OCC Inquest - Anderson 2016
Verdict of Coroner’s Jury
Office of the Chief Coroner
The Coroners Act – Province of Ontario
Given name(s): Lena Mary
Held at: Thunder Bay, ON
From: November 1
To: November 10, 2016
By: Dr. Michael B. Wilson, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Lena Mary Anderson
Date and time of death: February 1, 2013 at 1807 hours
Place of death: Kasabonika Lake Nursing Station
Cause of death: Hanging
By what means: Suicide
(original signed by Foreman and Jurors)
This verdict was received on the 10th of November, 2016
Coroner’s name: Dr. Michael B. Wilson
(original signed by Coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
Lena Mary Anderson
- To Ontario: In order to ensure transparency in this process, we recommend that the verdict and verdict explanation be translated into Cree, Ojibway and Oji-Cree and be easily accessible to the citizens of Nishnawbe Aski Nation ("NAN").
Implementation of Recommendations in the Spirit of the Truth and Reconciliation Commissions’s (“TRC”) Calls to Action ("CTA")
- To Canada and Ontario: In order to assess progress in the areas of health of First Nations communities, we support and endorse Recommendation 55 of the TRC’s Calls to Action that call upon all levels of government to provide annual reports or any current data requested by the National Council for Reconciliation so that it can report on the progress towards reconciliation. The reports or data would include progress on closing the gaps between Aboriginal and non-Aboriginal communities in a number of health indicators, specifically as it relates to the circumstances in Lena Anderson’s death for suicide, mental health, addictions, and the availability of appropriate health services.
- To Canada, Ontario, Kasabonika Lake Chief and Council and local Kasabonika Lake Health Authorities and social agencies: In order to support access to traditional Indigenous treatment, we support and endorse Recommendation #22 of the TRC's Call to Action that calls upon those who can affect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Indigenous healers and Elders where requested by Aboriginal patients.
- To Canada and Ontario: In order to support increased representation of Indigenous peoples within medical professions, we support and endorse Recommendation 23 of the TRC’s Calls to Action which calls upon all levels of government to:
- Increase the number of Aboriginal professionals working in the health-care field.
- Ensure the retention of Aboriginal health-care providers in Aboriginal communities.
- Provide cultural competency training for all healthcare professionals.
- To Canada, Ontario and Nishnawbe Aski Nation ("NAN"): In order to ensure that policing standards and service levels in First Nations communities are identical to those in non-First Nations communities in Ontario, the Police Services Act should be followed as the primary governing legislation. First Nations, Canada and Ontario will commit to work together to ensure that policing standards and service levels in First Nations communities are equivalent to those in non-First Nations communities in Ontario. Canada and Ontario will determine how to fund policing in First Nations communities. Funding levels will be sufficient to allow First Nations communities to comply with adequacy standards set out in the Ontario Police Services Act and the Policing Standards Manual of the MCSCS and Royal Canadian Mounted Police Guidelines. The governments of Canada & Ontario shall ensure capital and operational funding for First Nations police services in Ontario.
- To Canada, Ontario and NAN: Ensure the provision of adequate and sustainable funding to provide an adequate complement of backup officers and supervising officers to ensure that community members have access to the police services.
- To Canada, Ontario and NAN: Ensure adequate and sustainable funding and policy support to ensure that police officers in First Nations communities have access to a central communication dispatch centre that meets the requirements of the Police Services Act.
- To Canada, Ontario and NAN: Ensure adequate and sustainable funding to provide appropriate detachment buildings in each community.
- To Canada, Ontario and NAN: Ensure adequate and sustainable funding for the maintenance and upkeep of all detachment buildings at a level that meets all applicable legal standards.
- To Canada, Ontario and NAN: Ensure that all police officers receive training with a senior officer/coach officer in the community in which they will be stationed to ensure that officers are familiar with the community residents, by-laws, policies and practices.
- To Canada, Ontario and NAN: Ensure that all police officers review the policies on prisoner care and identification of individuals at risk of self-harm at annual block training.
- To Canada, Ontario and NAN: Conduct regular inspections of vehicles to address any potential for self-harm or injury.
- To Canada, Ontario and NAN: Ensure that detained prisoners are not held in police vehicles for any longer than is necessary to transport them to proper holding cells and detachments.
- To Canada, Ontario and NAN: Ensure that all police officers have access to peer and professional counselling to address issues related to vicarious trauma.
Tikinagan Child and Family Services ("Tikinagan")
- To Canada and Ontario: Provide funding to ensure that frontline Tikinagan workers receive training on suicide prevention.
- To Tikinagan: Develop a protocol that addresses and ensures the physical and emotional well-being of parents whose children have been apprehended by Tikinagan.
Kasabonika Lake Band By-law 347/86 and the Role of Band Security Officers in Kasabonika Lake
- To Chief and Council of Kasabonika Lake: Given that the by-law was passed in 1986, the Chief and Council in dialogue with Elders, community members and other service providers in the community should review and update their by-law. The Chief and Council should assess the efficiency of parts or all of the by-law. Attention to review and possible amendment should consider at minimum defining who is a Band Constable and what role if any do Band Security Officers play in enforcing the by-law. The Chief and Council should also review it for currency of law and contemplate written policy on enforcement.
- To Chief and Council of Kasabonika Lake: We recommend that Chief and Council define the duties of a Band Security Officer including the duties and responsibilities that a Band Security Officer can safely perform; hiring criteria and setting minimum standards for hiring; developing or enhancing policy materials for Security Officers; skills development and required training on an ongoing basis; seeking funding in order to ensure Band Security Officers are up to date and can carry out duties in a resourced and supported manner.
- To Chief and Council of Kasabonika Lake: Band Security Officers should be aware of all rules of law that apply to search and seizure and not just those contained in by-law 347/86. Compliance with the Charter of Rights and Freedoms and other applicable law and consequences of breaching such laws should be considered before entering a private home.
- To Chief and Council of Kasabonika Lake: Chief and Council should limit Security Officers’ assistance to particular duties and not those that are the duties of a Police/Peace Officer.
Suicide Intervention and Prevention
- To Canada, Ontario, Kasabonika Lake Chief and Council and local Kasabonika Lake Health Authorities and social agencies: Ensure that all workers providing social support or medical and mental health support receive cultural competency training about historic harms and impacts of systemic issues that impact First Nations people living on reserves, e.g., Indian Residential Schools.
- To Canada and Ontario: Provide sufficient funding for NAN First Nations communities to deliver Grief Recovery training and programming directed at individuals and service providers in the community dealing with unresolved grief as a result of loss through a suicide or other violent or traumatic event.
- To Kasabonika Lake Chief and Council: Provide grief recovery training or programming in a culturally relevant way to address unresolved grief for families, friends, community members and service providers that are experiencing unresolved grief as a result of a suicide or traumatic event or situation.
- To Canada and Ontario: Provide funding to all First Nations communities to assist in developing suicide prevention solutions. This funding should be used to create comprehensive suicide prevention programs in First Nations communities, led by the local health authority, in partnership with representatives from health ministries in federal and provincial governments.
- To Canada, Ontario, Chief and Council of Kasabonika Lake, and local Education and Health Authorities: Review and consider utilizing recommendations from the Mushkegowuk Council’s “Nobody Wants to Die. They Want the Pain to Stop: The People’s Inquiry into our Suicide Pandemic Report”. In taking any steps towards implementing the report’s recommendations, and, in regards to any coordination between partners to create or enhance suicide intervention and prevention, dialogue between the parties should include input and guidance from the Elders, Leaders and community members of Kasabonika Lake.
- To Canada, Ontario and the Chief and Council of Kasabonika Lake: Encourage the use of culturally safe spaces that may include Indigenous traditional practices and customs as an appropriate treatment plan to address suicide in Indigenous communities.
- To Chief and Council of Kasabonika Lake, and the local Education and Health Authorities: Recognizing the value of prevention education to young people in raising awareness and reducing suicide, we recommend that the Education and Health Authorities cooperatively develop age/grade appropriate school-based suicide prevention program that can be offered to all students each year as a component of the health education. We recommend that the local Education and Health Authorities consider implementing a program such as those described in Recommendation 33-34 of The Office of the Chief Coroner’s Death Review of the Youth Suicides at the Pikangikum First Nation 2006-2008:
- The school-based curriculum should incorporate traditional and cultural knowledge and should utilize the resource of incorporating elders when teaching the youth about such issues as cultural identity and self-pride. It should focus on mental, emotional, spiritual and physical well-being, and, particularly discuss the dangers of solvent abuse and emphasize the recognition of suicidal behaviours.
- The school-based health program should address such issues as alcohol and substance abuse, depression and suicide, domestic violence, sexual and/or physical abuse and bullying. It must convey and communicate, in plain language to the children, strategies for help-seeking where these issues exist in their lives, and de-stigmatize and dispel attitudes and dispositions which portray the seeking of help in a negative light.
- To the local Education and Health Authorities in Kasabonika Lake: We recommend that you consider developing a peer support program that is operated through the school and that you consider using counselling services and mental health and wellness services in the community to assist in oversight, management, mentoring and guidance to any peer support program that is implemented.