot in Kiralyn’s lungs, she says. But the same was not true of Joyce and Serenity, and the cause of their deaths was declared undetermined.

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The reality, wrote Judge Goudge in 2008, is that affected families on Ontario reserves know little or nothing about what is being done with the bodies of their loved ones and may be equally uninformed about how they died. “This situation,” he said then, “cannot be allowed to persist.”

Judge Goudge recommended, among other things, that if investigating coroners cannot get to remote First Nations, health workers or other people who live in the communities should be trained to do the coroners’ jobs – the approach now being recommended by Dr. Huyer, more than a decade later.

“We would not be replacing coroners to do this,” says the Chief Coroner. “This is a supplement and an adjunct and an addition that will facilitate the work we do in a responsible way.”

There are other models for handling deaths in Canada that do not rely on doctors who have their own busy practices. In Alberta, Manitoba, Nova Scotia and Newfoundland, the work of coroners is done by medical examiners who generally are forensic pathologists specializing in postmortem medicine. In British Columbia, Saskatchewan, Quebec, New Brunswick and the three territories, there are lay coroners (most often nurses, lawyers or former police officers) who leave the scientific part of the job to pathologists.

Still, getting death officials to remote communities is not a challenge limited to Ontario. Sheila North, the former grand chief of the Keewatinowi Okimakanak, in Northern Manitoba, says she does not ever remember seeing a medical examiner in her part of the country. The police, the band council or the staff at the nursing station would have to do the work of declaring the deaths and dealing with the bodies, Ms. North says.

It is a problem, she says, because “we are probably not capturing a true picture of what is happening” with trends in those deaths that also involve complex social issues, such as suicide and infectious diseases.

Matthew Bowes, the Chief Medical Examiner in Nova Scotia, co-wrote an editorial in the Canadian Medical Association Journal in 2016 calling for common standards across Canada. It pointed out that there is no national training or accreditation system for coroners or medical examiners, and no national agreement on the outcomes against which to evaluate their performance.

There is not even a common understanding across jurisdictions about how deaths should be classified – whether, for instance, the death of a driver who is high on drugs should be classified as drug-related or as the result of a motor-vehicle crash.

In a recent telephone interview with The Globe, Dr. Bowes said that, three years later, nothing has changed.







Open this photo in gallery Ms. Skunk stands in the spot at Mishkeegogaming where her sister's house once stood. David Jackson/The Globe and Mail

After the funeral, Ms. Skunk and her family cleaned the lot where her sister’s house once stood, and tried to turn it into a little garden. They buried her belongings and removed whatever traces of the fire were left in the yard. Ms. Skunk did not want her mother, who lived across the road, to be continually staring at a death scene.

But Ms. Skunk says the tragedy is always on her mind. “I think I am a bit stuck there,” she says. She envisions the bodies lying open to the elements.

“The house she lived in was a really old house. Even though she had the stove on full blast, it was still an icebox in there. She was cold and her daughters were complaining about being cold. And I felt bad that [their bodies] were out there for four days, because they didn’t like being cold.”

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When asked about the work of coroners in his territory, Alvin Fiddler, the Grand Chief of the Nishnawbe Aski Nation, which includes Mishkeegogamang and 48 other First Nations communities, points to the Ontario coroners’ motto: “We speak for the dead to protect the living.”

But, says Mr. Fiddler, “In order to speak for the dead, you have to be there when a death occurs.”

When a coroner does not arrive, he says, the message is clear: “Even in death, you are of lesser value.”





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