OCC Inquest - Wesley 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Wesley
Given name(s): Romeo
Age: 34

Held at: Cat Lake First Nation, ON
From: July 4
To: July 20, 2017
By: Dr. David Cameron, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Romeo Wesley
Date and time of death: Sept. 9, 2010 at 10:20 p.m.
Place of death: Cat Lake Nursing Station
Cause of death: Struggle and restraint (chest compression, prone positioning, handcuffing) as well as agitation and trauma (pain) in a man with a KCNJ2 mutation with acute alcohol withdrawal/delirium tremens.
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 20 of July, 2017
Coroner's name: Dr. David Cameron
(Original signed by coroner)


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


Inquest into the death of:

Romeo Wesley


Jury Recommendations

To: Cat Lake First Nation:

  1. Ensure all community members and affected personnel receive debriefing in the aftermath of a traumatic event.
  2. Ensure Cat Lake Chief and Council, Nishnawbe-Aski Police Service (NAPS) Officers, Nursing Station Personnel and National Native Alcohol and Drug Abuse Program (NNADAP) resource workers develop an open dialogue through monthly meetings to discuss events which have occurred in the community.
  3. Should utilize the expertise of its members to educate the youth on the dangers of solvents, drugs, and alcohol abuse at an early age.
  4. Provide clients with a choice as to whether they want traditional healing or conventional medicine when attending the nursing station.
  5. Install security cameras with an audio component in all public areas of the nursing station.
  6. Engage Health Canada and Sioux Lookout First Nations Health Authority for the funds required to adequately staff the nursing station.

To: The Government of Ontario:

  1. Should take all reasonable steps to ensure that legislation is tabled and implemented to permit NAPS to be designated as a police force under the Police Services Act, Ontario (PSA).

To: The Government of Canada and the Government of Ontario:

  1. Ensure the provision of adequate and sustainable funding to:
    1. Permit NAPS to hire 2-3 additional full-time Training Officers to conduct yearly Block Training for NAPS officers.
    2. Enhance the yearly block training for NAPS officers, specifically to assist NAPS in creating scenario based training for the officers.
    3. Enhance the training provided to NAPS officers regarding interactions with individuals who are experiencing a medical crisis.
    4. Ensure NAPS has an adequate complement of backup and supervising officers stationed in every remote community to respond to crisis situations.
    5. Ensure NAPS officers are able to effectively communicate with dispatch services and police headquarters by radio.
    6. Ensure NAPS officers and/or civilian employees who are involved in incidents that result in serious bodily harm or death to a member of the public receive post-incident counselling from an accredited health provider.
    7. Ensure NAPS officers and/or civilian employees involved in incidents that result in serious bodily harm or death to a member of the public receive post-incident debriefing with a training officer.
    8. Ensure NAPS can supply leg restraints to every detachment and provide training to NAPS officers on the use of leg restraints.
    9. Ensure NAPS training officers receive training on crisis management training to provide to officers during block training.
    10. Ensure NAPS provides crisis management training as part of its yearly block training.

To: Nishnawbe-Aski Police Service:

  1. Incorporate this incident into use of force training and shall make best efforts to incorporate other incidents in which its officers were involved in use of force that resulted in serious bodily harm or death into officer training to avoid similar harm in the future.
  2. Make best efforts to ensure that officers are partnered with appropriately experienced officers in the community, with junior officers being paired with senior officers.
  3. Make best efforts to recruit and retain Indigenous officers so that NAPS is staffed by Indigenous officers who are fluent in the language of their assigned community to the greatest extent possible.
  4. Consult with community leadership to develop a community policing model that focuses on building positive relationships and trust with Indigenous communities where it provides services.

To: The Ministry of Community Safety and Correctional Service and the Nishnawbe-Aski Police Service:

  1. The Ontario Police College (OPC) and NAPS should train officers that “excited delirium” may not be recognized as a medical or psychological condition.

To: The Ministry of Community Safety and Correctional Services:

  1. The OPC should provide advanced training about using the prone position during arrests and prone positional restraints with an emphasis on:
    1. frequent assessments of the breathing and consciousness of a detainee
    2. the involuntariness of detainee resistance to prone positional restraint, and
    3. moving an individual from the prone position to a recovery position as soon as practicable recognizing that there are increased risks associated with a detainee in a prone positional restraint.
  2. The OPC should provide new recruits with training on the use of leg restraints as a use of force restraint option.
  3. The OPC should increase the basic constable training program to six months to ensure recruits receive sufficient training.
  4. The OPC should provide fifteen hours of crisis-management training as part of Basic Constable Training. This training must include both theory and practical training (with the focus on scenario-based practical training):
    1. Theory should include: (1) The Science of Conflict; (2) Self-control; (3) The Psychology of Force; (4) Crisis Theory; and (5) Suicide.
    2. Practical skills should include: (1) Active listening skills (restatement, emotional labeling, minimal encouragers, mirroring, summarizing, silence; and (2) Active problem-solving skills (asking questions, giving advice and direction, self-disclosure, confrontation, explanation, and suggestion).

To: Sioux Lookout First Nations Health Authority and Health Canada:

  1. Create adequate and sustainable funding for the creation of a community health committee appointed by community governance to act as a liaison between healthcare providers and the community to ensure that, among other things, patients have a community point-person or group to bring their concerns to and oversee the engagement of stakeholders.
  2. Ensure that nurses, physicians, Community Health Representatives, security officers and other nursing station employees have access to licensed mental health professionals after an incident where a patient dies or suffers serious injury and the notification of a Coroner is required or for other such traumatic events.
  3. Ensure that debriefs identify, document and develop best practices to prevent future incidents.

To: Health Canada and the Government of Ontario:

  1. Ensure adequate and sufficient funding to increase physician services, specifically with a view to increasing the number of clinic days that physicians are spending in northern Indigenous communities.
  2. Ensure adequate resources for Indigenous communities to develop community profiles about their history, culture, and customs in order to provide an overview to service providers such as police, health care providers, etc. These community profiles should be reviewed by the community service providers in order to familiarize themselves to the community profiles provided by the Indigenous community.

To: Health Canada:

  1. Develop a protocol in consultation with local law enforcement with respect to police intervention at medical facilities in Indigenous communities.
  2. Develop a protocol in consultation with local law enforcement for treating patients in police custody in Indigenous medical facilities.
  3. Ensure that all nursing stations in Indigenous communities are equipped with a safe room where individuals who are agitated or in crisis can be safely treated by healthcare professionals.
  4. Ensure that all nurses working in Indigenous communities receive cultural awareness training prior to being stationed in a community.
  5. Implement a single client record that would be remotely accessible. The single client record could be in the form of an electronic medical record and/or a community electronic medical record. The concept of personal health records should be explored as a means to increase a patient’s access to their own information and control so that patients can share their personal information with whom they wish.
  6. Develop a protocol with hospitals in urban centres that serve Indigenous communities (e.g. Sioux Lookout, Thunder Bay, Kenora and Winnipeg) to ensure community medical staff have access to patient records.
  7. Provide funding to Indigenous communities for training security guards working in Indigenous medical facilities. The training should be done in consultation with local law enforcement.
  8. Provide security guards in Indigenous medical facilities with:
    1. Identification credentials and uniforms
    2. Basic CPR and First Aid training, and
    3. De-escalation and crisis management training.
  9. Make best efforts to hire medical staff who speak the language of the community serviced.
  10. Ensure that all medical staff (including CHRs and security guards) receives a debriefing with a Health Canada regional supervisor if a patient dies or other such traumatic events occur and the notification of a Coroner is required.
  11. Should provide onsite workshops to community members regarding recognizing the signs, symptoms, and risk factors of drug or alcohol withdrawal and delirium tremens in consultation with community leadership.
  12. Create a plan to provide a holistic approach to treatment in Indigenous communities to ensure continuity of care for patients and provide funding to hire a case manager who will follow up and provide directions to clients about available health services inside and outside the community.
  13. Install panic buttons in all nursing stations in Indigenous communities to alert police of emergencies.
  14. Implement the Anishnawbe Health Plan with a view to bringing healthcare administration in the Sioux Lookout Zone under First Nations governance and management.
  15. Reinstate access to 24/7 Community Health Representatives to translate, assist patients, and be an equal part of the nursing station healthcare team.
  16. Develop and implement an effective strategic plan in order to recruit and retain medical professionals (i.e. registered nurses, nurse practitioners) in northern communities.
  17. Ensure that patient charting follows the Subjective Objective Assessment Plan Implementation Evaluation (SOAPIE) model.
  18. Ensure, to the greatest extent possible, that medical charts include a family or friend as an emergency contact person.
  19. Ensure, in accordance with the 2015 Auditor General’s report recommendations and Health Canada’s agreement on same, all nurses deployed to northern communities are competent in:
    1. Advanced Cardiac Life Support
    2. International Trauma Life Support
    3. Pediatric Advanced Life Support
    4. Health Canada Nursing Education Module on Controlled Substances in First Nations Communities, and
    5. Immunization Competencies Education Modules.
  20. Ensure that access to clinical and client care services in remote Indigenous communities are comparable to similar sized communities.
  21. Ensure health care providers understand the Clinical Institute Withdrawal Assessment (CIWA) and treatment plans for patients at risk for alcohol withdrawal.
  22. Consult with Chief and Council before placing medical staff in nursing stations to determine suitability.
  23. mplement an interdisciplinary case management approach to individuals with complex chronic illness. This would include the implementation of the tools and training to support such a mode.
  24. Provide funding to hire crisis workers that are on-call 24/7.
  25. Provide adequate and sustainable funding to Cat Lake for the hiring and training of additional Community Health Representatives.
  26. Provide all nursing station staff with specific training in communicating with agitated patients, including strategies for de-escalation, crisis-management, and managing violence.
  27. Ensure all medical professionals working in Indigenous communities receive training in respect of the diagnosis and treatment of individuals experiencing drug or alcohol withdrawal and delirium tremens. Health Canada shall further ensure that medical professionals receive ongoing training on a regular basis.
  28. Investigate the safety benefits of replacing interior glass with plexi-glass in order to improve the safety of both staff and patients.
  29. Investigate the benefits of having a traditional healer working in conjunction with medical personnel in Indigenous communities.
  30. Make physical and chemical restraints available at each nursing station and provide appropriate training to the staff.
  31. Develop a maintenance log to ensure the proper operation of equipment, which should be audited for effectiveness.