Ministry of the
Solicitor General

Death Review of the Youth Suicides at the Pikangikum First Nation

Office of the Chief Corner

Office of the Chief Coroner

Publications & Reports

The Office of the Chief Coroner’s Death Review of the Youth Suicides at the Pikangikum First Nation – Executive Summary

2006 – 2008

Please note – A full copy of the report is available on request from the Office of the Chief Coroner at 416-314-4000, 1-877-991-9959 or by email at

Table of Contents

Letter to the Chief Coroner

Purpose of the Review

Process of Review


Executive Summary

Pikangikum First Nation: The Social Challenges

Pikangikum First Nation: The Review of the Deaths of the Youth

Pikangikum First Nation: Health care

Pikangikum First Nation: Education

Pikangikum First Nation: Policing Services

Pikangikum First Nation: The Provision of Child Welfare Services

Pikangikum: Social Determinants of Health

Advocate for Children and Youth’s Report: Summary

The Key Recommendations of this Report


Letter to the Chief Coroner

June 1, 2011

Dear Dr. McCallum,

I submit this report on the review of the deaths by suicide of the youth of Pikangikum First Nation which occurred in the Province of Ontario between January 1, 2006 and December 31, 2008.

The Review Team examined each of the 16 deaths that occurred and the report presents 5 of those deaths as representative examples. The report makes 100 recommendations in the areas of health care, suicide prevention, education, policing, child welfare, and the social determinants of health.


Doctor Bert Lauwers' signature

Bert Lauwers, MD, CCFP, FCFP
Project Manager, Pikangikum Youth Suicides
Deputy Chief Coroner – Investigations
Chair, Paediatric Death Review Committee
Office of the Chief Coroner for Ontario

Purpose of the Review

This report is a death review of the 16 children and youth between the ages of 10-19 who died as a result of suicide in the years 2006-2008 in the Pikangikum First Nation.

The Purpose of the review was to:

  1. Examine the circumstances of the death of each of the children and youth.
  2. To collect and analyze information about the deaths in order to prevent further deaths in similar circumstances.
  3. To make recommendations directed toward the avoidance of deaths in similar circumstances or respecting any other matter arising out of the review.

The Office of the Chief Coroner has observed, with increasing alarm, the rising toll of First Nation teenage death in northern Ontario youth living on reserve. As a result, a first review of 9 deaths in Pikangikum was completed in 2009, and was presented in the Annual Report of the Paediatric Death Review Committee and Deaths Under Five Committee. A recommendation arising from that review was that a community inquiry be convened to review:

  • The understanding and response of the Chief and Council to conditions in the community, which has led to the high rate of suicide.
  • The role that education, health and other community services could play in preventing the hopelessness, desperation, and ultimately, suicide of these young children.
  • The contributions of community members and natural leaders to the development of strategies to prevent youth suicide.
  • The community-wide suicide prevention strategies.
  • The development or results since the Sakanee Inquest into aboriginal youth suicide in 1999.

This death review considered and examined these issues.

Bert Lauwers, MD, CCFP, FCFP
Deputy Chief Coroner-Investigations
Chair, Paediatric Death Review Committee
Project Manager, Pikangikum Youth Suicides

Process of Review

The Office of the Chief Coroner (OCC) was a subject of the Inquiry into Paediatric Forensic Pathology presided over by Justice Goudge, whose report was received in October 2008. During the Goudge Inquiry, our office listened with great interest to the concerns of First Nations peoples represented by the Nishnawbe Aski Nation and the Aboriginal Legal Services of Toronto alliance (NAN/ALST). A clear message we received was that First Nations people living on reserve who died were not receiving the same scrutiny that our office brought to bear on other deaths occurring in the province, despite many compelling social and health-related issues that existed in these remote, fly-in communities. This report responds to that message. The OCC is very concerned about the surging death toll of children and youth taking their own lives by suicide in First Nations communities in the North West, and most recently, the North East of Ontario.

As the scope of this review was being developed, early consultation was obtained from the Chief of Pikangikum and the Nishnawbe Aski Nation. We were asked to conduct this review, not within the context of an inquest, but utilizing some other format. A death review was chosen, and as the scope was evolved, it became clear that a simple death review would be insufficient, given the breadth of issues that are encompassed within the rubric of First Nations youth suicide deaths. Therefore, this review focused on the community itself including infrastructure, policing, health, education, the delivery of child welfare as well as the social determinants of First Nations’ health.

The review has five contributing parts. The reader is referred to Appendix 1, the Project Charter for the details. Two trips with stops in Sioux Lookout and Pikangikum occurred in March and again in October, 2010. Accompanying the Office of the Chief Coroner on the trip in March were Mr. Jason Beardy from the Nishnawbe Aski Nation, Ms. Thelma Morris, Assistant Director of Service with Tikinagan Child and Family Services, Ms. Linda Nothing-Chaplin, formerly of the North-South Partnership, Sgt. Chris Amell with the Red Lake Detachment Ontario Provincial Police, and Ms. Susan Abell.

In part one, the OCC met with the Chief and Council, and conducted interviews with members of policing, healthcare, education, and child welfare organizations.

Part two was conducted by Mr. Irwin Elman and Ms. Laura Arndt from the Office of the Provincial Advocate for Children and Youth, utilizing his office’s expertise to represent the views and concerns of the living First Nations children and youth. Their observations are reflected in the section on the Child Advocate’s Report.

Part three was the Psychiatry, Child Welfare, and Coroner’s Death Review Panel which conducted an in-depth systematic review of each of the sixteen youth who died. The reader is referred to Appendix 2, the Audit Tool, for the details of each of the deaths which was examined. This panel consisted of a coroner, child welfare specialists Ms. Karen Bridgman-Acker and Ms. Susan Abell, and three psychiatrists including Dr. Richard Meen, a paediatric psychiatrist who has provided care in Pikangikum, Dr. Paul Links, the current Arthur Sommer Rotenberg Chair in Suicide studies at St. Michael’s Hospital in Toronto, and Dr. Cornelia Wieman, a First Nations woman who is also Canada’s first female First Nations psychiatrist. The panel also included Dr. Peter Menzies, a First Nations man who is the Clinical Head, Aboriginal Services at the Centre for Addiction and Mental Health (CAMH), as well as Ms. Sabrina Squire, a nurse of Métis heritage and currently a medical student at the University of Ottawa, who has provided primary health care service to 18 different First Nations remote communities in the North. The findings of this panel are presented in the sections, The Deaths of the Youths by Suicide, and Medical Care in Pikangikum.

In part four, Dr. Judy Finlay from the School of Child and Youth Care, Ryerson University, and Ms. Anna Nagy, Instructor, Department of Psychology, University of Toronto - Mississauga, provided a paper on the social determinants of health. Concepts arising from this paper are reflected in the section on the Social Determinants of Health.

In part five, Dr. Don Auger, a First Nations man who is a lawyer and the current Executive Director of Dilico Anishinabek Family Care Children’s Aid Society, provided a discussion paper on the challenges of providing child welfare in the north. Sections from his report and the observations of Ms. Bridgman-Acker comprise the majority of the section of this report on The Provision of Child Welfare in the North and to Pikangikum.

Recommendations arising from each of these five parts of the review are provided and presented throughout the report and in the consolidated recommendations. The recommendations are both of a systemic nature, and of a local community nature. It is the belief of the OCC that the recommendations directed at the community level to assist in abating the rising tide of youth suicide, if implemented, will be successful in Pikangikum. Further, these same recommendations could successfully be incorporated into any First Nation in Ontario, to assist in dealing with their community suicide surge. Prevention, intervention and postvention strategies are provided at the individual, family, community and regional level. The larger systemic recommendations speak to the need for system integration and seamless, coordinated care delivered to First Nations on reserve to restore mental, physical, emotional and spiritual well-being. Solvent abuse in the youth and alcohol abuse in their parents are major contributors to youth suicide, as the compelling stories of the youth will depict. These too, are addressed in recommendations.

The OCC would like to acknowledge our gratitude for the many contributions of the talented and knowledgeable people listed above who so willingly, and with interest, provided their time, thoughts and wisdom to this project to ensure its success.


It is most appropriate to begin acknowledgments with the children and youth of the Pikangikum First Nation. Their lives are a testimonial to stamina, endurance and resilience, and their futures hold great promise. The key is for those who are empowered to change their situation, to act. This concept is well captured in the Royal Commission on Aboriginal Peoples Final Report (1996):

“Aboriginal youth want to be the solution, not the problem. Healing youth today will lead to their empowerment tomorrow. With empowerment, they will have the mental, physical, emotional, and spiritual energy to help those around them: their peers, their parents, and their communities. The circle of wellness will grow.”1

The Investigators, Dr. Bert Lauwers, Ms. Susan Abell, Ms. Karen Bridgman-Acker, and Ms. Doris Hildebrandt, would like to acknowledge the following for their invaluable contributions to the Death Review:

  • Grand Chief Stan Beardy of the Nishnawbe Aski Nation for his guidance and patience in explaining First Nations’ perspectives.
  • Chief Jonah Strang, Deputy Chief Lyle Keeper and members of the Pikangikum First Nation Council as well as their legal counsel, Mr. Doug Keshen, for his advice and guidance and for supporting this initiative.
  • The Pikangikum Health Authority, specifically Mr. Billy Joe Strang and Mr. Brian Keeper, for their cooperation and assistance.
  • Mr. Jimmy Keeper of the Pikangikum Education Authority for his cooperation and assistance. Former principal Mr. Phil Starnes, current principal Ms. Joanne Donnelly, and teachers Mr. Kurtis MacRea, and Ms. Colleen Estes for their candour in discussing educational and community-based challenges.
  • Former Commissioner of the Ontario Provincial Police Mr. Julian Fantino, Superintendent Brad Blair, and Sgt. Chris Amell for their dedication to ensuring the success of this review, including providing logistical support and communication expertise, and their invaluable written submission on the provision of policing services in Pikangikum, which is reflected in the report on Policing in Pikangikum.
  • Ms. Jeanette Lewis, former Executive Director of the Ontario Association of Children's Aid Societies (OACAS) and former member of the Paediatric Death Review Committee, for her persistence and encouragement in promoting a review of First Nations’ youth suicide by the Office of the Chief Coroner. Also, Ms. Mary Ballantyne, the current Executive Director, for her continuing guidance and sharing of her expertise and knowledge to further the success of this report.
  • Mr. Micheal Hardy, Executive Director of Tikinagan Child and Family Services, and the employees of Tikinagan as well as their counsel, Ms. Catherine Beamish of Beamish McKinnon Aboriginal Law Firm, for their thoughtful representations to the Office of the Chief Coroner about First Nations child welfare.
  • Mr. James Morris, Executive Director of the Sioux Lookout First Nations Health Authority, and Mr. Kevin Berube of Nodin Child and Family Intervention Services, for explaining mental health services in the north.
  • Representatives from the Sioux Lookout Meno Ya Win Health Centre including Ms. Barb Linkewich, Vice President Health Services, Ms. Helen Cromarty, Special Advisor for First Nations Health, Dr. Bob Minty, Staff Physician, and Dr. Terry O’Driscoll, Chief of Staff, for explaining the complexities of primary, secondary and tertiary health care provided to First Nations in the Sioux Lookout Zone.
  • Dr. Peter Braunberger for explaining the challenges of providing child psychiatry services in the north.
  • Dr. Mark Lachmann, psychiatry resident and former First Nations primary care physician in the north, for sharing his views and experiences with respect to First Nations youth suicides.
  • AMDOCS, including primary care physicians Dr. Anton Meyer, Dr. Ekow Barnes, and nurses from the Pikangikum Nursing Station including Head Nurse Melanie Turpin and others, for explaining the provision of health services and the challenges of care in the community of Pikangikum.
  • Mr. Lachie Macfadden for explaining the prevalence and challenges of solvent abuse in Pikangikum.
  • Ms. Susan Pilatzke of the North West Local Health Integration Network (LHIN) for sharing the evolving vision of the LHIN for the provision of health services.
  • Ministry of Education, Ministry of Training, Colleges and Universities, French Language, and Aboriginal Learning and Research Division, for the provision of information about provincial aboriginal education strategies, provision of resources and challenges.
  • Ministry of Aboriginal Affairs for their encouragement and sharing of information.
  • A special thanks to Ms. Deborah Richardson who reviewed early and successive drafts of the document and provided valuable feedback.
  • Dr. Donald Auger for his thoughtful provision of published materials which greatly assisted the project.
  • Ms. Rowena Cruz for her administrative and formatting expertise.
  • Ms. Dorothy Zwolakowski and Ms. Kathy Kerr from the Office of the Chief Coroner for their review and providing editorial suggestions.
  • The Project Manager would like to thank Ms. Doris Hildebrandt for her valuable edits.

The investigators would also like to thank Dr. Andrew McCallum, Chief Coroner for Ontario, for his insight and belief that a physician-coroner led death investigation system can and should properly focus on social justice issues to improve the health, safety, and well-being of the citizens of Ontario, all citizens, whether Aboriginal or non-Aboriginal.

Executive Summary

In the years from 2006-2008, 16 children and youth between the ages of 10-19 killed themselves by hanging in the Pikangikum First Nation. The Office of the Chief Coroner undertook a review of these tragic deaths.

Pikangikum First Nation: The Social Challenges

The Pikangikum First Nation is a remote community approximately 100 kilometres north of Red Lake. It can only be accessed by winter roads across Lake Pikangikum, or by aircraft as it is a fly-in community. It has approximately 2,400 residents, with a high birth rate. Teen pregnancy is common, and about 70-90 babies are born there each year.

Picture 1. Map of the Province of Ontario.

There are approximately 450 homes in the community. Of these, 340 have no indoor plumbing or running water. The school, government buildings, and 43 houses are connected to a sewage lagoon. A water treatment system exists that is 16 years old. Through underwater pipes, it delivers water to distribution posts where people collect their drinking water in containers. On April 15, 2011, the First Nation declared a state of emergency due to a lack of potable and running water. This crisis challenged the financial resources of the community, posed a potential health risk and required an integrated and dedicated response.

The community is not connected to the hydro grid. Power in the community is at its capacity, is diesel generated, and can be unreliable. Efforts are being made to connect to the grid.2 In 2008, there were 170 jobs in the community, with 50 held by persons from outside the community such as teachers and nurses. The 170 jobs are dedicated to teaching (50); Band office (40); health (30); buildings, renovation (20); trades, roads, power, IT (20); and the White Feather Forestry Project (10). There are 542 heads of households receiving social assistance. “Virtually all of the Band’s financial resources come from the Federal Government.”3

Pikangikum is an impoverished, isolated First Nations community where basic necessities of life are absent. Running water and indoor plumbing do not exist for most residents. Poverty, crowded substandard housing, gainful employment, food and water security are daily challenges. A lack of an integrated health care system, poor education by provincial standards and a largely absent community infrastructure are uniquely positioned against the backdrop of colonialism, racism and social exclusion arising from the historical plight of First Nations people including the effect of residential schools. These all contribute to the troubled youth, who appear to exist in a dysphoric state, caught between the First Nations traditions and cultures of their forefathers, and contemporary society which they are poorly equipped to navigate and engage.

“Many Nishnawbe Aski young people are struggling with questions of who they are and where they belong. They are exposed to lavish lifestyle through the media, while attending urban high schools, and when travelling to larger centres; but the living conditions of the families and communities leave them with only the reality of extreme poverty. They are called “Indians” but they know that they are not “Indians.” They know that their lifeline should be connected to the land and its resources, but nothing in the mainstream education system or the media helps them build this connection. They wonder who they are or why they exist. Coupled with the physical, emotional and/or sexual abuse that has become intergenerational as a result of residential schools and loss of identity, it is not surprising that some young people decide it is easier to leave this world than to live in it. Suicide comes to be a viable alternative when there seems to be no hope of finding help or relief from an unending cycle of poverty and abuse: social, racial, physical and sexual.”4

An environmental scan of the First Nation is well captured by the report of the North South Partnership for Children. That report stated, “The community experiences significant social, health, infrastructure, economic, capacity, and governance deficits. These deficiencies are not minor. They are linked, they contribute to and compound each other and they are not susceptible to quick fixes.”5

Pikangikum First Nation: The Review of the Deaths of the Youth

Striking characteristics and details emerged as a result of this review:

  • The suicides occurred largely in clusters.
  • The youth were very young when they took their lives, many being less than 15 years of age.
  • All of the deaths were due to hanging.
  • None of the children had sought help from a trained professional in the month before they died.
  • Many had a history of mental health problems.
  • Almost all of the children were solvent abusers.
  • Over half of the children had a history of exposure to suicide in their families, including parents and siblings.
  • School engagement and attendance appears to have been very limited.
  • Domestic violence was common in their families.
  • Substance abuse in parents was common.
  • Being victims of violence, and/or perpetrating violence on others were common occurrences.

Most troubling is the solvent abuse problem. In Pikangikum, young girls in Grades 3 and 4 recently self-reported that as many as 27% had tried sniffing gasoline. Exact numbers are unknown, and it is estimated that there are as many as 300 solvent abusers in the community of 2,400.

Pikangikum First Nation: Health care

Healthcare services to First Nations on reserve are provided by a myriad of providers, federally and provincially, in multiple jurisdictions. For example, in the Pikangikum Nursing Station, AMDOCS provides different physicians, although continuity is attempted. When a patient is sent out of the community, a different and usually unknown physician will assume the care of the patient in hospital, usually in Sioux Lookout. There is no case management. There is no electronic file which is readily reproducible and transferable between healthcare providers involved in the circle of care.

Health care is provided in a fragmented, chaotic and uncoordinated system. Also, there are clear gaps in service, and in some cases, qualified people to deliver that service. The community has arguably the most significant mental health and substance abuse issues in the entire province. The Pikangikum Health Authority has evolved a model which is seeking to integrate services through the Pikangikum Social Health, Education and Elders (SHEE) Committee. The Health Authority’s efforts to provide for integration of services represent a promising path.

However, several key themes emerge:

  1. Jurisdictional issues exist between federal and provincial providers, and these issues can impact service provision.
  2. Accessing necessary programs and services can be challenging in this remote First Nations community.
  3. Even if a service is reported to exist within the community, the benefit to the individual client/patient at the community level may be minimal to nonexistent. (See solvent abuse and NNADAP programs).
  4. This First Nations community has unique mental health and substance abuse issues amongst its youth.
  5. Services are best characterized as existing in silos with lack of integration and coordination.

Pikangikum First Nation: Education

The school burned down in 2007, and has yet to be replaced. A cluster of deaths by suicide occurred shortly after the destruction of the school. The community needs a school with all of the opportunities a fully functioning physical plant has to offer. Indian and Northern Affairs Canada has reportedly committed to building a new school.

Truancy remains a significant problem in the community. There are currently 520 children enrolled in school for 2010-2011. There are another 300-500 children of school age who are likely eligible for school. The exact number is unknown. Children not attending school will experience increasing isolation from mainstream Pikangikum society, lack of programming and healthy activity, and could easily fall into the lure of solvent abuse. As noted by First Nations’ leadership, children need to attain education to have marketable skills and therefore, hope for the future. They must attend school to do this. The Pikangikum First Nation needs to meaningfully decide the role their school should play in the lives of their children.

Pikangikum graduates just 8 or 9 youth from a high school stream each year. These children are largely not equipped for post-secondary education, and in fact, none of the youth who graduated in 2009 sought college or university educations following graduation. Children who demonstrated academic aptitude were previously given the opportunity to obtain a high school education at a First Nations’ High School located in Pelican Falls. These children have been identified as bright and motivated, and might have the ability to obtain a college or university education, if exposed to a quality high school education. Currently, the only option is to obtain their education at Pikangikum. The Office of the Chief Coroner was told that the privilege of attending an advanced First Nations’ high school has recently been revoked by the Northern Nishnawbe Education Council (NNEC). If possible, it should be re-instated. Pikangikum needs its children and future leaders to be exposed to the best high school educational opportunities.

The funding disparity that exists between what the federal government spends and what the Province of Ontario spends per student leaves First Nations children receiving education on reserve at a significant disadvantage. Most concerning, they represent the very students at greatest need within the province. This should be addressed. The provincial Ministry of Education also has genuine expertise in the delivery of education. The constitutional and treaty obligations resulting in the fiduciary responsibilities of the federal government to provide education to First Nations on reserve should not be relinquished. However, serious consideration should be given to expanding and utilizing the expertise of the province in the delivery of education. This might include either a committed tripartite agreement between the province, the federal government and First Nations, or alternatively, the complete transfer of this responsibility, from federal to provincial jurisdiction with funding provided by the federal government.

The creation of a First Nations school board for the north, managed and operated by the First Nations on behalf of their own children and youth, should be considered. The school board would have the ability to create its own opportunities for enhanced student achievement, provide models for the effective stewardship of resources, and delivery of education uniquely First Nations respecting culture and tradition.

The Pikangikum Education Authority should create improved health opportunities for young women and their children, including a Day Nursery to care for the children of young women who deliver infants in their teenage years so that they can have the opportunity to continue their educations. Full-day kindergarten would be of great benefit to the community, given the large number of births each year, and the knowledge that children graduating from the Pikangikum School are actually 3 years behind mainstream Ontario students.

Pikangikum First Nation: Policing Services

The OPP has a long history of providing policing to Pikangikum and in supporting the officers who have worked there. Pikangikum is currently policed under the Ontario First Nations Policing Agreement (OFNPA) by First Nations constables employed by the community and supported by the OPP. Pikangikum is the busiest First Nations community in Ontario in terms of policing. There were approximately:

  • 4,700 calls for service in 2009
  • 3,000 lock ups per year, and up to 60 persons in cells at one time is not uncommon

Pikangikum has a complement of seven First Nations constables under the OFNPA and one position through the five-year Police Officer Recruitment Fund (PORF). The community is rarely able to maintain its full First Nation constable complement and even if the designated staffing level could be maintained, the community would be critically short of police officers, based on the number of calls for service.

The community wants to see its First Nations constable positions filled with qualified candidates and the OPP supports this position. Recruitment and retention of First Nations constables is difficult given significant challenges ranging from issues of workload, remoteness, housing, accommodation shortages, and the challenges of the stresses inherent where these constables have to police their neighbours, and at times, their families.

The community has a high crime rate compared with other First Nations communities. The OPP has a stabilizing effect and diminishing their capacity to respond has the potential to lead to an escalation of chaos and significant harm, particularly to those who are most vulnerable, such as children, youth, and the elderly. There is a need for police to be allowed to exercise their policing expertise in the absence of local Pikangikum First Nation political interference.

Pikangikum First Nation: The Provision of Child Welfare Services

Provincial child welfare services were extended to Indian Reserves following major changes to the Indian Act in 1951. The changes included a section (now Section 88) that provided for the application of provincial laws of a general nature to “Indians on reserve.” This change allowed Children’s Aid Societies (CAS) to apprehend children from Indian Reserves. As a result of this change, there were exceedingly large numbers of Indian children who were taken into the care of a CAS. Many of these children were eventually placed for adoption with non-aboriginal parents around the world. This is generally known as the “60’s scoop” even though it occurred throughout the period from 1951 to about 1980. For example, in 1980, there were just over one thousand Indian children in the care of CAS’s, with more than half of them in the care of Kenora-Patricia Children’s Aid Society.6

Aboriginal leaders thought it important to stop this process and take control of child welfare themselves. They wanted to stop the loss of children, and the destruction of the family, the community social fabric, and culture that occurred through this process. In 1981, the Chiefs of Ontario Indians passed a resolution denouncing these laws and calling for a means for Indian communities to look after their own children. In 1984, the Child and Family Services Act was amended and the new Part X of the Act allowed for the creation of First Nations child welfare authorities and societies. Not long after, several incorporated groups were recognized under Part X as “child welfare authorities” and later, as societies.

When parents drink, they sometimes abandon, neglect, and abuse their children. When this occurs, CAS workers step in to care for the children. The result of this involvement is that the number of Aboriginal children across the north that are in care is much higher than the provincial average. There are a disproportionate number of Aboriginal children in care (CIC’s) in all areas of Ontario. Seventeen per cent (17%) of all children in care in the province are of Aboriginal descent. The rate per hundred thousand of Aboriginal children in care in Ontario is 2,875 while the rate for all children in Ontario is 640. Thus, the rate for Aboriginal children is about four and a half (4.5) times the provincial rate.

Tikinagan Child and Family Services is a First Nations children’s aid society required to provide service to extremely challenging clients in Pikangikum. The clients themselves often do not have even the basic necessities of life such as adequate housing, running water, and safe, affordable food sources. Added to this, is the complexity of trying to administer child welfare services where the client may not speak English, in a community that can only be accessed by airplane, or winter road. Tikinagan has encountered great difficulty in identifying and retaining adequately trained staff. Resources, both human and fiscal, have been traditional areas of great tension. The Ministry of Children and Youth Services should ensure that children’s aid societies providing service to First Nations communities, have unique and adequate funding to provide that service equivalent to provincial standards, or as closely approximating the level of service provided in other jurisdictions in Ontario as is reasonably possible.

Tikinagan is but one of a few available service providers to the community. They find themselves in the unenviable position of trying to mitigate a series of compelling difficulties such as domestic violence, crime, parental substance abuse, or solvent abusing suicidal youth, with limited to no community resources or supports to assist them. They have become the default provider for many absent services, which are easily accessible and exist in southern Ontario.

Currently, there are approximately 200 open files with approximately 80 children in care in Pikangikum, a community of 2,400. Lack of adequate housing and overcrowding has created a situation whereby children in care must be sent out of the community to foster homes far away. This has been a source of ongoing tension between the First Nation, Chief and Council and the Society.

Pikangikum: Social Determinants of Health

The social determinants of health are the economic and social conditions under which people live which determine their health. A contemporary Aboriginal view of the social determinants of health considers the following:

  • Proximal determinants of health include health behaviour, physical environments, employment and income, education, and food security.
  • Intermediate determinants of health include healthcare systems, educational systems, community infrastructure, resources and capacities, environmental stewardship, and cultural continuity.
  • Distal determinants of health include colonialism, racism and social exclusion, and self-determination.

The tangible and readily achievable goals would include such rudimentary items such as having running fresh and safe water delivered to their homes, hook-ups to a viable and safe sewage system, and linking to the power grid. This would address such issues of lack of water in homes, the use of pit privies for toilets, and reliance on a diesel fuel generated power system. The most important social determinant of health, however, is education. There is no greater barrier to improving the health, mental health, and suicide rate in Pikangikum than through its education system. Many of the children do not go to school. Many of these children sniff solvents. Those that do go to school are not being given the quality of education which prepares them for the contemporary world outside of Pikangikum. Almost none of these children seek post-secondary education.

The Whitefeather Forest Management Corp. is Pikangikum owned and has been working in close co-operation with the Ontario Ministry of Natural Resources (MNR) to meet the terms and conditions for acquiring the Sustainable Forest License (SFL). A conditional SFL based on the work that has been completed to date included an approval for an Environmental Assessment coverage for Forest Management Planning. The sole work to be completed is the Forest Management Plan (FMP), which is on schedule for completion in early 2012.

Once the Forest Management Plan (FMP) is completed, (projected for the spring of 2012), Pikangikum will have management control over approximately 1.3 million hectares of Crown lands (traditional ancestral lands of the people of Pikangikum known as the Whitefeather Forest), and will have approval to commence commercial forestry operations. It is estimated that approximately 350 jobs, on a sustainable, permanent basis, will be generated, both in the woodlands operations and in the opportunities that will be created in the sawmill and plants that will produce value-added products.

To position its youth to secure the Whitefeather Forest Project employment opportunities, Pikangikum has committed to the strategic purchasing of LKGH, a market logging business. This will provide immediate employment opportunities in the forest area adjacent to the projected Whitefeather Forest lands. In addition to the acquisition of an annual timber harvest, the purchase includes woodlands harvesting equipment and an option for a lease-to-purchase of the sawmill owned by LKGH in Red Lake.

The youth of Pikangikum need hope and promise for their future. Health is intimately linked to economic prosperity. If successful, the Whitefeather Forest Project has the potential to be transformative for the youth and future generations of Pikangikum. Significant and sustainable employment for the youth and community of Pikangikum is integral for the success of the many health-related recommendations to prevent youth suicide.

Pikangikum must educate a critical mass of its young children and youth, and adequately prepare them to face the world and lead Pikangikum to a better and brighter future. As education increases, relative income and health increases. Education enables capacities and resiliencies to withstand life’s stressors. Education will contribute to health and prosperity of Pikangikum’s people by giving them the knowledge and skills to control their life circumstances and problem solve. When this happens, the unfathomable deprivation they face through poverty, lack of running water, crowded inadequate housing, lack of a sewage system, and the death of their youth through suicide will finally abate.

Advocate for Children and Youth’s Report: Summary

Overview: The Office of the Provincial Advocate for Children and Youth

The Office of the Provincial Advocate for Children and Youth (OPACY) is an Independent Commission of the Legislature of Ontario established under the Provincial Advocate for Children and Youth Act, 2007. The mandate of the Office, outlined in the opening paragraphs of the legislation7, is to:

  • Provide an independent voice for children and youth, including First Nations (FN) children and youth and children with special needs.
  • Encourage communication and understanding between children and families and those who provide them with services.
  • Educate children, youth and their caregivers regarding the rights of children and youth.

The Office provides direct advocacy support to children and youth, as well as systemic advocacy focused on improving the delivery of services and supports to children and youth in Ontario. As part of its duties, the Office conducts reviews of programs in its mandate and/or creates and participates in the development of reports to governments and the public.

In the spring of 2010, the Advocate’s Office was asked by the Office of the Chief Coroner’s Deputy Chief Coroner, Investigations, to prepare a submission for a report into the catastrophic impact of suicide in one of Ontario’s on-reserve First Nations communities. It was hoped that a submission from the Office of the Provincial Advocate for Children and Youth would link the voices of First Nations youth to a review of the issues directly impacting their lives.

This request came at the same time that the Advocate’s Office was engaged in two key activities. The first was OPACY’s discussions with the Chiefs of Ontario, Nishnawbe Aski Nation and meetings with on-reserve communities and services in remote and fly-in communities across Northern Ontario. The second was OPACY’s involvement in the development of the Canadian Council of Provincial Child and Youth Advocates position paper, “Aboriginal Children and Youth in Canada: Canada Must Do Better.”8

The decision to write the submission was contingent upon assurances that the independence of the Advocate’s Office in this work would not be impeded upon and that the views and voices of young people would be given equitable consideration as part of the broader review into the suicide deaths of First Nations young people in one of their communities. Ultimately, the decision to participate in this work was supported as we believe the inclusion of the voices of First Nations young people is of critical importance when seeking solutions to a broad scope of issues impacting their lives, issues that can contribute to the decision by some First Nations youth to end their lives.

Wherever possible direct quotes from young people are incorporated in the submission in order to accentuate and reinforce the depth of feeling and intensity of commitment to changing the status quo these youth bring to discussions about their life situations.

The Key Recommendations of this Report

The Pikangikum First Nation has comprehensively reviewed the report. Their views are presented in a letter sent to the Office of the Chief Coroner and can be found in Appendix 5, as well as throughout the report. They have identified seven main priorities for implementation of the recommendations of the report. These are presented below:

  1. Indian and Northern Affairs Canada (INAC) should fulfill its commitment to build a new school in Pikangikum as soon as possible. The school should be built to:
  • accommodate all children currently of school age and projected future enrolment,
  • include children’s playgrounds, soccer fields, baseball diamonds, and basketball courts,
  • include an auditorium where community members can gather for traditional and cultural community events; and
  • include a daycare facility.
  1. INAC should be a stakeholder in the housing strategic study (see recommendation #89) and plan for the building and upgrading of sufficient housing units to address the critical housing shortage and overcrowding that exists in the Pikangikum First Nation. It is the belief of the current Chief and Council that to effectively alleviate overcrowding, 50 new homes are required.
  2. INAC and the Pikangikum Housing Authority should ensure that all homes built in the future are connected to water for indoor plumbing, and the sewage disposal lagoon. In addition, the Pikangikum Housing Authority should study and determine which homes could be retrofitted to allow for indoor plumbing and sewage. Funding for the projected improvements to the homes which could be retrofitted for indoor plumbing and sewage disposal should be provided by INAC.
  3. INAC and the Pikangikum First Nation should complete its earlier project to connect the First Nation to the hydro grid. Funding for this initiative should be provided by INAC.
  4. The Government of Canada, Indian and Northern Affairs Canada should support the Pikangikum First Nation’s Whitefeather Forestry Project.
  5. Pikangikum First Nation should develop a community Healing Treatment Centre with funding provided by Health Canada, Inuit and First Nations Health Branch. The Centre could house multiple providers of health services under one roof including Tikinagan Child and Family Services, the community mental health workers, NNADAP workers and the solvent abuse workers. Children who are apprehended by police for solvent intoxication would not be lodged in police cells overnight, but rather, would be brought to a safe sheltered environment in the Centre to be monitored by peace keepers until they are no longer intoxicated. The comprehensive in-community Solvent Abuse Program after-care could be delivered at this location.
  6. The Pikangikum Housing Authority should clearly identify its future land needs as a product of its study (see recommendation #89) and with the assistance of Indian and Northern Affairs Canada, obtain reserve lands to allow for sustained population growth in its membership.

The Pikangikum First Nation recommended that the Social Health Education and Elders Committee (SHEE) implement the balance of the recommendations referencing recommendations #1-99, and further, that a semi-annual meeting take place between the Office of the Chief Coroner, the Pikangikum First Nation, the Province of Ontario and Government of Canada.

The Office of the Chief Coroner has identified the following recommendations in addition to those of the First Nation which it considers vital:

  1. The Pikangikum Health Authority should develop a Comprehensive Mental Health and Addictions Program for children, youth and adults. This program should consider:
  • A Comprehensive Community Suicide Prevention Program.
  • Developing plans to address the solvent and alcohol abuse crises.
  • The need for integrated provision of mental health services including models which incorporate traditional practices as defined by the Pikangikum First Nation.
  1. INAC and the Pikangikum First Nation should review the current water treatment system and identify the need for any upgrades to ensure that Pikangikum has access to safe healthy potable water, immediately and in the future. Funding for the projected improvements to the water treatment system should be provided by INAC.
  2. INAC and the Pikangikum First Nation should review the sewage disposal system and identify the needs for any upgrades to ensure that Pikangikum has a safe, healthy sewage disposal system in the future; one which will not compromise the First Nations drinking water supply. Funding for the projected improvements to the sewage disposal system should be provided by INAC.
  3. The Federal Government, Indian and Northern Affairs Canada should develop an antipoverty strategy for Aboriginal people, particularly focusing on those living in remote and isolated First Nations reserves such as Pikangikum. This strategy could be modelled after provincial strategies such as Ontario’s Poverty Reduction Act, 2009 or Nova Scotia’s Poverty Reduction Strategy.
  4. A Committee should be struck called the Pikangikum Steering Committee:
  • Joint chairs should be named from a Provincial Ministry and the Federal Health Canada, First Nations and Inuit Health Branch.
  • The Province of Ontario should have inter-ministerial representation at the Assistant Deputy Minister level from the Ministries of Health and Long-Term Care, Aboriginal Affairs, Children and Youth Services, Community Safety and Correctional Services, Health Promotion and Sport, and Education.
  • The Pikangikum First Nation should be represented on the Committee by the Chief, Deputy Chief, a youth leader and an Elder.
  • Federal Government representatives on the Committee should include Indian and Northern Affairs Canada, and Health Canada, First Nations and Inuit Health Branch.
  • Invited members might include the North West Local Health Integration Network, the Sioux Lookout and First Nations Health Authority, the Nishnawbe Aski Nation, the Sioux Lookout Meno-Ya-Win Health Centre, Nodin Child and Family Intervention Services, Tikinagan Child and Family Services, the Ontario Provincial Police, the Ontario Child and Youth Telepsychiatry Program, and a paediatric and adolescent psychiatrist providing services in the North West of Ontario.
  • The purpose of the Pikangikum Steering Committee would be to advance the recommendations included in this report.


The children and youth of Pikangikum have been taking their lives at an extraordinary rate for a number of years. This death review focused on 16 of the deaths that occurred between the years 2006-2008. The themes that emerged from a review of the circumstances of the deaths and the lives of the youth, was not a story of capitulation to death, but rather, a story of stamina, endurance, tolerance, and resiliency stretched beyond human limits until finally, they simply could take no more.

This review has endeavoured to examine, as an alternative to an inquest, the deaths of the youth, and the societal factors that contributed to the deaths. The mental health and well being of these children and youth is a complex, multifactorial integrated response to many factors in their lives, including social determinants of health, which consists of amongst other factors, the poverty and deprivation in which they exist.

Practical recommendations are provided, and the Office of the Chief Coroner believes that the implementation of both the systemic and health service delivery recommendations in this document have the potential to address suicidal behaviour of First Nations youth and children both in Pikangikum, and in other First Nations communities suffering with surges in suicide and parasuicidal behaviours in their youth.

The tragedy of the deaths of these children and youth presents a universal challenge. Meaningfully addressing these deaths goes to the leadership of all who are involved at a community level, regional level, provincial level, and federal level, both for First Nations and non-First Nations Canadians.

“But we also know that the health of any society or collectivity depends upon a series of vital processes that allow individuals to grow, discover their identity, and learn the skills and ways of knowing their people. When these processes have been disrupted or are absent, the young people of the community not only are extremely vulnerable to negative pressures from the outside but can become so demoralized that they also commit themselves to a kind of death. “Where there is no vision, the people perish (Proverbs 29:18).””9

1 The Royal Commission Report on Aboriginal Peoples (1996), Volume 4, Perspective and Realities, Chapter 4, The Search for Belonging: Perspectives of Youth.

2 North South Partnership for Children and the Pikangikum Community Members Participatory Assessment of Pikangikum, February 2008, p. 12.

3 Ibid., p. 14.

4 Horizons of Hope: An Empowering Journey. Youth Forum, Final Report, Nishnawbe-Aski Nation Youth Forum on Suicide, 1996, p. viii-ix.

5 Ibid., p. 14.

6 Brubacher, Maurice. Coming Home, The Story of Tikinagan Child and Family Service. Sioux Lookout, Tikinagan Child and Family Services, 2006.

7 Provincial Advocate for Children and Youth Act, 2007, S.O. 2007, c. 9

8 Canada, Canadian Council of Provincial Child and Youth Advocates, “Canada’s Aboriginal

Children and Youth Must Do Better” (2010)

9 Shkilnyk, Anastasia M. A Poison Stronger Than Love, The Destruction of Ojibwa Community. Yale University Press, New Haven, 1985, p. 231.