OCC Inquest - Assin 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Assin
Given name(s): Gloria
Age: 42

Held at: Kenora
From: June 12
To: June 15, 2017
By: Dr. Michael Wilson, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Gloria Assin
Date and time of death: Sept. 23, 2012 at 2:46 a.m.
Place of death: Lake of The Woods Hospital, Kenora
Cause of death: Numerous thoracic and spinal blunt force injuries due to or as the consequence of motor vehicle collision
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 15 of June, 2017
Coroner's name: Dr. Michael Wilson
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Gloria Assin


Jury Recommendations

To the Nee-Chee Friendship Center and the OPP:

  1. Work in partnership and include any other relevant service providers to explore the feasibility of a community-based triage response for people who are publicly intoxicated, as an alternative to law enforcement.

To the Nee-Chee Friendship Center, OPP, Lake of the Woods Hospital, Morningstar Detox Center and Saakaate House:

  1. Meet about how best to ensure direct lines of communication and develop a process to deliver intoxicated people to the appropriate service.
  2. Identify opportunities in all agencies to provide information about services to each other and cross training.
  3. Work together to raise public awareness of the benefits of harm-reduction services and managed alcohol programs.

To the Nee-Chee Friendship Center:

  1. Advocate for or work with partners to identify additional funding to increase the Street Patrol program to operate to meet the needs of the community.
  2. Work with community partners, particularly Aboriginal organizations & First Nations to increase capacity to provide services to meet the diverse needs to the community. Such services should be focused on harm-reduction, providing culturally sensitive wrap around services to meet clients needs. These could include managed alcohol programs and counselling to address past trauma.
  3. Reach out to the Kenora Situation Table to participate.

To the Kenora detachments of the OPP:

  1. Increase information to police officers about efforts to coordinate services (such as Situation Table, Substance Abuse and Mental Health Task Force) so all officers are fully aware of the services available and coordination efforts.
  2. Ensure that the Community Mobilization Officer remains involved in coordination of service providers to assist people experiencing homelessness and people living with addictions.
  3. Increase the number of Community Mobilization Officers in the Kenora OPP Detachment.
  4. Continue efforts to reduce the use of s. 31(5) of the Liquor Licence Act and continue to monitor the success of these projects.
  5. Ensure that OPP uniform officers receive training in accordance with TRC recommendation #57.

    Truth and Reconciliation Commission of Canada: Calls to Action

    Professional Development and Training for Public Servants

    57. We call upon federal, provincial, territorial, and municipal governments to provide education to public servants on the history of Aboriginal peoples, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, Indigenous law, and Aboriginal–Crown relations. This will require skills based training in intercultural competency, conflict resolution, human rights, and anti-racism.

  6. Share the OPP Resource Guide with other community agencies.
To the OPP:
  1. Prioritize installing center pull seat belt design (or similar seat belt devices) in all police vehicles which transport prisoners where available.
  2. a) Update the OPP Police Order with regard to seat belt usage, considering the following:
    • Officer safety
    • The important role seatbelts play in the safety of all people in vehicles
    • Whether oral direction for the person to put on their seat belt will be effective
    • Whether the vehicle is equipped with center pull seat belt design and
    • Whether the prisoner is handcuffed.
    b) Clarify who is required to wear seatbelts.
  3. Ensure training to all front-line officers about the seatbelt policy.
  4. In order to facilitate reflective learning, where possible after an incident with OPP officers resulting in serious injury or death to a member of the public, the supervisors of the officers involved should review the situation to determine if additional training or guidance about policies and best practices is warranted, and, if so, ensure the officers receive that additional training or guidance.
  5. Ensure that ongoing refresher training is provided to all front line officers on non-critical policies.
  6. Consideration be given that when there are two officers in a police vehicle that the passenger officer should be the primary radio operator when possible.

To Grassy Narrows Chief and Council:

  1. That the government of Grassy Narrows take responsibility to meet with Kenora community partners to review services available to the homeless in Kenora and Grassy Narrows and to promote collaboration with regards to homeless people.

To the Governments of First Nations surrounding Kenora within a 100km radius:

  1. Take responsibility to meet with community partners in their catchment area to review services available to the homeless and to promote collaboration with regards to homeless people.