OCC Inquest - Gray 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Gray
Given Name(s): Brian
Age: 39

Held at: Lac Seul Event Centre, Ontario
From: May 2
To: May 11, 2016
By: Dr. Roger Skinner, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Brian Gray
Date and time of death: May 9, 2010 at 10:42 a.m.
Place of death: Meno Ya Win Health Centre, Sioux Lookout, Ontario
Cause of death: Gunshot wound to the torso
By what means: Homicide

(Original signed by: Foreperson and Jurors)


The verdict was received on May 11, 2016
Coroner's name: Dr. Roger Skinner
(Original signed by coroner)


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


Inquest into the death of:

Brian Gray


Jury Recommendations

Lac Seul First Nation (LSFN), Lac Seul Police Service (LSPS), Ministry of Aboriginal Affairs (MAA), Ministry of Health and Long Term Care (MOHLTC), Indigenous and Northern Affairs Canada (INAC), Health Canada, Ontario and Public Safety Canada.

  1. The above named should expand funding for mental health and addiction services in LSFN and integrate these    services into the LSPS. This initiative should endeavour to train and employ community members and to incorporate traditional healing and faith based counselling. 
  2. The above named should review the resourcing of LSPS with a view to increasing police services in LSFN. 

Lac Seul First Nation (LSFN), Ministry of Aboriginal Affairs (MAA), Ministry of Health and Long Term Care (MOHLTC), Indigenous and Northern Affairs Canada (INAC), Health Canada

  1. LSFN should receive funding to hire a certified mental health counsellor, to hire and train additional mental health workers, to train its existing mental health workers, and to increase awareness of mental health issues and to initiate early intervention within the community.
  2. LSFN should receive funding to create an inpatient alcohol treatment program within the community.
  3. LSFN should receive funding to train and develop a post-crisis team to provide post-crisis mental health support to affected families and community members.  This could take the form of mental health workers, certified counsellors, Elders and other community support persons.

LSFN, LSPS, Ontario Provincial Police (OPP)

  1. LSFN should create a means of identifying roads and residences for the use of first responders, including ambulance, fire and police services.
  2. LSFN and the OPP should explore improving GPS capabilities in police and emergency responders' vehicles.
  3. When a critical incident occurs, an individual or individuals should be identified by LSFN to liaise between the police, First Nation and family of the subject, for the purpose of improving communication, and keeping the families informed of the progress of an incident.
  4. LSPS training should be expanded to include incident command training of the LSPS Police Chief and/or appropriate members.
  5. LSPS members should be equipped with, and trained in the use of, conducted energy weapons.
  6. LSPS members should receive awareness training from the OPP in regard to working with the OPP in situations requiring a tactical response.

Ontario Provincial Police (OPP), Ministry of Community Safety and Correctional Services (MCSCS)

  1. Strategies should be explored to reduce the response time for provision of OPP tactical resources for critical incidents in Ontario, especially in the Northwest.
  2. Options for more effective tactical response should be explored, including but not limited to enhanced Emergency Response Team (ERT) training, upgrading the North Western Region ERT team to level 2 Tactical capabilities, and placing a Tactics and Rescue unit (TRU) team in Northern Ontario
  3. The OPP should ensure that all members working with aboriginal communities and people receive Aboriginal Awareness Training that should be updated when necessary.
  4. When OPP Officers are deployed in a location where they might be expected to attend on a First Nation, they should attend and be familiarized with that First Nation soon after being deployed to that Detachment.

Government of Ontario, Ministry of Community Safety and Correctional Services, Ontario Association of Chiefs of Police, First Nations Chiefs of Police Association

  1. Ontario and OACP, in consultation with the FNCPA, with respect to tactical capabilities and resources, should work together to develop adequacy standards and a process for standardization, coordination and interoperability for mutual support.
  2. Police agencies, the Government of Ontario (including the Ministry of Transportation (MTO), and Federal agencies involved in law enforcement, should cooperate to improve the access by these agencies to information and data held by other agencies, with a view to improving intelligence-led policing.

OPP, Director of the Special Investigations Unit (SIU), LSPS, Ontario Association of Chiefs of Police

  1. The above named parties should determine which party is responsible for making a death notification to the family of a deceased when a death occurs in a situation in which the SIU has invoked its mandate.