OCC Inquests - Seven First Nations Youths 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Jethro Anderson, Curran Strang, Paul Panacheese, Robyn Harper, Reggie Bushie, Kyle Morrisseau, Jordan Wasasse
Held at: Thunder Bay, ON
From the: 5th of October, 2015
To the: 28th of June, 2016
By: Dr. David Eden, Coroner for Ontario
having been duly sworn/affiremed, have inquired into and determined the following:

Surname: Anderson
Given name(s): Jethro
Age: 15
Date and time of death: November 11, 2000
Place of death: Kaministiquia River, Thunder Bay
Cause of death: Drowning
By what means: Undetermined

Surname: Strang
Given name(s): Curran
Age: 18
Date and time of death: September 26, 2005
Place of death: McIntyre River, Thunder Bay
Cause of death: Drowning, with ethanol intoxication
By what means: Accident

Surname: Panacheese
Given name(s): Paul
Age: 21
Date and time of death: November 11, 2006
Place of death: Thunder Bay Regional Health Sciences Centre
Cause of death: No anatomical or toxicological cause of death
By what means: Undetermined

Surname: Harper
Given name(s): Robyn
Age: 18
Date and time of death: January 13, 2007
Place of death: 366 County Blvd., Thunder Bay
Cause of death: Acute ethanol toxicity
By what means: Accident

Surname: Bushie
Given name(s): Reggie
Age: 15
Date and time of death: November 1, 2007
Place of death: McIntyre River, Thunder Bay
Cause of death: Drowning, with acute ethanol intoxication
By what means: Accident

Surname: Morriseau
Given name(s): Kyle
Age: 17
Date and time of death: November 10, 2009
Place of death: McIntyre River, Thunder Bay
Cause of death: Drowning, with acute ethanol intoxication
By what means: Accident

Surname: Wabasse
Given name(s): Jordan
Age: 15
Date and time of death: May 10, 2011
Place of death: Kaministiquia River, Thunder Bay
Cause of death: Drowning
By what means: Undetermined

(original signed by Foreman and Jurors)


This verdict was received on the 28th of June, 2016
Coroner’s Name: Dr. David Eden
(original signed by Coroner)


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


Inquest into the deaths of:

Jethro Anderson, Curran Strang, Paul Panacheese, Robyn Harper, Reggie Bushie, Kyle Morrisseau, and Jordan Wasasse


Jury Recommendations

Table of Contents

General
Reconciliation: Principles of Interpretation
Education: Structural Issues
Education: On-reserve
Education System and Symposium
Living Conditions and Health Issues: On-reserve
Assisting On-reserve Students for Transition to Outside Communities
Youth Participation in Decisions
Education: Off-reserve
Missing Person Investigations and Searches
Stand-alone Missing Person Legislation
Protocol for Volunteer Community Searches
Other Investigation/Police Issues
Other Recommendations to Assist First Nations Students in Thunder Bay
Other Recommendations to Foster Greater Collaboration and Partnerships
Implementation of Recommendations in the Spirit of the Truth and Reconciliation Commission’s Calls to Action
Shannen’s Dream
Recommendation Follow-ups


General

To: Ontario

  1. 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”).
  2. In order to commemorate the lives of Jethro Anderson, Curran Strang, Paul Panacheese, Robyn Harper, Reggie Bushie, Kyle Morrisseau and Jordan Wabasse, work with the families of the seven youths, students and former students of Dennis Franklin Cromarty High School (“DFCHS”) and the Matawa Learning Centre (“MLC”), and other interested parties to develop a memorial in their honour.

To: Canada and Ontario

  1. The terms “on-reserve” and “off-reserve” should not be a restriction for any First Nation education and health care funding frameworks.
  2. To renew the relationship between Canada and Indigenous Peoples, nation-to- nation, Canada and Ontario should follow the priorities outlined in the letter (exhibit 144) to the Honorable Carolyn Bennett by the Right Honorable Justin Trudeau, Prime Minister of Canada.

To: Canada, Ontario and NAN

  1. No student should be denied access to a provincial or First Nations high school program for lack of space or supported living arrangements.

To: Canada, Ontario, Northern Nishnawbe Education Council (NNEC), Keewatinook Okimakanak (KO) and MLC

  1. In order to commemorate the lives of Jethro Anderson, Curran Strang, Paul Panacheese, Robyn Harper, Reggie Bushie, Kyle Morrisseau and Jordan Wabasse, and in consultation with their families, memorial scholarships should be awarded to students in high school who excel at the talents in which the seven youths were gifted.

Reconciliation: Principles of Interpretation

To: Canada, Ontario, the City of Thunder Bay, Thunder Bay Police Service, NAN, NNEC, KO, DFCHS and MLC

  1. In moving forward with any initiatives that respond to the Inquest recommendations, the parties should be guided by the following statements:
    1. All of the Treaty Partners, including Indigenous communities and governments, Canada and Ontario, must respect the treaty rights of others and work together towards fulfilling treaty obligations;
    2. First Nations governments exercise inherent control over their education systems;
    3. First Nation communities seek to have greater responsibility to govern their own spiritual, cultural, social, and economic affairs;
    4. Without the improvement of conditions in First Nations reserve communities, a gap in education outcomes between Indigenous and non- Indigenous students will remain;
    5. Canada should support individual First Nations communities as they develop local solutions to the effects of colonial policy; and
    6. In order to ensure timely delivery of publicly funded services to First Nations children, where jurisdictional divisions or disputes within or between governments threaten to delay or impede the provision of services, Jordan’s Principle should apply.

Education: Structural Issues

To: Canada

  1. In order to achieve equity for First Nations students, provide funding for education (on and off-reserve) that is sufficient to ensure that:
    1. First Nations schools on and off-reserve can provide the full range of programs and services that are available to non-Indigenous children in Ontario, including new and innovative programs and services;
    2. First Nations schools on and off-reserve can provide additional programs and services required as a result of the unique circumstances and challenges faced by First Nations students, their schools and their communities;
    3. the gap between educational outcomes for First Nations students and non-Indigenous students is substantially reduced every year, and completely eliminated in 10 years so that the next generation of First Nations children will have the same educational advantages as other children in Canada;
    4. First Nations students from remote communities receive the same educational advantages as other children in Canada regardless of where they are born, where their families choose to reside, and whether they attend school away from their home communities; and
    5. all education decisions regarding First Nations children are made with the best interests of those children in mind.
  2. In order to improve education outcomes of First Nations youth, in consultation with First Nations education providers, provide sufficient funding and necessary resources to ensure that First Nations schools are able to:
    1. develop and implement culturally appropriate curricula and programs.
      Staff hired for these programs should include on-site Elders; cultural and traditional land-based teachers; and after-school activity co-ordinators;
    2. develop and implement languages curricula and programs (including individual courses and full/partial immersion);
    3. assess and identify students with special education needs and provide the necessary supports to those students including, but not limited to, speech and language therapy; occupational and physical therapy;
    4. ensure the safe transportation of students to and from school;
    5. create and implement safe school protocols;
    6. decrease absenteeism by hiring a community-school liaison worker or having a community Elder attend at the homes of absent students to reinforce the importance of attending school and to encourage students and their families to make all efforts to attend school on a regular basis;
    7. increase capacity in new and existing First Nation education institutions;
    8. analyze current and historical education data as provided by First Nations and organizations designated by First Nations;
    9. address and overcome the unique challenges facing First Nations students, schools, and communities (e.g. socio-economic disadvantage, remoteness and isolation, small school size, special needs incidence rates, population growth, etc.);
    10. assess needs, develop estimates of cost, and develop processes for adjusting those costs over time to keep pace with inflation, education best practices and changes in legislation and student need; and
    11. educate students on the United Nations Convention on the Rights of the Child, the United Nations Declaration on the Rights of Indigenous Peoples, then work of the Truth and Reconciliation Commission and Treaty Rights to strengthen the knowledge of students regarding their rights and protections.
  3. In order to encourage early progress on structural reforms, Canada should immediately and publically commit to the funding criteria listed in recommendations 8 and 9 above, and incorporate that criteria into policy documents prior to March 31, 2017 (ie: the next fiscal year), including the Terms and Conditions and National Program Guidelines for the First Nations education programs.
  4. In order to ensure sufficient and stable funding for First Nations education, Canada and First Nations should jointly develop a new and fully transparent funding framework for First Nations education that is based on actual student needs and that ensures that recommendations 8 and 9 are achieved. Canada should provide funding for First Nations to participate as an equal partner in the development and ongoing assessment of this new funding framework.
  5. In order to remove impediments to sound planning and budgeting Canada should ensure that funding under the new framework will be provided via a stable and predictable mechanism that allows for long term strategic planning and discretionary decision making. Canada should cease the practice of providing funding for core or ongoing activities, services and expenses (e.g. salaries, travel, etc.) through proposal based funding.
  6. In order to ensure timely implementation of Recommendations 8 through 12, Canada should establish a joint First Nations working group that will determine agreed upon milestones and timelines such that a new funding framework and performance measurement and reporting protocol can be established within one year from the date of these recommendations.
  7. In order to promote funding sufficiency, Canada should fund an assessment of the financial cost of fully and adequately funding First Nations education, including the cost of achieving the above recommendations. Canada should provide funding for First Nations to participate as an equal partner in this needs assessment process. This assessment should be updated on a yearly basis in sufficient time for its results to be included in the federal budget. The assessment should be developed through a transparent process and the final report made public.
  8. Newly developed policies, as well as existing policies/procedures amended as a result of this inquest, should be reviewed annually to prevent equity and equality gaps in education, health and living conditions.
Access to Funding, Programs and Services

To: Canada

  1. Establish and fund a Federal Advocate for First Nations Children and Youth to monitor the progress toward closing the outcome gaps between First Nations children and non-Indigenous children in areas such as education, health, economic well-being and social services and to report directly to Parliament on this progress on an annual basis. The office should also be mandated to assist First Nations in identifying and accessing programs, funding and services. In response to a request, a complaint, or on its own initiative, the Federal Advocate would act on behalf of concerns of Indigenous individuals, families, communities, or organizations and could initiate reviews, make recommendations, and provide advice to governments, facilities, systems, agencies, or service providers.

To: Ontario

  1. Work with Indigenous individuals, families, communities or organizations on identifying and, where appropriate, creating points of contact within the Ontario government to assist Indigenous communities in identifying and accessing Ontario programs, funding and services.
Programs and Services for First Nations Children and Families – Structural Issues
Pre-School Early Childhood Education

To: Canada

  1. Canada should develop and fund a program that will ensure that all First Nations pre-school age children have access to early childhood education programs to further their physical, social, emotional, spiritual, and cognitive development and to prepare them for kindergarten. Canada should develop this program jointly with First Nations and should provide funding for First Nations to participate in the development and ongoing assessment of the program as an equal partner.
Traditional Activities

To: Canada

  1. Canada should fund and develop a program that will ensure that all First Nations children and youth have access to a robust offering of high-quality cultural and traditional activities and knowledge. These offerings should focus on developing important values such as self-esteem, cultural pride, resiliency, and leadership. Canada should develop this program jointly with First Nations (including youth and Elders) and should provide funding for First Nations to participate in the development and ongoing assessment of the program as an equal partner. The program should ensure comprehensive access for all First Nations children regardless of the communities they live in or the financial means of their parents.
Other Extra-curricular Activities

To: Canada

  1. Canada should fund and develop a program that will ensure that all First Nations children and youth have access to a robust offering of high-quality extra-curricular activities including traditional, cultural, recreational, academic, artistic, and athletic activities. The extra-curricular offerings should focus on developing important values such as self-esteem, cultural pride, resiliency, and leadership. Canada should develop this program jointly with First Nations (including youth and Elders) and should provide funding for First Nations to participate in the development and ongoing assessment of the program as an equal partner. The program should ensure comprehensive access for all First Nations children regardless of the communities they live in or the financial means of their parents.

To Canada and NAN:

  1. Canada should provide funding for NAN to develop a program for youth to receive leadership training so that they can run summer, evening and weekend activities for their peers.
Putting Children First

To: Canada and Ontario

  1. Canada and Ontario should agree to the following principle: Where jurisdictional divisions within or between governments threaten to delay or impede the provision of services or funding for First Nations children that are available to other Canadian children, the federal or provincial government of first contact should provide the services or funding and may seek reimbursement after the fact. The services or funding should be provided without delay such that First Nations children, and the organizations that serve First Nations children, do not need to wait for the jurisdictional issue to be resolved.
  2. This principle should be applied to gaps in services and funding faced by the Northern Nishnawbe Education Council, such as operations and maintenance funding for its off-reserve schools, tuition for First Nations students living off- reserve, and so on.
Social Determinants of Health

To: Canada

  1. Canada and First Nations should develop and implement a comprehensive and holistic plan to close the outcome gaps between First Nations people and other Canadians. Canada should provide funding for First Nations to participate as an equal partner in the development and implementation of this plan, including through the participation of First Nations youth and Elders. The plan should involve the following elements:
    1. The identification of outcome gaps in areas such as health, economic wellbeing, social services, living conditions, and so on;
    2. The establishment of publically reported targets and timelines for the elimination of those gaps;
    3. Annual reports to Parliament on the achievement of the targets and timelines for the elimination of health, economic, wellbeing, living conditions and social services gaps;
    4. The development of new funding mechanisms for programs for First Nations that are transparent and based on robust assessments of needs;
    5. The provision of sufficient funding to implement the plan in the various program areas and to ensure that the targets and timelines are met;
    6. The enactment of a statutory guarantee of funding sufficiency;
    7. A program to measure and report on progress in meeting those targets and to revise the plan if targets and not being met; and
    8. A review of social programs in communities in other countries facing similar circumstances (e.g. socio-economic disadvantage, small communities, dispersed and isolated communities, distinct culture, etc.) to determine best practices regarding the framework and structure for program delivery.

Education – on reserve

Specific Funding Needs

To: Canada

  1. In order to provide the foundation required to achieve better education outcomes, subject to the plans, priorities and needs of each First Nation community in NAN territory, provide additional core funding to expand existing facilities or build new facilities (and thereafter to maintain and operate those facilities) for the purpose of housing the following educational/instructional services sufficient for a growing population:
    1. a day care program/early childhood education program/drop-in program for all pre-school age children in the community. This facility should be designed and built to further the physical, social, emotional, spiritual and cognitive development of the children and to prepare them for kindergarten;
    2. an elementary school for all children in JK to grade 8 in the community.
      This facility should be designed and built to further the physical, social, emotional, spiritual and cognitive development of the children and to prepare them for high school. It should also be designed and built to accommodate extra-curricular activities that include traditional, cultural, recreational, academic, artistic and athletic activities;
    3. a high school for all children grades 9-12 in the community. This facility should be designed and built to further the physical, social, emotional, spiritual and cognitive development of the children and to prepare them for post-secondary education. It should also be designed and built to accommodate extra-curricular activities that include traditional, cultural, recreational, academic, artistic and athletic activities;
    4. an adult learning centre for adults in the community who wish to complete their high school diploma; and
    5. should ensure that all existing facilities and all new facilities meet the needs of individuals with barriers to accessibility.
  1. In order to recruit teachers and encourage them to remain in First Nation communities and build lasting relationships with students, provide funding to:
    1. construct, enlarge, refurbish (as required), and maintain living accommodation for teachers and other professionals;
    2. ensure all professional accommodations have adequate space to accommodate the staff that will be required for the growing population of the communities and the projected population growth in the coming years;
    3. develop programs to increase the number of on-reserve teachers who are local First Nations community members through:
      1. financial assistance to those seeking education and training as teachers;
      2. initiatives to encourage First Nations people to become teachers;
        and
      3. initiatives to specifically seek out, train, and recruit First Nations people as teachers;
    4. support schools in NAN Territory to provide salaries, pension, benefits, compensation and overall remuneration of teachers, principals, administrators, and education staff at a level on par with their provincial counterparts;
    5. provide all teachers on-reserve with access to the Teach for Canada program; and
    6. provide isolation pay for teacher retention on remote reserves to help with the high cost of living.
  1. In order to provide healthy learning environments that encourage attendance and participation by students, provide funding to:
    1. ensure that all education facilities have reliable and sufficient sources of heat, potable water; and sanitation;
    2. ensure that education facilities have adequate internet bandwidth to support full access to all available on-line learning for all learners;
    3. ensure that the education facilities include a kitchen capable of producing three (3) hot meals a day for all of the learners, teachers and staff housed in the facilities and for the parents/caregivers who bring their children to the facilities for educational purposes; and
    4. offer all learners access to well-equipped:
      1. gymnasium(s);
      2. exercise space;
      3. computer labs;
      4. libraries;
      5. music rooms;
      6. art rooms;
      7. drama classes;
      8. special education classes;
      9. science labs (as appropriate);
      10. spaces for traditional, cultural activities;
      11. spaces for Elders;
      12. purpose built space for social workers, youth workers, addiction counsellors, and activity coordinators;
      13. general purpose classrooms; and
      14. spaces large enough to host graduation celebrations and other education-related celebrations for the community.
  1. Commencing in 2017, the facility goals set out above should be achieved for a predetermined number of First Nation communities in NAN territory based on priority needs, and an equal number of communities each year thereafter until all of the communities in NAN territory have achieved their facility goals.

To: Canada and Ontario

  1. Each remote First Nation community should be provided with reliable high speed internet access to allow for youth to:
    1. receive high school education at home;
    2. community and family connectivity when youth are away from home for school or for other reasons; and
    3. career options for youth and their families within their communities.
Timeline and Implementation Plan

To: Canada

  1. In order to show its commitment to the implementation of Recommendations 25 through 29, issue a public announcement after the verdict regarding that commitment, and consider incorporating the criteria set out in the recommendations in documents relating to First Nations education programs, including the National Education Program Guidelines.
  2. In order to ensure timely implementation of Recommendations 25 through the joint First Nations working group, as described in Recommendation 13, should develop agreed upon milestones and timelines such that a performance measurement and reporting protocol can be established within one year from the date of these recommendations.

To: Canada and Ontario

  1. Provide resources through the Education Partnerships Program (“EPP”) or another source to establish a First Nation working group in Thunder Bay, Ontario, composed of First Nation education experts who will provide their expertise to assist NAN, the Tribal Councils and the First Nations in NAN territory in conducting the following assessments:
    1. an assessment of the current educational achievement gap in NAN territory;
    2. an assessment of the educational programs and secondary services that would be required to close the educational achievement gap in NAN territory within one generation;
    3. an assessment of the amount of resources required to create and implement the educational programs and services required to close the educational achievement gap in NAN territory within one generation; 
    4. an assessment of the feasibility and mechanism for the creation of a database that would collect and store information related to education in NAN territory.

Education System and Symposium

To: Canada and NAN

  1. In order to optimize opportunities to increase awareness on the development of a NAN-wide education system:
    1. hold a conference within 6 months of receipt of this verdict for First Nations communities in NAN territory; and
    2. discuss innovations in First Nation education at the regular Chiefs Assemblies.

Living Conditions and Health Issues – On-reserve

To: Canada

  1. In order to address and improve social determinants of health, provide sufficient funding:
    1. for the building and upgrading/repair of sufficient housing units suitable to the conditions in Northern communities that will address the critical housing shortage and overcrowding that exists in NAN First Nations;
    2. to review the current water treatment systems in individual communities and identify the need for any upgrades to ensure that NAN First Nations community members have access to safe, healthy, potable water, immediately and in the future. Funding for the projected improvements to the water treatment systems should be provided by Indigenous and Northern Affairs Canada (“INAC”);
    3. to review the wastewater systems in individual communities and identify the need for any upgrades to ensure that NAN First Nations community members have access to a safe, healthy sewage disposal system in the future that will not compromise the First Nation’s drinking water supply. Funding for the projected improvements to the wastewater system should be provided by INAC;
    4. to develop an antipoverty strategy for NAN First Nations community members, and to assist individual First Nations in creating economic opportunity that emphasizes self-reliance, local control, and the relationship between the people and the land; and
    5. to develop a sustainable funding framework and plan to address housing needs into the future, based upon population growth expectations. This framework should include a budget for on-going housing maintenance.

To: Canada, Ontario and NAN

  1. In order to achieve parity of services, community health and safety, and quality of life as between First Nation and non-First Nation communities, develop a method for measuring and establishing equivalence in health outcomes and services between NAN communities and non-First Nation communities. The unique characteristics of remote NAN communities should be addressed.
  2. In consultation with youth and Elders commencing in 2016, develop a suicide prevention strategy to address the continuing inter-generational suicide trauma experienced by children and youth in the remote NAN First Nation communities. The federal and provincial government should fund the strategy development and implementation.

To: Canada and Ontario

  1. Assist NAN First Nation communities in the development of a comprehensive Mental Health program for children, youth and adults. This program should consider the need for integrated mental health services including models which incorporate traditional practices as defined by the individual First Nation.

To: Ontario

  1. Work with the Federal government and First Nations to improve consistency, enhance coordination, and increase resources to support mental health and wellness, including programs on-reserve.
  2. Review and revise the Ontario Public Health Standards where appropriate and/or develop guidance documents to support the interpretation of the Ontario Public Health Standards, with regard to the provision of services in First Nations communities. These documents should be made available to the people living in First Nations communities.
Addressing Youth Substance Abuse Issues On-reserve

To: Canada, Ontario and NAN

  1. In order to raise awareness among youth regarding issues relating to alcohol/substance misuse, through Health Canada, the Ministry of Health and Long-term Care, the Ministry of Finance, the Liquor Control Board of Ontario, and others, develop and deliver health promotion materials aimed at educating Indigenous youth on-reserve regarding the consequences of alcohol/substance misuse.

To: Canada and Ontario

  1. In order to assist First Nations youth in all First Nation communities dealing with addiction issues, address the need for more comprehensive addictions programs by:
    1. developing detoxification programs;
    2. funding a culturally-based treatment program and facility that would utilize Elders; and
    3. funding aftercare programs for youth leaving addictions treatment programs.
  1. In order to respond to the ongoing issue of substance and alcohol misuse in First Nations communities, increase funding to the National Native Alcohol and Drug Abuse Program ("NNADAP").

Assisting on-reserve students for transition to outside communities

To: Canada and Ontario

  1. In order to provide an opportunity for students from remote First Nations communities to meet with their Thunder Bay peers and to be introduced to the City of Thunder Bay in a positive, supervised environment, provide sufficient funding to ensure that grade 7 and 8 students from First Nation communities are able to be part of classroom learning or orientation sessions in Thunder Bay so that they and their families can familiarize themselves with the schools and the community prior to beginning high school away from home.

To: Canada, Ontario and NAN

  1. In order to allow students and parents to make an informed choice regarding the school options available to them off-reserve, in consultation with First Nations education providers and public school boards, develop a comprehensive information package, funded by Canada and Ontario, that will include the following information:
    1. description of schools, including curriculum, student base, and staffing
    2. limitations regarding programs offered, including availability of academic stream courses
    3. accommodation arrangements while residing away from the home community
    4. travel allowances while residing away from the home community
    5. after-school activities and recreational resources
    6. community supports
    7. availability of supports for students with special needs
    8. other supports available, including guidance counsellors, nursing staff, social workers, mental health workers, alcohol/drug programs, addiction counsellors, and
    9. contact information, including links to websites and videos, to provide easily accessible information to students, families and their communities
  1. In order to ensure that representatives from First Nations schools, including DFCHS and MLC, are provided with sufficient time and resources to meet with prospective students and their parents, in consultation with representatives from the schools, NNEC, KO, and MLC, determine the following:
    1. frequency and appropriate timing for representatives to attend remote communities
    2. time required to meet directly with schools, students, parents and education authorities
    3. appropriate composition of representatives, including students enrolled in off-reserve schools, and
    4. funding and associated expenses for required travel to remote communities to meet with students and families.
  1. order to ensure the needs of students required to attend school off- reserve are identified and addressed while residing away from their home communities, in consultation with First Nations Health Authorities or health providers, ensure funding and resources are provided to conduct comprehensive assessments of all students prior to leaving their home communities. The assessments will be conducted with a view to balancing the safety and well-being of the students with their privacy interests. NNEC, KO, and MLC representatives should be very clear with students, families, schools and education authorities that the information is being gathered to ensure the safety and necessary supports are in place prior to the student’s arrival for their success in high school – not as a basis for denying the student access to an education. Students who do not consent to the testing will not be denied access to schooling off- reserve. The assessments will:
    1. include physical, psychological and emotional assessments
    2. identify any substance or alcohol issues
    3. be shared, with the school, subject to appropriate consent, the nature of the information, and the role of the worker with access to the information (i.e. physician or nurse, vs. prime worker), and
    4. funding for these assessments should commence for the 2016-2017 school year.

To: NAN

  1. In order to ensure that consistent information is being provided to remote communities regarding education off-reserve and the issues raised at this inquest, organize a meeting to be attended by NAN community education representatives to discuss the following:
    1. expansion of the role of education counsellors to include secondary school
    2. importance of education counsellors attending schools off-reserve to observe progress of students from remote First Nations communities
    3. purpose and importance of comprehensive assessments of students prior to leaving home communities, and
    4. purpose and importance of information requested on student application forms.

To: Nishnawbe Aski Police Service (NAPS) and the Thunder Bay Police Service (TBPS)

  1. In order to establish positive relationships with students from remote First Nations communities continue to pursue and expand the joint “Grade 8 Visit Program” initiative that will enable officers from the TBPS to travel with members of NAPS to remote communities in the spring and summer months of 2016 to meet grade 8 students who will be coming to Thunder Bay as students in the fall of 2016.

To: Canada, Ontario, the City of Thunder Bay, NAN, NNEC, KO, DFCHS and MLC

  1. In order to provide students from First Nations communities in NAN Territory and their families with firsthand information regarding the community supports and opportunities that are available when they attend school in Thunder Bay, consult with other community partners to encourage and facilitate visits by those community partners to the NAN communities to speak and engage with students prior to their move to Thunder Bay.

Youth Participation in Decisions

To: NAN

  1. In order to provide First Nations youth with a voice in regard to on-reserve policies and programs that will have an impact on their future, bring the Youth Voices Survey Summary (exhibit 150) to the attention of the NAN First Nations Chiefs, as well as a recommendation to create a youth council or youth leadership position in their communities to develop a strategic plan for addressing the challenges they face on a local level.

Education – Off-Reserve

A. Funding – Capital and Facilities

Existing Secondary School Facilities in Thunder Bay

To: Canada, NNEC and MLC

  1. Canada, NNEC and MLC should form a working group to establish a mutually beneficial relationship in regards to sharing resources in one central facility in Thunder Bay

To: Canada

  1. In order to ensure that First Nations schools located off-reserve have adequate funding for building, operations and maintenance, revise INAC policies to cover costs relating to building, operations and maintenance of schools and student accommodations operated by First Nations organizations off-reserve.
  1. In order to provide a safe, healthy learning environment in high school that encourages attendance and participation by students, and retention of teachers, provide funding to:
    1. ensure that the teaching facilities include a cafeteria capable of producing three (3) hot meals each school day, and
    2. offer all learners access to well-equipped:
      1. gymnasium(s);
      2. exercise space;
      3. computer labs;
      4. libraries;
      5. music rooms;
      6. art rooms;
      7. drama classes;
      8. special education classes;
      9. science labs (as appropriate);
      10. spaces for traditional, cultural activities;
      11. spaces for Elders;
      12. purpose built space for social workers, youth workers, addiction counsellors, and activity coordinators;
      13. general purpose classrooms; and
      14. spaces large enough to host graduation celebrations and other education-related celebrations for the community.
  1. In order to determine whether the current site of DFCHS is suitable for providing a safe, healthy and nurturing learning environment on par with provincially funded high schools, in consultation with representatives from NNEC, KO, and DFCHS, provide funding for a site analysis of DFCHS to determine needs relating to those outlined in Recommendation 53, in addition to the following:
    1. space required based on projected enrollment for the next 15 years;
    2. adequacy of current space and need to install dedicated computer lab;
    3. adequacy of current space and need to install dedicated music room;
    4. adequacy of existing gymnasium and space dedicated to physical fitness;
    5. adequacy of existing classrooms, including need for dedicated culinary classroom; and
    6. cost/benefit analysis of performing necessary repairs and renovations versus acquisition of a new facility.
  1. INAC should immediately, in the interim, provide DFCHS with sufficient funding to make the following renovations to the school:
    1. Removal of asbestos as recommended in exhibit 185, and
    2. A new boiler and heating system.
  1. To determine whether the current site of MLC is suitable for providing a safe, healthy and nurturing learning environment on par with similar provincially funded schools, INAC and Matawa Tribal Council and representatives from MLC should conduct a financial audit and a comprehensive needs assessment. If it is determined that a site analysis of MLC is required, INAC should provide funding to determine:
    1. additional space is required based on projected enrollment for the next 15 years
    2. adequacy of existing classrooms, including need for dedicated culinary classroom, and
    3. cost/benefit analysis of performing necessary renovations versus acquisition of a new facility.
  1. Upon completion of the reports regarding the site analyses performed at DFCHS, if the cost/benefit analysis supports performing the necessary repairs and renovations, or acquiring a new facility, provide funding to implement the recommendations contained in the reports.

Secondary Schools in the Future

To: Canada

  1. In order to provide First Nations students from remote communities with a secondary school education that recognizes the unique circumstances and challenges faced by these students, their families and their communities, establish a working group that includes representatives from NNEC, KO, MLC, and other First Nation Education Councils. The purpose of that working group would be to conduct community consultations to determine:
    1. those communities who desire to have their own high school and have the capacity to support a high school on-reserve
    2. those communities who support high school education off-reserve
    3. for those communities who support high school education off-reserve, the preferred model for education and accommodation of students while living off-reserve, including
      1. specific schools designated for Grades 9 and 10 (e.g. Pelican Falls First Nations High School, "PFFNHS"), to allow students to make the transition to Thunder Bay (or other schools off-reserve) on a gradual basis
      2. accommodation in residences for Grades 9 and 10
      3. accommodation in residences for all grades
      4. accommodation in boarding homes for Grades 11 and 12
      5. accommodation in boarding homes for all grades

To: Canada

  1. To meet the unique needs of First Nations and to help ensure student safety, Canada should provide sufficient funding to NNEC to design, build, furnish, maintain, operate and adequately staff a student residence in Thunder Bay for the students from NNEC communities who have to come to the city to attend school at DFCHS:
    1. INAC should sufficiently fund NNEC for the costs of operating and maintaining the residence on an annual basis pursuant to the eligible expense of “group home costs” as noted in section 5.0 D – Student Support Services of Canada’s policy and guideline entitled Grants and Contributions to Support First Nations Elementary and Secondary Educational Advancement
    2. NNEC should consult with its member First Nations communities, current and existing students, NAN, KO and other affiliated tribal council on the design and proposed operation of the residence. Canada should provide sufficient funding to NNEC to carry out this consultation exercise
    3. Canada should provide appropriate funding to commence construction of the proposed residence by the start of the fiscal year commencing April 1, 2017 so that construction may begin in spring of 2017

To: NNEC and the City of Thunder Bay

  1. The City of Thunder Bay should work with NNEC to ensure that any zoning and by-law issues that may arise for the construction of facilities can be avoided or resolved.

Improving Efficiencies at Existing School Facilities

To: NAN

  1. In order to gain efficiencies and avoid unnecessary duplication of resources and facilities, facilitate a working group of member education authorities to determine the means by which certain activities could be coordinated and resources could be shared. In particular, a working group should be struck to coordinate the work of the NNEC and KO Secondary Student Support Programs (“SSSP”) at DFCHS to ensure that their resources are used effectively and that similar practices and rules are followed with respect to all of the students attending DFCHS.
B. Funding – Instructional Services

To: Canada and Ontario

  1. In order to achieve equity and equality for First Nations students, Canada should:
    1. revise current policies to provide tuition to be paid for any First Nation student who wishes to attend a First Nation school off-reserve or MLC regardless of their or their parents’ normal place of residence
    2. pending the revision of policies to allow any First Nation student to attend a First Nation high school off-reserve regardless of normal place of residence, work with school boards in Northwestern Ontario to ensure that reverse tuition agreements are in place
    3. eliminate proposal based funding for instructional services identified as core activities (as determined by needs assessment described in Recommendations 12 and 14
    4. determine the required annual increase for core funding to ensure that First Nations education and service providers operating off-reserves are able to meet the needs of their students; and
    5. all funding for education of First Nations students off-reserve should be long-term, stable, reliable and predictable.

To: Canada and Ontario

  1. In order to recruit and retain teachers and staff and encourage them to commit to long-term employment at First Nation schools off-reserve, provide funding to:
    1. ensure that salaries, pensions, benefits, compensation and overall remuneration of teachers, administrators, and other staff at First Nations schools off-reserve are at a level on par with their provincial counterparts
    2. ensure that staff from First Nations schools off-reserve are offered all professional development opportunities that the Ministry of Education makes available, including access to their databases and eLearning programs
    3. develop programs to increase the number of First Nations teachers and staff at off-reserve schools through:
      1. financial assistance to those seeking education and training as teachers
      2. initiatives to encourage First Nations people to become teachers
      3. initiatives to specifically seek out, train, and recruit First Nations people as teachers; and
    4. provide all teachers with access to the Teach for Canada program
C. Funding – Cultural Needs

To: Canada, NNEC, KO and MLC

  1. In order to improve education outcomes of First Nations youth who attend secondary school in Thunder Bay and to develop important values, in consultation with NNEC, KO, DFCHS, PFFNHS and MLC, provide on-going, predictable and reliable funding to ensure that there is an appropriate staff complement and programs to address the cultural needs of DFCHS, PFFNHS and MLC students starting for the 2016-2017 school year, including:
    1. appropriate ratio of education assistants to students
    2. appropriate number of Elders (male and female) to be available during school hours;
    3. dedicated space for the Elders to spend time with students and resources for the activities that they wish to engage in with the students
    4. curriculum development that supports language, culture and traditional activities
    5. regular professional development for teachers with respect to how to incorporate traditional language, culture and activities in day-to-day teaching
    6. additional staff member or members required for each school whose sole role is to take the lead in teaching traditional skills, culture and land based learning
    7. funding for land-based learning, and
    8. funding to facilitate the development and implementation of Ojibway/Cree immersion programming.

To: NNEC, KO and MLC

  1. All intake forms, behaviour contracts, report cards and any other documentation that is given to the parents regarding their children should be provided to them in their preferred language.
D. Funding – Emotional and Physical Needs

To: Canada

  1. In order to improve education outcomes of First Nations youth who attend secondary school in Thunder Bay and in recognition of the unique challenges that they face due to exposure to adverse socio-economic circumstances prior to arriving in Thunder Bay, in consultation with NNEC, KO, DFCHS, PFFNHS and MLC, immediately provide adequate funding separate from core institutional funding required to ensure that there is an appropriate complement of qualified staff and programming to address the needs of DFCHS, PFFNHS and MLC students starting in the 2016-2017 school year, including:
    1. social workers
    2. trauma counsellors
    3. mental health workers
    4. addiction workers or counsellors
    5. life skills programs
    6. on-call drivers
    7. community liaison workers
    8. school nurses and
    9. provision of healthy meals during school hours
E. Funding – Recreational and Personal Needs

To: Canada

  1. In order to improve education and health outcomes of First Nations youth who attend secondary school in Thunder Bay and to develop important values, in consultation with NNEC, KO, DFCHS, PFFNHS and MLC, provide on-going, predictable and reliable funding required to ensure that there is an appropriate staff complement and programs to address the recreational needs of DFCHS, PFFNHS and MLC students, including:
    1. adequate annual/monthly allowances to be provided to students for their recreational and personal needs
    2. adequate annual/monthly clothing allowances to be provided to students
    3. adequate annual/monthly tutoring allowances to be provided to students
    4. after-school activities co-ordinators
    5. registration fees for participation in extra-curricular activities (at the highest level that the student is capable of and interested in) and the equipment to support that participation, including special adaptive aids for special needs students
    6. lessons in: music, art, dance, martial arts, drama etc. and the equipment to support participation, including special adaptive aids for special needs students
    7. individual tutoring as required
    8. travel to other cities in Ontario and Canada, and
    9. fishing trips/camping trips
F. Funding – Maintaining Family and Social Connections

To: Canada

  1. In order to allow First Nations students to maintain family and social connections while they attend secondary school in Thunder Bay, in consultation with NNEC, KO, MLC, and community education counsellors, determine the appropriate frequency and required level of funding for travel of students between their home communities and Thunder Bay as well as funding for communication between students and their home communities. Consideration should include:
    1. at a minimum, travel during the school year in the fall, at Christmas, and at Spring Break
    2. travel of students for community celebrations or emergencies
    3. travel of parents or caregivers to Thunder Bay in case of emergency
    4. supply or funding for students to have regular computer or telephone access with their families and home communities, and
    5. investment or increase in technology at schools to allow students to communicate on a regular basis with their families and social contacts in their home communities
  2. In order to promote and preserve the connection between students, their families and to help ensure student safety, amend current policies to ensure that any parent or legal guardian who moves away from their home community to live with their child/children while the child/children attend secondary school will meet the definition of "boarding parent” and will be entitled to receive the same stipend as a boarding parent.
G. Funding – Student Transportation within Thunder Bay

To: Canada

  1. In order to provide all First Nations students living in Thunder Bay with reasonable travel time and safe transportation to school and access to all extracurricular activities, in consultation with NNEC, KO, DFCHS, and MLC, conduct an assessment of funding required to ensure that DFCHS and MLC students have access to reasonable transportation while attending school or extracurricular activities. Funding should be adequate to cover:
    1. the purchase or lease of vehicles to transport students
    2. the appropriate number of qualified drivers to operate such vehicles
    3. insurance for vehicles
    4. maintenance and operating costs for vehicles, and
    5. the assessment of the feasibility of using a local school bus company.
H. Assessment of Students upon arrival in Thunder Bay

To: Canada, NNEC, KO and MLC

  1. In order to ensure that any special needs or supports required for First Nations students are identified and addressed while attending secondary school in Thunder Bay, ensure that funding and resources are in place upon arrival of students in Thunder Bay to identify:
    1. special education needs
    2. substance and/or alcohol abuse issues
    3. mental health issues, and
    4. any other supports required, including gaps in academic achievements that require additional supports or additional time for achieving necessary credit for graduation.
I. Support Services and Support Workers

To: Canada

  1. In order to ensure that the appropriate level of support services are in place for First Nations students upon arrival in Thunder Bay, ensure that NNEC, KO and MLC have sufficient additional funding, staff and technology to:
    1. convene a meeting with each student, their parents, their boarding parents and prime workers prior to the student’s arrival at high school
    2. conduct a separate meeting with the student upon arrival in Thunder Bay to identify any needs and concerns of the student as well as goals and aspirations
    3. convene monthly check-ins between each student, their parents, the boarding parents and prime workers after the student has begun school, and
    4. ensure timely reports to parents and/or education authorities regarding concerns relating to absenteeism, missed curfews or substance/alcohol use.
J. Orientation of Students upon Arrival in Thunder Bay

To: NNEC, KO, DFCHS and MLC

  1. In order to ensure that students receive orientation at the time of their arrival as well as ongoing support as they transition to life in Thunder Bay, in addition to the current orientation sessions conducted by DFCHS, MLC, the City of Thunder Bay and other community partners, new students should be partnered with peer mentors who have experience in Thunder Bay and are willing to assist with day-to-day issues that may arise, including:
    1. resisting negative peer pressure
    2. reporting incidents of racism
    3. encouraging students to attend school and apply themselves to their studies
    4. reporting concerns regarding boarding homes
    5. promoting healthy lifestyles, and
    6. organizing activities to reduce risk factors.

To: The City of Thunder Bay

  1. The City of Thunder Bay, through their Travel and Tourism division, should be part of the student welcome orientation session mentioned in Recommendation 73 to help new students by providing them with city maps, transit maps and a list of community centers and activities offered throughout the city.

To: Canada, Ontario and the City of Thunder Bay

  1. In order to provide peer leaders and mentors with the capacity, communication skills and self-confidence they need to apply positive influence on other students, the City should act as a resource to identify community partners including, but not limited to, Ontario and Canada, who could support and provide funding in order to create and sustain peer leaders at DFCHS and MLC. Explore the option of having peer leaders and mentors receive volunteer hours credited toward their OSSD requirements.
K. Boarding Homes

To: Canada and NAN

  1. In order to increase the number of quality boarding homes for First Nations students in Thunder Bay, in consultation with representatives from NNEC, KO, MLC, student support workers and long-term boarding parents, establish a working group that will:
    1. determine the appropriate level of funding for boarding parents, and
    2. establish minimum expectations with respect to boarding parent’s responsibility to ensure student’s safety and well-being, attendance at school and academic success.
  2. In order to enhance and standardize the procedure for the screening and approval of boarding homes for First Nations students attending school off-reserve, within six months of the date of this verdict, establish a working group including representatives from NNEC, KO, MLC, and other appropriate stakeholders to determine existing best practices and to consider:
    1. minimum standards for all boarding homes
    2. standardized screening and vetting of boarding home applicants, including:
      1. monthly visits and scheduled inspections
      2. criminal record checks for all residents aged 18 years and over and updates of criminal record checks on an annual basis
      3. mandatory completion of training, including first aid training and management and care of intoxicated students
      4. demonstration of financial stability
      5. standardized contract including:
        • provisions that clearly outline expectations of boarding parents, including regular communication with student support or prime workers and parents/guardians
        • provisions that clearly outline conduct that will result in termination, and
        • provision in contract for unannounced visits as may be deemed necessary and at the discretion of the school
    3. minimum standards for written policies and procedures relating to screening and approval of boarding parents and homes.
L. Additional Support Services to Students

To: Ontario

  1. In order to assist First Nations students who move to Thunder Bay to attend secondary school, the Ontario Ministries of Education, Children and Youth, Municipal Affairs and Housing, Health and Long-Term Care and Community and Social Services should work with Canada, the Thunder Bay District Social Services Administration Board, the City of Thunder Bay and Indigenous communities and organizations to support a well-coordinated suite of housing, income, recreation and health services and supports to assist students in accessing supports and services.
  2. In order to provide First Nations students with additional supports to achieve academic success and to have a positive experience while living in Thunder Bay, continue to provide funding to qualified organizations to deliver the After School Program at DFCHS and work with MLC and KO to explore providing funding to qualified organizations to deliver After School Programs for students from the Matawa and KO communities attending school in Thunder Bay.
  3. Work with agencies funded under the Aboriginal Healing and Wellness Strategy (AHWS) to explore creating more employment opportunities for youth (e.g. peer mentors).
M. Harm Reduction Strategies

To: NAN, NNEC, KO, DFCHS and MLC

  1. In order to ensure the safety of all First Nation students while going to school on-reserve or off-reserve, conduct annual training of all staff and boarding parents associated with First Nation schools with respect to:
    1. recognition, management and care of intoxicated students
    2. crisis intervention
    3. suicide prevention, and
    4. first aid, including cardiopulmonary resuscitation.

To: Canada

  1. In order to ensure the safety of First Nation students while living in Thunder Bay, provide funding to NNEC, KO, and MLC to conduct training as described in Recommendation 81 and to permit on-reserve and off-reserve First Nations schools to create and implement safe school protocols.

To: NNEC, KO, DFCHS and MLC

  1. In order to increase awareness regarding risks related to alcohol, substance and solvent use and ensure consistent mandatory education of First Nations students attending school in Thunder Bay, in consultation with local community partners, including the Centres for Addiction and Mental Health, the Thunder Bay District Health Unit and Dilico ensure that students are provided with regular, appropriate, accurate, up-to-date information relating to:
    1. the health and social issues associated with alcohol, substance and solvent use
    2. the legal consequences of underage drinking
    3. the resources available in the community to address issues relating to alcohol, substance and solvent use
    4. current misconceptions relating to "accepted" drinking practices (ie: drinking homebrew vs spirits), and
    5. the importance of assisting and staying with intoxicated peers and reporting any concerns to boarding parents, on-call workers, and other support workers.

To: Canada, NNEC, KO, DFCHS and MLC

  1. In order to allow students to continue their education in Thunder Bay while dealing with substance or alcohol issues, in consultation with local community partners, NNEC, KO and MLC should continue to develop harm reduction programs to address alcohol and substance use by students at their schools. The development of such programs should consider including a day program (if necessary) or a course option for students at the school. Canada should sufficiently fund NNEC, KO and MLC for these activities.

To: Canada, NNEC, KO, DFCHS and MLC

  1. In order to assist First Nations students in Thunder Bay with alcohol/substance use and addiction problems, in consultation with community partners, including the Centres for Addiction and Mental Health, Dilico, and St. Joseph’s Care Group, explore alternatives to sending students back to their home communities, including treatment programs that would allow students to pursue their studies in Thunder Bay.
  2. In order to increase awareness of DFCHS and MLC students regarding the risks associated with the purchase of alcohol through second party purchasers (“runners”), consider incorporating the Crimestoppers video made by DFCHS students into the orientation session held upon the arrival of new students in Thunder Bay each September. If the Crimestoppers video is not incorporated, include information in the orientation regarding the risks associated with the purchase of alcohol through second party purchasers.

To: Canada, Ontario, NAN, NNEC, KO, DFCHS and MLC

  1. In order to ensure continuity of care and increased prospect (where desired) of a return to Thunder Bay for those students who are sent back due to health and safety concerns, make all efforts to ensure that community supports, including a continuing education, health and mental health plan, are in place prior to sending a student back to his or her home community. Canada and Ontario should ensure that there is sufficient funding and resources in place for these support programs.

To: P.A.R.T.Y. Program of Thunder Bay

  1. In order to raise awareness of First Nations students regarding the risks associated with alcohol/substance use and to enhance the delivery of the P.A.R.T.Y. program to First Nations youth attending school in Thunder Bay:
    1. offer the P.A.R.T.Y. program to grades 9 through 12 for DFCHS and MLC
    2. offer the P.A.R.T.Y. program at least twice a year (September and January) to ensure that new students and returning students (after Christmas break) receive the program information when first arriving in Thunder Bay and to reinforce the message upon return to Thunder Bay for the second semester
    3. consider the option of an “in-school” P.A.R.T.Y. program for DFCHS and MLC students
    4. include Elders in the regular P.A.R.T.Y. program to meet the needs of First Nations students attending high school in Thunder Bay
    5. in consultation with P.A.R.T.Y. International, develop a program with a focus on addressing the specific needs of Aboriginal youth, and
    6. if considering the inclusion of the scenarios involving the deaths of the First Nations youth who are the subject of this inquest in the P.A.R.T.Y. program, P.A.R.T.Y. International must consult and obtain consent from the families involved.
N. Addressing health needs of First Nations students in Thunder Bay

Canada (Health Canada)

  1. In order to ensure continuity of care for First Nations students while in Thunder Bay:
    1. review existing policies with regard to providing health services to First Nations students attending high school off-reserve
    2. develop, fund, and implement an Electronic Medical Records system for all NAN communities in which all medical information from clinics and nursing stations in the communities is readily available to medical professionals all across Ontario. This will ensure continuity of care for all First Nation youth who require medical care while residing outside of their home communities
    3. provide additional funding for NNADAP programs
    4. fund aftercare programs for First Nations youth leaving addictions treatment programs, and
    5. create and implement policy that allows health authorities to make decisions regarding medical transport in an efficient and timely manner irrespective of location of First Nation student at the time of need.

Youth Participation in Decisions

To: Canada, NAN, NNEC, KO, DFCHS and MLC

  1. In order for First Nations youth to have a voice regarding decisions relating to their education off-reserve, and to ensure that there is accountability in decisions made regarding their education and well-being, NNEC, KO, and MLC, with the support of Canada and NAN, should consider creating a special seat on their Boards of Directors for a youth representative who is a student or former student of DFCHS or MLC under the age of 25. Canada should provide the funding for any costs associated with this position.

Missing Person Investigations and Searches

To: NAN, the City of Thunder Bay, TBPS, NAPS, NNEC, KO, DFCHS and MLC

  1. In order to ensure timely reporting of missing students and consistent practice among institutions when students are reported missing or during sudden death investigations, the City of Thunder Bay; TBPS; NAN; NAPS; NNEC; DFCHS; KO; and MLC should establish a working group to discuss best practices applicable to their respective roles pertaining to students from remote First Nations communities attending secondary school in Thunder Bay ("Students"). The working group should consider:
    1. The need to ensure timely reporting to police of all missing person matters that involve a Student: The working group should review and revise current education authority policies and procedures in order to generate a consistent set of policies. In particular, the document entitled Missing Student Protocol Guide [Exhibit Number 133 at Tab 31] should be reviewed and revised with the benefit of information learned at the joint inquest to help generate a consistent set of policies and procedures. The revised set of policies and procedures, once agreed upon, should be disseminated to - and adopted by – NNEC, KO and MLC. The revised procedures should include language that directs education authority employees to file a missing person report with police as soon as any member of the education authority determines that a search needs to be undertaken for a student whose whereabouts are unknown.
    2. Public awareness: The working group should discuss implementation of a public information campaign emphasizing the importance of reporting missing person matters to police without delay.
    3. Information Sheets: The working group should discuss the preparation of information forms for all Students to be stored with education authorities. The working group should also review the steps necessary to obtain appropriate consent to disseminate these individual forms to police in the event that a missing person report is filed.
    4. Social Media Search: The working group should consider how to utilize social media to assist in missing person searches and should designate roles and responsibilities for all parties accordingly;
    5. Press Releases: The working group should discuss approaches to press releases pertaining to any missing person matter that involves a Student. The working group should also discuss approaches to press releases in the event that a Student is found deceased. The working group should discuss the various circumstances that may influence when media releases should or should not go out. The working group should also discuss circumstances that may influence how a media release may need to be worded.
    6. Best Practices for Interviews: The working group should discuss best practices to facilitate interviews of young people in exigent, non-criminal, circumstances. The working group should also discuss best practices to facilitate interviews in exigent, non-criminal, matters with individuals of any age who may be unfamiliar or uncomfortable dealing with individuals in positions of authority.
    7. Internal Search Plans: The working group should ensure that appropriate participant institutions have an internal search plan that can be implemented if a Student goes missing. Without limiting the generality of what the internal plans may include:
      1. internal search plans should identify pre-determined internal points of contact to act as information coordinators and liaisons to third parties in the event of a missing person search involving a visiting student
      2. internal search plans should set out a clear supervisory structure so that each institution is able to identify an individual(s) who will ensure that the internal search plan is properly executed
      3. internal search plans should set out how information will be provided to family members and will contain provisions that permit family members to identify third parties to act as their agents/advocates as they prefer. The plan should ensure that more than one individual can be designated by family members to receive information where necessary
      4. internal search plans should also set out how employees will share information externally with any other relevant institutions, political bodies or family members
      5. all internal search plans should contemplate the possible arrival of community searchers and how to manage such volunteers. Internal search plans should explain best search practices for non-police searchers with particular emphasis on, among other things, evidence preservation
    8. Global Search Plans: The working group should also ensure that each internal search plan dovetails into a larger global search plan that should be implemented by all participant institutions in the event that a Student goes missing:
      1. Global search plans should adopt pre-determined points of contact within each institution that are consistent with the internal search plans discussed above
      2. Global search plans should include at least one Appendix that will contain a handout listing the best practices for community to community searchers discussed above. This document can be disseminated to community searchers as needed
    9. Missing person risk factors: The working group should share expertise on risk factors that may need to be considered when assessing the risk level in a missing person matter that involves a Student. The working group should create a list of risk factors that should be considered by all parties. The revised risk factors should be shared among participants and, once agreed upon by all, imported into the forthcoming TBPS 2016 missing person procedure as well as all internal search plans
    10. The working group should also review the revised TBPS missing person questionnaire that arises under the 2016 missing person policy and should consider what revisions, if any, should be made based on: (i) the expertise obtained by education authorities arising out of their own search efforts and (ii) information contained in search forms prepared by other police services that may be available by way of the Ontario Association of Chiefs of Police, including but not limited to, the Ontario Provincial Police
    11. Training: The working group should fix deadlines for completion of staff training on all issues as follows:
      1. parties other than the TBPS should ensure that all staff are fully trained on revised procedures within 1-year from the completion of the working group deliverables, and
      2. TBPS will ensure that all of its members are trained on the forthcoming revised 2016 missing person policy by December 31, 2016
    12. The working group should prepare an anonymized training case scenario based on evidence canvassed at, and lessons learned from, the joint inquest. The case scenario should be used to assist in training TBPS officers, education authority staff and NAPS officers to participate in investigations relating to Students which may involve:
      1. civilian search teams
      2. alcohol or substance use
      3. reports made to police after the whereabouts of the subject individual have been unknown for a lengthy period of time
      4. interviews involving young people who may be reluctant to speak to police officers fearing that they may get in trouble or may be betraying the confidence of their friends, or
      5. cultural and systemic barriers that may limit the fulsome disclosure of information to persons in positions of authority and
    13. The working group should identify an appropriate external consultant to be hired to assist the TBPS (and any other interested organizations) to revise current training modules to ensure that curriculum covers cultural issues that are relevant to members of the Indigenous community in and around Thunder Bay and:
      1. TBPS will also present an annual report on training to the Police Services Board to provide the public with information on police training. This report will be made during the public session and will include, among other things, a summary of the number of officers who completed training courses in different policing areas and will include information about training curriculum related to Indigenous issues.

To: Ontario

  1. Establish a working group to review issues relating to ground searches for missing persons and missing persons investigations and to make recommendations to the Ministry of Community Safety and Correctional Services ("MCSCS") regarding (i) provincial standards relating to missing persons searches and investigations; (ii) training of police officers involved in missing persons searches and investigations; and (iii) any other issue that the working group considers appropriate for a recommendation. The membership of this working group should include representatives of MCSCS, the Ontario Association of Chiefs of Police, the Ontario Police College, the OPP Police Academy, at least one municipal police service, and at least one First Nations organization.

Stand-alone Missing Person Legislation

To: Ontario

  1. Develop and propose new missing persons legislation, in consultation with policing partners, Indigenous communities and organizations, and other partners to assist police in investigating missing persons cases.

Protocol for Volunteer Community Searchers

To: Ontario

  1. Create a joint protocol translated in Cree, Ojibway, and Oji-Cree for distribution to community search teams explaining best search practices for non-police searchers with particular emphasis on:
    1. safety considerations for community searchers
    2. evidence preservation
    3. importance of communication/debriefing with assigned liaison officer, and
    4. issues relating to private property.

Other Investigations/Police issues

Pattern Recognition and Reporting of "Runners"

To: Liquor Control Board of Ontario ("LCBO") and Ontario

  1. In order to decrease the purchase of alcohol by persons under 19 years of age through "runners" or second party purchasers:
    1. review and revise (where necessary) LCBO guidelines for the detection of second party purchases
    2. enhance opportunities and methods employed to identify second party purchases and review existing practices for detecting and deterring this practice

To: LCBO and TBPS

  1. In order to decrease the opportunity for underage drinking (persons under 19) and to deter individuals from purchasing alcohol for underage individuals, create a task force or working group comprised of LCBO managers and/or regional managers and staff (as appropriate) and TBPS representatives to:
    1. review and revise (where necessary) the list of "triggers" already being used by the LCBO to identify second party purchases, and
    2. based on the recommendations of the LCBO and TBPS task force/working group, develop a protocol for the reporting of suspected second party purchases to the TBPS

To: Ontario, LCBO and TBPS

  1. All parties should work together to develop a campaign to raise public awareness about second party purchases and the associated legal consequences. This campaign should make use of social media as well as posters in LCBO establishments.

Other Recommendations to assist First Nations Students in Thunder Bay

To: Canada (Health Canada)

  1. To help alleviate homesickness for students, KO Telehealth should develop a program to allow families to utilize their services to communicate with their children who are attending high school off-reserve. This program should commence for the 2016-2017 school year.

Social Media and Internet Resource Development

To: The City of Thunder Bay

  1. The City of Thunder Bay should advertise, promote and consult with students on the best way to notify students of opportunities for Youth, including employment, recreation and volunteering at the City of Thunder Bay, whether that is on the City’s website, other social media or another “youth friendly” format. This information should be provided at all schools in the local district.
  2. The City of Thunder Bay should explore options for promoting youth opportunities and programming to youth, by “speaking their language” and utilizing sources such as Twitter, Facebook, and other social media websites.

Recreation Information and Activities

To: Ontario

  1. The Ministry of Tourism, Culture and Sport should provide adequate funding to sustain the Regional Multicultural Youth Centre’s initiatives at DFCHS to keep students busy and safe after school, reduce risks and create a generation of active Aboriginal youths.

To: The City of Thunder Bay

  1. The City of Thunder Bay should consult and liaise with NNEC, DFCHS, KO and MLC in order to develop a plan for assisting those students who would like to attend City programs or have questions with respect to any City programs but may have some issue to overcome such as transportation issues to and from the venue.
  2. The City of Thunder Bay through the Aboriginal Liaison should liaise with DFCHS and MLC to provide copies of the community recreation guide "The Key" each session, and other promotional materials for City recreation opportunities on an ongoing basis, to be circulated in the schools including in libraries, guidance offices and recreation spaces.
  3. The City of Thunder Bay should promote the P.R.O. Kids program to stakeholders such as NAN, NNEC, DFCHS, KO and MLC to encourage subject students to participate if they are interested.
  4. The City should consult with and assess the needs of the community with respect to Youth and Youth programming through the efforts of the City of Thunder Bay Recreation & Facilities Master Plan "Stakeholder + Public Consultation Plan", whose goals include identifying:
    1. the community’s vision for the development of recreation
    2. the current demands for and gaps in recreation services and facilities as well as emerging needs, and
    3. the experience of Users by facility in terms of their level of satisfaction and barriers to recreation services such as transportation.

    The consultation process should include tapping into the voices of the City’s Youth, including Youth from the First Nations and Métis communities within and surrounding Thunder Bay.

  5. Once the goals of the Stakeholder + Public Consultation Plan have been achieved, and the needs with respect to Youth programming in the City are identified - including a consideration of the need for a Youth Centre or Youth Centres in Thunder Bay - the City should identify and pursue funding and other resources to meet those needs, including consultation with the Federal and Provincial governments to support programming and/or infrastructure development.

To: The City of Thunder Bay, NNEC, KO, DFCHS and MLC

  1. The City of Thunder Bay Aboriginal Liaison, NNEC, DFCHS, KO and MLC should work together - perhaps through designated contact people in the schools - to co-ordinate participation of DFCHS and MLC students in Thunder Bay recreation programs and City sponsored events that students may be interested in attending throughout the school year - for example, the use of skating rinks in the winter.

Transit Training

To: The City of Thunder Bay

  1. The City of Thunder Bay should develop policy and procedures for dealing with incapacitated individuals, specifically youth 18 and under. These policies should also address the safety of youth who are denied or removed from transit service or who exit a transit vehicle while incapacitated. The City of Thunder Bay should provide training to its Operators and Controllers on these policies and procedures.
O. Indigenous Youth Employment

To: The City of Thunder Bay

  1. The City should develop and report on employment equity targets for Indigenous Youth hired by the City, including both full time and part time employment.

City’s Commitment to Indigenous Peoples

To: The City of Thunder Bay

  1. The City should review its current “Welcome Thunder Bay” slogan and programming to consider ways in which to incorporate a better reflection of the Indigenous presence in the territory for millennia.
  2. The City should post its Declaration of Commitment dated March 29, 2010, in all of its buildings.

Community Safety Considerations

To: The City of Thunder Bay

  1. The City of Thunder Bay should encourage and support the combined efforts of the Anti-Racism and Respect Committee and the Thunder Bay Crime Prevention Council, and, in consultation with the Thunder Bay Police Services Board, DFCHS, NNEC, KO, MLC, and the Indigenous community of Thunder Bay, should develop a public education campaign identifying and discussing the issue of racially motivated crimes, specifically those involving the Indigenous communities residing in and around the City of Thunder Bay.

To: Ontario and the City of Thunder Bay

  1. Ontario and the City of Thunder Bay, in exercising its appointment power to the Thunder Bay Police Services Board ("TBPSB"), should take into account the need for an Indigenous representative to reflect the nature of the Indigenous peoples within the City of Thunder Bay which is served by the TBPSB.

To: Canada, Ontario, the City of Thunder Bay, NAN, NNEC, KO and MLC

  1. Consultations should occur between the City of Thunder Bay through the Thunder Bay Drug Strategy, the TBPSB, Health Canada, the Ministries of Health and Long-term Care and Child and Youth Services, the Northwest Local Health Integration Network ("NWLHIN"), EMS, the Thunder Bay Regional Health Sciences Centre ("TBRHSC"), NAN, NNEC, KO, Shibogama, Independent First Nations Alliance ("IFNA") and MLC in order to develop of an alternative facility for intoxicated youth, including remote First Nation students who cannot return home until their intoxication level has subsided. Such an alternative facility could include a shelter or detox unit, open to youth who are 25 years or younger, with appropriately trained staff.

To: The City of Thunder Bay, TBPS, NNEC, KO, DFCHS and MLC

  1. The City of Thunder Bay, TBPS, NNEC, DFCHS, KO, IFNA, Shibogama and MLC should consult on the terms of reference for a safety audit of the river areas frequented by First Nation students and youth in the evenings. The consultation and resulting audit should be undertaken as soon as practicable. Subject to the findings of the audit, some possible responses to identified issues could include improved lighting, emergency button poles, under-bridge barricades, or increased police patrols.

Community Leadership Role

To: The City of Thunder Bay, NAN, DFCHS and MLC

  1. In order to increase public awareness in the City of Thunder Bay regarding the issues raised during this Inquest, including the obstacles and challenges faced by First Nations students from remote communities who are residing in Thunder Bay, the City should work with First Nations expertise to develop a local and social media campaign as well as a public forum which highlights and addresses:
    1. the obstacles and challenges faced by First Nations students in Thunder Bay
    2. the health and social issues often experienced by First Nations students in Thunder Bay
    3. the subject of this Inquest through a discussion of the various roles and responsibilities of community partners and members of the community in assisting First Nations students in Thunder Bay
    4. the current misconceptions relating to First Nations students from remote communities who are residing in Thunder Bay
    5. racism experienced by First Nations students in Thunder Bay, and
    6. facilitates discussion regarding how to address and report racism towards First Nations students in Thunder Bay

To: The City of Thunder Bay, NNEC, KO, DFCHS and MLC

  1. The City of Thunder Bay, NNEC, KO, DFCHS, and MLC should consult with community partners to arrange for speakers or skills instructors to attend the schools in order to make presentations on topics which are aimed to engage and provide information to the students.

To: The City of Thunder Bay

  1. The City should review the Calls to Action from the Truth and Reconciliation Commission which apply to municipal government, including Number 57, and consider appropriate future action.
  2. The City should review and consider the United Nations Convention on the Rights of the Child and the United Nations Declaration of the Rights of Indigenous Peoples.

Call for Consultation and Funding

To: Canada, Ontario and the City of Thunder Bay

  1. Canada and Ontario should meet with and consult with the City of Thunder Bay in order to discuss any funding requirements or additional resources necessary to assist the City in implementing and supporting the Recommendations aimed at supporting Indigenous youth travelling to the City in order to access a secondary education program.

Other Recommendations to Foster Greater Collaboration and Partnerships

To: Ontario

  1. In order to serve the best interests of First Nations youth in a collaborative fashion, continue to implement the Ontario Indigenous Children and Youth Strategy (formerly the Aboriginal Children and Youth Strategy) with Indigenous communities and organizations including NAN. This strategy will address the priority of improving outcomes and opportunities for First Nations children and youth, including the specific needs of those in remote northern communities, and will focus on the needs of children and youth through community-driven holistic services that recognize culture and identity as foundational.
  2. Through the Ministry of Education, work with First Nation communities, in collaboration with district schools boards, to share currently existing ministry- developed education resources, reference materials and professional learning related to any provincial policies, programs or initiatives upon request of the First Nation schools and/or educators.
  3. In order to foster greater collaboration between First Nation schools and provincially-funded schools, through the Ministry of Education, engage with First Nation communities to identify opportunities to share information and expertise to support capacity building within First Nation schools.
  4. Through the Ministry of Education, work with First Nations communities, school boards, and the federal government to address issues related to tuition agreements.
  5. Through the Ministry of Education, work with NAN through the Education Partnership Program to foster local relationships between school boards and First Nation communities in order to support student transitions between provincially-funded schools and First Nation schools.
  6. Through the Ministry of Education, continue ongoing work regarding supports for students experiencing racism and continue to work with its partners to support the learning in the curriculum to address this issue.
  7. Through the Anti-Racism Directorate, undertake research and engage with Indigenous communities to develop an Indigenous-informed Anti-Racism public education and awareness campaign.
  8. Through the Ministry of Education, expand its work with partners, including First Nation, Métis and Inuit partners, to develop authentic resources that support learning about Indigenous histories, cultures, issues, perspectives and contributions in the curriculum and that build educator capacity to deliver the learning for all students with confidence and competence.
  9. Through the Ministry of Education, work with the Ministry’s School College Work Initiative (SCWI) partners to expand opportunities for more students from DFCHS to explore and pursue postsecondary pathways through participation in dual credit programs with Confederation College. In addition, the Ministry should explore opportunities to expand dual credit programing to students at MLC. The Northwestern Ontario SCWI Regional Planning Team includes representatives from Confederation College and eight district school boards including the Lakehead and the Thunder Bay Catholic District School Boards.

Issues Relating to the Office of the Chief Coroner

To: The Office of the Chief Coroner

  1. In order to track and analyze death rates of First Nations youth on and off-reserve, The Office of the Chief Coroner should develop a process or protocol to improve data collection and analysis.
  2. The Office of the Chief Coroner should explore new approaches to providing coroner services to remote areas through consultation with communities affected.
  3. In order to ensure consistency in all sudden death investigations, wherever possible, and taking into account the resources available in a community, coroners on call should coordinate their schedules to avoid other responsibilities that would prevent them from attending a scene.
  4. The Office of the Chief Coroner should work in partnership with Indigenous leadership and communities to develop a communications protocol for communications between the coroner’s office and Indigenous peoples which prioritizes communication with the families.
  5. The Office of the Chief Coroner should amend policies to allow for extended family members to access information about the deceased, consistent with legislation.
  6. At the Annual Education Course for Coroners and Pathologists in 2017, the progress/results from recommendations 130 through 134 should be presented and discussed.

Implementation of Recommendations in the spirit of the Truth and Reconciliation Commission’s ("TRC") "Calls to Action" ("CTA")

To: Canada

  1. In order to improve education outcomes of First Nations youth, we support and endorse Recommendations 7 through 11 of the Truth and Reconciliation Commission’s Calls to Action that call upon the federal government to:
    1. develop with Aboriginal groups a joint strategy to eliminate educational and employment gaps between Aboriginal and non-Aboriginal Canadians (CTA#7)
    2. eliminate the discrepancy in federal education funding for First Nations children being educated on reserves and those First Nations children being educated off reserves (CTA#8)
    3. prepare and publish annual reports comparing funding for the education of First Nations children on and off reserves, as well as educational and income attainments of Aboriginal peoples in Canada compared with non-Aboriginal people (CTA#9)
    4. draft new Aboriginal education legislation with the full participation and informed consent of Aboriginal peoples, and committed to the following principles (CTA#10):
      1. providing sufficient funding to close identified educational achievement gaps within one generation
      2. improving education attainment levels and success rates
      3. developing culturally appropriate curricula
      4. protecting the right to Aboriginal languages, including the teaching of Aboriginal languages as credit courses
      5. enabling parental and community responsibility, control, and accountability, similar to what parents enjoy in public school systems
      6. enabling parents to fully participate in the education of their children
      7. respecting and honouring Treaty relationships
      8. providing adequate funding to end the backlog of First Nations students seeking a post-secondary education

To: Canada, Ontario and NAN

  1. In order to improve health outcomes of First Nations youth, we support and endorse Recommendations 18 through 20 of the Truth and Reconciliation Commission’s Calls to Action that:
    1. call upon the federal, provincial, territorial, and Aboriginal governments to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools, and to recognize and implement the health-care rights of Aboriginal people as identified in international law, constitutional law, and under the Treaties (CTA#18)
    2. call upon the federal government, in consultation with Aboriginal peoples, to establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and to publish annual progress reports and assess long-term trends. Such efforts would focus on indicators such as: infant mortality, maternal health, suicide, mental health, addictions, life expectancy, birth rates, infant and child health issues, chronic diseases, illness and injury incidence, and the availability of appropriate health services (CTA#19), and
    3. in order to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves, call upon the federal government to recognize, respect, and address the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples (CTA#20)

To: Canada and Ontario

  1. In order to assess progress in the areas of education and health of First Nations youth, we support and endorse Recommendation 55 of the Truth and Reconciliation Commission’s Calls to Action that calls 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, but not be limited to:
    1. comparative funding for the education of First Nations children on and off reserves
    2. the educational and income attainments of Aboriginal peoples in Canada compared with non-Aboriginal people, and
    3. progress in closing the gaps between Aboriginal and non-Aboriginal communities in a number of health indicators such as: infant mortality, maternal health, suicide, mental health, addictions, life expectancy, birth rates, infant and child health issues, chronic diseases, illness and injury incidence, and the availability of appropriate health services

To: Canada, Ontario and the City of Thunder Bay

  1. We support and endorse Recommendation 57 of the Truth and Reconciliation Commission’s Calls to Action that calls upon federal, provincial, territorial, and municipal governments to provide skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism 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.

To: Canada and Ontario

  1. In order to achieve reconciliation through education, we support and endorse Recommendation 62 of the Truth and Reconciliation Commission’s Calls to Action that calls upon the federal, provincial, and territorial governments, in consultation and collaboration with Survivors, Aboriginal peoples, and educators, to:
    1. make age-appropriate curriculum based on the history of residential schools and legacy effect, 60’s Scoop, colonialism, Treaties, and Aboriginal peoples’ historical and contemporary contributions to Canada a mandatory education requirement for Kindergarten to Grade 12 students to counteract the harmful stereotypes and false and misleading histories/stories that play out in the media
    2. provide the necessary funding to post-secondary institutions to educate teachers on how to integrate Indigenous knowledge and teaching methods into classrooms
    3. provide the necessary funding to Aboriginal schools to utilize Indigenous knowledge and teaching methods in classrooms, and
    4. establish senior-level positions in government at the assistant deputy minister level or higher dedicated to Aboriginal content in education

To: Ontario

  1. In addition, in order to further efforts toward reconciliation through education, we support and endorse Recommendation 63 of the Truth and Reconciliation Commission’s Calls to Action that calls upon the Council of Ministers of Education Canada (upon its creation) to maintain an annual commitment to Aboriginal education issues, including:
    1. developing and implementing Kindergarten to Grade Twelve curriculum and learning resources on Aboriginal peoples in Canadian history, and the history and legacy of residential schools
    2. sharing information and best practices on teaching curriculum related to residential schools and Aboriginal history
    3. building student capacity for intercultural understanding, empathy, and mutual respect, and
    4. identifying teacher-training needs relating to the above

Shannen’s Dream

To: Canada

  1. In order to give effect to the motion passed unanimously by the House of Commons on February 27, 2012, relating to Shannen’s Dream, as set out below, we would support the inclusion of the wording of the motion in federal documents relating to First Nations education:

    That, in the opinion of the House, the government should adopt Shannen's Dream by: (a) declaring that all First Nation children have an equal right to high quality, culturally-relevant education; (b) committing to provide the necessary financial and policy supports for First Nations education systems; (c) providing funding that will put reserve schools on par with non-reserve provincial schools; (d) developing transparent methodologies for school construction, operation, maintenance and replacement; (e) working collaboratively with First Nation leaders to establish equitable norms and formulas for determining class sizes and for the funding of educational resources, staff salaries, special education services and indigenous language instruction; and (f) implementing policies to make the First Nation education system, at a minimum, of equal quality to provincial school systems.

Recommendation Follow-ups

Canada, Ontario, the City of Thunder Bay, TBPS, NAPS, NAN, NNEC, KO, DFCHS, MLC, LCBO, P.A.R.T.Y Program of Thunder Bay and the Office of the Chief Coroner

  1. All organizations that receive recommendations should prepare an annual report following up on the recommendations that:
    1. indicates whether each recommendation is (a) accepted, (b) accepted in part, or (c) rejected
    2. provides an explanation for any recommendations that are not accepted in whole or in part and indicates an alternative approach to achieve the same aim
    3. indicates, for all recommendations that are accepted, whether implementation is (a) pending, (b) in progress, or (c) complete
    4. provides a detailed update regarding the steps that have been taken and are planned with respect to the implementation of the accepted recommendations
    5. is sent by email to any person who requests to receive a copy, and
    6. is prepared each year for delivery at 10 a.m. on the anniversary date of the release of the inquest recommendations (until the party has provided an annual report indicating that all of the recommendations it received have either been rejected or implemented)
  2. The organizations receiving recommendations should endeavour to agree on a process whereby the annual reports will be posted in a central location on the internet (e.g. on a website of one of the organizations). Acknowledging that the First Nations parties who receive recommendations have limited resources, those parties should prioritize actual actions responding to recommendations over reporting on those actions and should only be expected to provide annual reports if they have the resources to do so.
  3. Organizations that accept recommendations should revise their current policies to reflect new tasks and procedures.