1 2 3 THE INQUIRY INTO PEDIATRIC FORENSIC 4 PATHOLOGY IN ONTARIO 5 6 7 8 ******************** 9 10 11 BEFORE: THE HONOURABLE JUSTICE STEPHEN GOUDGE, 12 COMMISSIONER 13 14 15 16 Held at: 17 Offices of the Inquiry 18 180 Dundas Street West, 22nd Floor 19 Toronto, Ontario 20 21 22 ******************** 23 24 February 29th, 2008 25


1 Appearances 2 Linda Rothstein ) Commission Counsel 3 Mark Sandler ) 4 Robert Centa (np) ) 5 Jennifer McAleer (np) ) 6 Johnathan Shime (np) ) 7 Ava Arbuck (np) ) 8 Tina Lie (np) ) 9 Maryth Yachnin (np) ) 10 Robyn Trask (np) ) 11 Sara Westreich (np) ) 12 Jill Presser (np) ) 13 14 Wally McKay ) Facilitator 15 16 Brian Gover ) Office of the Chief Coroner 17 Luisa Ritacca ) for Ontario 18 Teja Rachamalla (np) ) 19 20 Jane Langford (np) ) Dr. Charles Smith 21 Niels Ortved (np) ) 22 Erica Baron (np) ) 23 Grant Hoole (np) ) 24 25


1 APPEARANCES (CONT'D) 2 William Carter (np) ) Hospital for Sick Children 3 Barbara Walker-Renshaw (np)) 4 Kate Crawford ) 5 6 Paul Cavalluzzo (np) ) Ontario Crown Attorneys' 7 Association 8 9 Mara Greene (np) ) Criminal Lawyers' 10 Breese Davies (np) ) Association 11 Joseph Di Luca (np) ) 12 Jeffery Manishen (np) ) 13 14 James Lockyer (np) ) William Mullins-Johnson, 15 Alison Craig (np) ) Sherry Sherret-Robinson and 16 Phillip Campbell (np) ) seven unnamed persons 17 18 Peter Wardle (np) ) Affected Families Group 19 Julie Kirkpatrick (np) ) 20 Daniel Bernstein (np) ) 21 22 Louis Sokolov (np) ) Association in Defence of 23 Vanora Simpson (np) ) the Wrongly Convicted 24 Elizabeth Widner (np) ) 25 Paul Copeland (np) )


1 APPEARANCES (cont'd) 2 Jackie Esmonde ) Aboriginal Legal Services 3 Kimberly Murray (np) ) of Toronto and Nishnawbe- 4 Sheila Cuthbertson (np) ) Aski Nation 5 Julian Falconer ) 6 7 Suzan Fraser (np) ) Defence for Children 8 ) International - Canada 9 10 William Manuel ) Ministry of the Attorney 11 Heather Mackay (np) ) General for Ontario 12 Erin Rizok (np) ) 13 Kim Twohig (np) ) 14 Chantelle Blom (np) ) 15 16 Natasha Egan (np) ) College of Physicians and 17 Carolyn Silver (np) ) Surgeons 18 19 Michael Lomer (np) ) For Marco Trotta 20 Jaki Freeman (np) ) 21 22 Emily R. McKernan (np) ) Glenn Paul Taylor 23 24 25


1 TABLE OF CONTENTS Page No. 2 Opening Prayer 3 Traditional Drum Ceremony 4 5 TRADITIONAL PRACTICES REGARDING DEATH OF CHILDREN IN 6 ABORIGINAL COMMUNITIES: 7 ELIZABETH MAMKEESIC 8 Questioned by Mr. Mark Sandler and Mr. Wally McKay 14 9 10 PANEL 1 - BARRIERS TO PEDIATRIC FORENSIC DEATH 11 INVESTIGATIONS IN REMOTE ABORIGINAL COMMUNITIES: 12 JOHN DOMM 13 DAVID EDEN 14 CONNIE GRAY-MCKAY 15 VERNON MORRIS 16 Questioned by Mr. Mark Sandler and Mr. Wally McKay 22 17 Questioned by Mr. Julian Falconer 71 18 19 PANEL 2 - CRIMINALLY SUSPICIOUS INVESTIGATIONS IN 20 PEDIATRIC DEATH CASES: 21 MARY JEAN ROBINSON 22 BARBARA HANCOCK 23 Questioned by Mr. Mark Sandler and Mr. Wally McKay 79 24 Questioned by Ms. Jackie Esmonde 114 25


1 TABLE OF CONTENTS (Con't) Page No. 2 PANEL 3 - COMMUNITY INVOLVEMENT WITH DEATH INVESTIGATIONS: 3 JIM MORRIS 4 DAVID EDEN 5 Questioned by Mr. Mark Sandler and Mr. Wally McKay 122 6 Questioned by Mr. Julian Falconer 156 7 8 PANEL 4 - IMPROVING COMMUNICATIONS BETWEEN ABORIGINAL 9 COMMUNITIES AND THE OCCO: 10 NATHAN WRIGHT 11 DR. BONITA PORTER 12 DR. DAVID EDEN 13 DEPUTY GRAND CHIEF ALVIN FIDDLER 14 15 Questioned by Mr. Mark Sander 166 16 Questioned by Mr. Brian Gover 184 17 Questioned by Mr. Julian Falconer 186 18 19 Certificate of transcript 199 20 21 22 23 24 25


1 --- Upon commencing at 9:35 a.m. 2 3 MR. MARK SANDLER: Good morning, 4 Commissioner. Good morning, ladies and gentlemen. 5 Commissioner, this morning, as you know, and -- and for 6 the balance of the day we're going to be addressing some 7 of the challenges in providing pediatric forensic 8 pathology services to Aboriginal communities, and we have 9 a wonderful array of experts to provide some assistance 10 to you in the course of the day. 11 I'm going to call upon Jeff Neecan to 12 introduce our roundtables this morning through a 13 traditional ceremony. Jeff is originally from 14 Mishkeegogamang First Nation. He currently resides in 15 Thunder Bay with his family and attends Lakehead 16 University working towards a degree in social work. 17 Jeff...? 18 MR. JEFF NEECAN: Good morning. 19 MR. MARK SANDLER: And we'll start with 20 our opening prayer from our Elder. 21 ELDER ELIZABETH MAMKEESIC: Good morning. 22 23 (OPENING PRAYER ELDER ELIZABETH MAMKEESIC) 24 25 (TRADITIONAL DRUM CEREMONY)


1 MR. MARK SANDLER: Thank you so much. 2 Very good opening for today's events. 3 Commissioner, before we proceed further, I 4 want to introduce Wally McKay, who's to my immediate 5 right. Wally is the former Grand Chief of Nishnawbe-Aski 6 Nation, a former Regional Chief of the Chiefs on Ontario, 7 a proud member of Sachigo First Nation, and -- and he's 8 going to be assisting, and facilitating our roundtables 9 today. So welcome, Wally. 10 I'm going to ask Wally to introduce our 11 Elder, who will be making our first presentation on 12 traditional practices regarding the death of children in 13 the Aboriginal community. 14 Wally...? 15 MR. WALLY MCKAY: Thank you very much, 16 Mr. Sandler. Mr. Commissioner, the presenter is 17 Elizabeth Mamkeesic. Elizabeth has lived all her life in 18 Sandy Lake First Nation community. She has -- she 19 started working -- her working career at a local nursing 20 station in Sandy Lake in 1970. 21 From that time on, she carried on the 22 responsibilities of assisting the nurses in all phases of 23 providing nursing care to whatever requirements were 24 needed at that particular time. And then she became what 25 -- what is titled as the community health representative


1 from 1990 to 2006. She is now retired and in the process 2 of moving to Winnipeg to -- to -- to live there. 3 She -- she has numerous grandchildren and 4 she says, Now I only am living with one (1) grandson. 5 She says, That's all they give me is one (1) grandson to 6 live with. And so were very happy. She's -- she's 7 adopted one (1) son. She has her own family but on top 8 of that she adopted a son and she adopted a daughter 9 along the way with that. So she's a -- a family 10 caregiver. 11 We will listen to -- to Elizabeth just 12 preliminary comments on it. In the First Nations, in the 13 Aboriginal community, the children, when they are born, 14 they're looked upon as gifts to the -- to the families, 15 to the parents, but also to the community. They're given 16 -- they're looked upon gifts. 17 Unfortunately, certain things happen that 18 --that -- that -- that the gift is no longer there. 19 Something happens and the -- the child is -- the embrace 20 is lost. And Elizabeth is going to talk to us about the 21 culture of the community, what happens in that regard. 22 So it is a privilege to ask to have 23 Elizabeth Mamkeesic from Sandy Lake First Nation to 24 present to us the -- that side of the community. 25 Elizabeth...?


1 2 TRADITIONAL PRACTICES REGARDING DEATH OF CHILDREN IN 3 ABORIGINAL COMMUNITIES: 4 ELDER ELIZABETH MAMKEESIC: Bonjour. And 5 I was kind of surprised that they -- they ask me to come 6 and --at the -- a roundtable, but I don't even know what 7 a roundtable was. I didn't know I was going to be 8 sitting here. 9 But they ask me what's happening in my 10 community, what I know about the babies, what happened to 11 them when they have a crib death or -- or miscarriage. 12 And sometimes a crib death or -- or a baby is sleeping 13 with the parents in a bed, and that's what we brought up 14 back, I don't know when, but as long as I know, all my 15 sisters and brothers, my -- my mom is sleeping with the 16 baby. And so that's some of the -- the parents are doing 17 the same thing, to be bond with that baby, the one -- the 18 one they were carrying for nine (9) months. They still 19 want to bond that baby close to them. 20 And they -- they didn't realize -- they 21 didn't know about the -- a crib and other beds. They 22 didn't have that. But they -- they share a whole bed 23 with them. And sometimes there's a death when it 24 happens, when they snuggle the baby or a crib death. 25 But right now, they're starting to --


1 they're starting to -- those young people, they're 2 starting to have cribs, so that the baby could sleep all 3 by themselves. 4 And -- and one time, I didn't -- I don't 5 know if it was they're sleeping with the baby or if they 6 were -- if he was sleeping alone on a crib but early in 7 the morning they have -- they call me up that then the 8 baby is gone, first thing in the morning, and then the 9 baby was blue already. 10 And I tried to do a CPR on her and -- and 11 he was already gone, because they found him not breathing 12 when they woke up. And -- and then that the mother -- 13 they -- they ask him if they could take it -- take the 14 baby out and the mother says, I don't know, the baby is 15 gone already. 16 But I explained to her that they have to 17 check -- check the baby so they'll know what causes that, 18 or -- or if -- if he was smothered on the -- on the bed 19 or -- with you guys. So they want to know what happened 20 to the baby. And those parents did -- didn't understand 21 why they has to be taken out, but the mother -- that -- 22 the young woman's and -- mother is talking to her and I 23 was talking to her explaining to her why it has to be 24 taken out. 25 And sometimes when it happens like that


1 and -- and they ask the parents if they could do 2 something or open the baby up and then they -- they said 3 no, we don't want that. We want that baby to be perfect 4 the way he -- and the baby came in on this earth, and we 5 want that baby to go back perfect, not all cut up. 6 But some -- some say and some they agree, 7 and especially the grandmothers and the -- the in-laws. 8 And -- and sometimes when they buried the baby, sometimes 9 they -- they bury the baby on top of the -- the recent 10 grave. And sometimes they have their own -- their own 11 graves. 12 And the one -- the ones are buried on -- 13 with somebody else on top of the grave is the ones that 14 are not developed when they have miscarriage, and -- and 15 they can't see the baby, and that's when they put it on - 16 - on top of the grave. And when they have miscarriage 17 and the baby is all developed and full grown, they have 18 their own -- their own grave. 19 And -- and I used to go ask my Elder, my - 20 - guidance that -- what should -- what should I do, and 21 so he gave me those things that -- because I never -- I 22 never thought I'll be talking about this, because it -- 23 it happens already, and -- but I'm glad -- I'm glad that 24 -- it has to be heard -- it has to be heard. 25 What my community wants -- sometimes they


1 don't want anything to be cut up after the baby is born, 2 and -- and one time that -- I don't want my baby cut up 3 because when I see -- when they bring it back and I don't 4 want to get hurt again. And I said, you don't have to 5 see it, you don't have to, but if -- if you want to see 6 it, go ahead. And he says my memory is going to be -- 7 stay with me for a long time if I see what they are doing 8 to my baby. 9 And sometimes those -- the grandparents is 10 having a hard time with them and -- because in my 11 community we -- we help each other when a person died and 12 we -- usually almost fill up the church and go and 13 respect for the family and for the -- the baby. 14 Sometimes no one -- there's hardly anybody showed up 15 because -- and then that -- the -- the family is hurt, 16 they're -- they're hurting because no one come and see 17 them, come and support the parents. 18 And -- and so we -- even when I'm working 19 I have to drop everything and go and do my respect with 20 them, because I was with them when -- when it happens, 21 and they wanted me to be seen in -- in church and so I 22 have to -- to do that. That's how much respect I have 23 for babies because I didn't have any. 24 I only -- I only given to look after 25 babies and I wanted to do more -- to do more for other --


1 other babies. And meeqwetch. 2 And I could answer if somebody wants to 3 ask a question, if I have an answer. 4 5 QUESTIONED BY MR. MARK SANDLER AND MR. WALLY MCKAY: 6 MR. MARK SANDLER: I wonder if you could 7 just help the -- our Commissioner out on -- on one (1) 8 point, and that is, we've heard a little bit about the 9 length of time that it can sometimes take when -- when a 10 baby is taken to Toronto or to Winnipeg for an autopsy 11 and then brought back. 12 And perhaps you could -- just to describe 13 for the Commissioner the difficulties that arise when a - 14 - when a lengthy period of time or some time passes 15 before the baby's return for burial. 16 ELDER ELIZABETH MAMKEESIC: And yeah, it 17 is hard for the parents to wait and wait. And sometimes 18 they can't see the baby and sometimes they -- it depends 19 what they -- they say and when the baby's back. And it's 20 really hard for the parents to wait for days to -- a baby 21 to come back. 22 Because sometimes the weather is bad. You 23 never know how the weather is because we only go by plane 24 and so they have to wait. And sometimes a parent is 25 going with the baby, sometimes -- or go and get the body,


1 go and get the body to bring it -- bring the baby home, 2 and that way the parents is near -- near the baby while 3 they're -- while they are doing -- so -- and sometimes 4 they can't -- they can't go with the baby. They have to 5 stay there, and wait and wait for -- to come back, and -- 6 and all that time, those -- those parents and 7 grandparents, and -- and we have to be with them. 8 We -- we don't leave them alone. We just 9 be with them until the -- the baby's back. And sometimes 10 it takes a while to do that. 11 Imagine how the mother is feeling, because 12 -- when are they going to bring my baby back. And they - 13 - and they haven't heard anything. And -- or even it's 14 too far away -- too far away from home to -- to the baby 15 to be gone. 16 Is that -- that what you wanted to know? 17 MR. MARK SANDLER: That's what I wanted 18 to know. Thank you very much. 19 MR. WALLY MCKAY: Elizabeth, maybe you 20 can explain to the Commission -- you talk about 21 grandparents having a hard time when a child dies -- 22 maybe explain how the death of a child affects the 23 community, you know, so that they have a better idea of, 24 you know, what happens in -- on a reserve, okay? 25 ELDER ELIZABETH MAMKEESIC: That the


1 parents, they're -- they're just like their own -- their 2 own child. For us, the grandmothers, we're more close to 3 the child than -- than the mother. I -- I used to think 4 that my -- my grandkids, when they were born, that's my 5 baby because they -- they brought them to my place. And 6 -- and the same thing with the -- the other grandmothers. 7 They are doing the same thing. That's how much -- that's 8 how much they love their -- their grandkids. And one (1) 9 -- one (1) grandmother was saying that I love -- I love 10 my grandkids more than my own. 11 And it's really sad for -- for the 12 grandparents when the baby -- when they find out that the 13 baby is gone, the first thing in the morning. Or one (1) 14 time they -- they said how come you didn't look after 15 your baby, while the baby's sleeping. And the mother was 16 sleeping. It just happens. 17 He was trying to say something -- he's 18 trying to blame some -- somebody, and -- but it just 19 happens like that. One (1) day, that person is gone. 20 Every one (1) of us will be like that. And we don't know 21 when the baby will -- will not wake up in the morning, or 22 even when they have miscarriage, they -- they don't know 23 when it's going to happen, and how it's going to happen. 24 And that's when the grandmother is really 25 feeling sad, upset. At the same time, is angry at the


1 mother, the parents, because the grandmother thinks that 2 that's -- that's their babies. 3 MR. WALLY MCKAY: I just want -- if I can 4 ask you to explain further when you talked about the baby 5 dying, no matter what -- why -- it's not about why -- but 6 when you said that the -- the parents or the grandparents 7 have problems when they're asked for the child to have an 8 autopsy done, and you said to be cut up. And you said 9 that they want the child to go back perfect. 10 Can you explain that more. 11 ELDER ELIZABETH MAMKEESIC: Yeah. They - 12 - they don't want anything to happen because the baby's 13 gone already and -- and the reason why -- that the 14 parents want that baby to be perfect when they bury them. 15 And -- and if they see a mark on him, they 16 -- they get hurt more. They're hurting and they can't 17 get rid of that -- that feeling. And sometimes the 18 mother can even say anything to anybody, because he -- 19 when he sees the baby like that he just lock it in his 20 heart -- or her -- and -- and it stays there. And he -- 21 and they don't know how to talk about it or ask for help. 22 Sometimes that -- that a person with that child is 23 throwing something or start drinking or -- or nagging at 24 everybody. 25 And -- but that -- those -- those parents,


1 they need help. They -- sometimes they don't want to 2 hear anything, but they -- they need help when -- that's 3 how -- how hurting they are. They usually say that the 4 baby's gone, why -- why do they have to open the baby 5 and -- and look inside them, because they don't und -- 6 they don't understand why they -- they are doing that. 7 If -- if the baby was -- it caused by something else, or 8 -- or the parents are doing that, so that we don't -- we 9 don't like -- know exactly. 10 And I was -- I was trying to explain to 11 that woman when he -- she didn't want to let the baby go, 12 but I -- I talked to him and -- because that baby -- I 13 was -- I was trying to do my CPR on the baby but the baby 14 was already blue. And I don't know when he -- when he 15 was start -- when he stopped breathing. That was first 16 thing in the morning. 17 And those parents are really devastated 18 for losing a child, and on top of that if they're gonna 19 take the baby out and -- and open -- open the baby up and 20 they get more hurt. And... 21 MR. WALLY MCKAY: Thank you very -- thank 22 you very much. (OJI-CREE TONGUE SPOKEN) 23 I thank you very much on behalf of the 24 Commission. (OJI-CREE TONGUE SPOKEN) 25 ELDER ELIZABETH MAMKEESIC: Meeqwetch.


1 MR. MARK SANDLER: Thank you so much. 2 You can either remain there for the next roundtable or 3 you can have a seat in the audience. 4 5 (BRIEF PAUSE) 6 7 MR. MARK SANDLER: Commissioner, I'm 8 going -- 9 ELDER ELIZABETH MAMKEESIC: Excuse me, 10 they want me to stay? This for them. 11 MR. MARK SANDLER: We're -- we're happy 12 to have you there. That's good. Okay. 13 Commissioner, we're going to turn to our 14 next roundtable discussion and it's entitled "Barriers to 15 Pediatric Forensic Death Investigations in Remote 16 Aboriginal Communities". 17 And if I can introduce the participants to 18 you. to your far left is the Deputy Chief, John Domm. 19 He is the Deputy Chief of Police for the Nishnawbe-Aski 20 Police Service. This is the largest First Nation Police 21 Service in Canada. He is based in Thunder Bay, Ontario, 22 and he oversees staff and operations at thirty-eight (38) 23 different locations across Northern Ontario. 24 The Deputy Chief has a Bachelor of Applied 25 Arts from the University of Guelph and a college diploma


1 in law and security administration from Georgian College. 2 Prior to joining the Nishnawbe-Aski Police Service, he 3 spent nearly seventeen (17) years, I believe, with the 4 Halton Regional Police Service, and he specialized in 5 criminal investigations which led him to be involved in 6 handling a number of homicide cases while he was with 7 that service. Welcome, Deputy Chief. 8 Beside Deputy Chief Domm is Dr. David Eden 9 who you're well familiar with from previous roundtables 10 and testimony at our Inquiry. For those who are watching 11 for the first time today, Dr. Eden is the Regional 12 Supervising Coroner for the North Region. He was 13 originally appointed a coroner in 1992, became a regional 14 supervising coroner for Niagara in 1998, and recently 15 assumed his current position in North Region. Welcome 16 again, Dr. Eden. 17 I'd next like to introduce Chief Connie 18 Gray-McKay. Chief Gray-McKay is the first female chief 19 of her community of Mishkeegogamang Ojibway Nation and is 20 in her second term after being re-elected in July of 21 2007. Prior to becoming Chief, she held the positions of 22 councillor, head councillor, and was the community's 23 education director. 24 She is a wife and mother to six (6) 25 children, somehow finding the ability and time to balance


1 work and family. She values her community members who 2 have stood by her side and who believe she could 3 represent them locally and outside as chief. 4 And I should say on a personal note that 5 the Commissioner and I had the opportunity to visit her 6 community and well -- and were very much made welcome by 7 her community and very much impressed by her tremendous 8 devotion to her people. So welcome, Chief. 9 And last but not least, I'd also like to 10 introduce Chief Vern Morris. We also had the benefit of 11 visiting Chief Morris's community in Muskrat Dam and were 12 also very much well received by his community when we 13 were there, for which we were very grateful. 14 This is Chief Morris's fourth term as 15 chief and he's been involved with the leadership of his 16 community for the past twenty-six (26) years. 17 And for those who do not know, Muskrat Dam 18 First Nation is a fly-in community of approximately three 19 hundred and seventy-seven (377) people -- you can tell me 20 if I have that number right -- located 252 miles north of 21 Sioux Lookout in Northwestern Ontario. 22 Good morning, Chief Morris, and, again, 23 thank you for joining us. 24 25 PANEL 1 - BARRIERS TO PEDIATRIC FORENSIC DEATH


1 INVESTIGATIONS IN REMOTE ABORIGINAL COMMUNITIES: 2 3 JOHN DOMM 4 DAVID EDEN 5 CONNIE GRAY-MCKAY 6 VERNON MORRIS 7 8 QUESTIONED BY MR. MARK SANDLER: 9 MR. MARK SANDLER: I'm going to start, if 10 I may, with Deputy Chief Domm. And, Deputy Chief, we 11 want to get some sense of what happens from the police 12 perspective in Nishnawbe-Aski Nation when a -- a baby 13 suddenly and unexpectedly dies, particularly in some of 14 the remote communities that we've heard about and -- and 15 have visited, such as a fly-in community within your 16 jurisdiction. 17 So can you take us through the police 18 involvement in those kinds of cases, the -- and the 19 interplay with the community and with the Coroner's 20 Office. 21 DEPUTY CHIEF JOHN DOMM: Certainly. 22 Thank you. As discussed, we are in small isolated remote 23 communities in Northern Ontario, and as a result our 24 staffing levels are also relatively restrained. 25 So in many communities we regrettably only


1 have one (1) officer, in others we may have two (2), and 2 in a select few, we have several. However, they're not 3 always working at the same time, so our ability to police 4 the communities are strained. 5 And in these circumstances, 1), it's a 6 very serious event, and it's a very difficult event, and 7 it's quite pronounced in the community when it involves a 8 child, as in any community, quite frankly. 9 So it's a -- it's a very trying encounter 10 for our officers to deal with and -- and the officer, but 11 in a small community, they are the only go-to person, 12 essentially. They are the -- quite often, the only 13 emergency responder in the community, and it -- places a 14 significantly tall order upon them, so they would be the 15 first responder in any sudden death of this nature, and 16 quite often, they would be on their own with some ability 17 to call in a second or subsequent first responders. 18 Now, as a first responder, they have 19 limited expertise in death investigations is the first 20 challenge, but they have a number of demands placed upon 21 them when initially dealing with this type of call. It's 22 emotionally charged, clearly. You have immediate and a 23 periphery family on scene, so you're dealing with a 24 multitude of adults that are related to this particular 25 child or infant, and of course, that poses a number of


1 challenges. 2 Beyond that, they have job to do, 3 essentially, and of course, you've got your preservation 4 of life is first and foremost; unless it's obvious, you 5 have pronouncement of death issues to deal with. 6 The officers also have to be concerned 7 with the collection of evidence at the particular scene, 8 security of the evidence, continuity of that evidence, as 9 well as, you know, the preliminary investigation usually 10 will demand on some key questions that need to be 11 addressed and -- and answers that need to be captured in 12 those first hours of the investigation in order to secure 13 those -- those answers, and that's going to drive the 14 investigation thereafter. 15 So for one (1), maybe two (2) officers, if 16 you're fortunate enough to deal with the family liaison 17 issues, to deal with the security evidence at the scene, 18 perhaps a bedroom or what have you, the collection of 19 other physical evidence, and of course, interviews of -- 20 of key individuals that play is a lot to deal with, as 21 well as the coordination of additional resources to come 22 into the community to assist. 23 And we do have trained investigators 24 throughout the organization. We're structured sort of an 25 east, northeast, and northwest type of division across


1 Ontario and each sort of region, if you will, we do have 2 trained investigators who can handle death 3 investigations, who are equipped to handle death 4 investigations. 5 Quite often in these cases, we will also 6 request the services of the OPP to join us. It's -- any 7 death needs to be treated seriously, and we need to put 8 in the appropriate resources, up front, in order to 9 secure evidence, essentially, and come out with the 10 determination of facts, so we do call upon the OPP to 11 assist us. 12 The reality of it is is we have a lag in 13 time from the first responder attending to the call and 14 dealing with a multitude of issues until such time that 15 additional resources can be put together, coordinated, 16 and respond via aircraft. You're quite often talking 17 several hours. In some cases, depending on weather, as 18 we've heard, the delay can be quite substantial. 19 Again, this puts added strain on the first 20 responders, and it ultimately effects what type of 21 evidence and information we collect and the quality of 22 information that we can collect as a first responder. 23 The other challenge that our officers face 24 in dealing with these types of investigations is, I -- I 25 already mentioned the pronouncement of death is one (1).


1 Coroners -- I don't think in my short time 2 with NAPS, I haven't seen a coroner, or heard of a 3 coroner respond to a scene -- to a remote scene. My 4 understanding it's done via the telephone. 5 But a more difficult aspect is the 6 location of the deceased. Where will that be? On 7 occasions, a particular scene would be held down, perhaps 8 in the home itself -- in the bedroom itself, if that's 9 possible. 10 That's not always possible. There are 11 occasions when the decedent needs to be removed from -- 12 from the scene, and quite often when we're called, the -- 13 the decedent's already moved from the scene. And the 14 only facility in the remote communities are nursing 15 stations, and that's typically where we'll deal with 16 these types of investigations, is in the setting of a 17 nursing station. 18 How they get from point A to B varies. 19 And it's a challenge for our officers because, of course, 20 1) there's no body removal services in the north; 2) 21 there are very few communities that have ambulatory care. 22 So in some -- or in urban centres, you 23 quite often will have somebody that perhaps is -- is 24 ultimately transported via ambulance, although that's not 25 -- normally that -- the case when death is known, and


1 confirmed right off the bat, but it does, and can happen. 2 So the -- the transportation of -- of a 3 decedent can be -- can be difficult and a challenge for 4 our officers. And of course, once in the nursing 5 station, we must keep in mind that this is, in many 6 cases, one (1) officer. 7 So how does the officer maintain security 8 of the decedent, and continuity of the decedent to ensure 9 that they're not handled, or -- or anything of that 10 nature, as well as maintaining and securing continuity of 11 the actual scene, where the -- where the child last -- 12 last rested? 13 And of course, how does this one (1), or 14 two (2) officers also collect the evidence from the key 15 witnesses, and other -- any other physical exhibits that 16 may exist? 17 So this functions somehow generally, and 18 largely, our officers are very talented, but there - 19 there are limitations, clearly. And it -- the end result 20 is, I -- I guess, deterioration of the quality of work 21 and information that they can actually gather. They do 22 do the job. They do get it done, but the quality of 23 information is hampered by a lack of these resources. 24 The investigation -- once we have the 25 investigators attend the scene, of course, that frees up


1 the first responder. 2 The collection of evidence is improved, 3 providing they get there. Of course, again you have the 4 lag in time, and communication commences more in depth 5 with the coroner's office and determination of what is 6 going to transpire with the decedent. 7 We also have, of course, coroner's 8 warrants issues that would be addressed via telephone and 9 facsimile. And beyond that, we all -- we have the issues 10 of again transportation of the decedent from the 11 community to a facility where an autopsy is going to be 12 performed. 13 When we get to that point, we have the 14 issues again of what method are we going to transport the 15 decedent in. What -- what type of measures, or what 16 physical properties do we have for that transportation? 17 They're not readily provided, and we don't 18 readily have them with us, and that can be an issue. 19 And, of course, if the officer -- normally 20 an officer would attend with the decedent to the urban 21 centre for the autopsy, and with that, 1) it creates some 22 difficulties with the fact that now their -- maybe their 23 only policing respond -- or policing service may be 24 removed from the community to attend with the deceased. 25 And it's a matter of, you know, can we do this better?


1 Is this a requisite, for one? Are there other ways to 2 transport the decedent that we can secure or be confident 3 with the security and continuity issues? 4 But beyond that it's -- the next stage 5 would be dialogue with the pathologist. And I guess at 6 this stage we -- we clearly communicate with pathologists 7 with respect to what -- what information we know, what 8 information we have at that point in time. 9 And I know on the roundtable draft one (1) 10 of the discussions and topics is how much information do 11 we provide? should we be providing it directly to the 12 pathologists? In what form should we be providing that 13 information? Should that information, that dialogue, be 14 recorded? How should that be recorded? Should there be 15 parameters on what types of information we provide to the 16 pathologists? And what are the limitations in that 17 regard? 18 That's briefly the chronology of some of 19 the scenarios that we may deal with in the -- in the 20 remote north and how the flow of an investigation would - 21 - would occur. 22 Post-autopsy, the families usually get 23 involved and -- and burial issues are -- are addressed at 24 that point in time. 25 COMMISSIONER STEPHEN GOUDGE: Can I ask


1 just a couple of questions, Deputy Chief? You have an 2 officer in every community, at least one (1)? 3 DEPUTY CHIEF JOHN DOMM: Regrettably 4 right now we are short officers, and I know that we have 5 a couple of vacancies across the north? 6 COMMISSIONER STEPHEN GOUDGE: In a couple 7 of communities? 8 DEPUTY CHIEF JOHN DOMM: Correct. 9 COMMISSIONER STEPHEN GOUDGE: And what 10 would be the normal posting in a community? How long 11 would an officer be there? 12 DEPUTY CHIEF JOHN DOMM: Well, we hire 13 our officers for a full career as -- 14 COMMISSIONER STEPHEN GOUDGE: But are 15 they kept in the same community or are they moved from 16 community to community? 17 DEPUTY CHIEF JOHN DOMM: They can 18 transfer, and quite often do transfer. Some officers 19 will remain in a community if it happens to be their home 20 community for quite some time. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 DEPUTY CHIEF JOHN DOMM: And that's 23 certainly not the majority of the case with our work 24 force. 25 COMMISSIONER STEPHEN GOUDGE: Right. And


1 are the officers in the community equipped or able to 2 take photographs of scenes, for example? 3 DEPUTY CHIEF JOHN DOMM: Yes, they are 4 all provided with digital cameras now -- 5 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 6 DEPUTY CHIEF JOHN DOMM: -- so for 7 immediate capture of -- of scenes and some evidence -- 8 fleeting evidence we can capture that. 9 COMMISSIONER STEPHEN GOUDGE: And is 10 there any facility to transmit the digital imaging from 11 the communities to Thunder Bay or elsewhere? 12 DEPUTY CHIEF JOHN DOMM: We do have -- we 13 are connected via internet across all of our communities. 14 They -- regrettably the internet does go up and down 15 sometimes in the north, and we have a variety of 16 different scenarios of how the internet is provided. 17 In some circumstances, some communities 18 we've had difficulties with -- with the service, and 19 we've gone to our own satellite systems in order improve 20 the consistency of that service. 21 COMMISSIONER STEPHEN GOUDGE: Right. 22 Then you talked about your own investigating officers, 23 are they based in Thunder Bay? 24 DEPUTY CHIEF JOHN DOMM: No, the 25 investigators are based in Sioux Lookout, which is our


1 Northwest Regional Office. 2 COMMISSIONER STEPHEN GOUDGE: Mm-hm. 3 DEPUTY CHIEF JOHN DOMM: And they work 4 out of Sioux Lookout, and when they need to respond 5 they'll respond to a satellite community from there. On 6 the northeast side our investigators are based in 7 Cochrane. And again, they'll do the same thing. They'll 8 leave Cochrane to a satellite community. 9 COMMISSIONER STEPHEN GOUDGE: And they 10 would get to the community by charter? 11 DEPUTY CHIEF JOHN DOMM: By charter 12 and/or our own plane and/or sched. 13 COMMISSIONER STEPHEN GOUDGE: Does NAPS 14 have a plane? 15 DEPUTY CHIEF JOHN DOMM: We have a -- a - 16 - yes, one (1) designated plane to our -- that's made 17 available to us. Quite often we have multiple demands in 18 one (1) day so -- 19 COMMISSIONER STEPHEN GOUDGE: I'm sure 20 that's right. 21 DEPUTY CHIEF JOHN DOMM: -- so we'll 22 utilize our main plane. We'll also charter a different 23 plane from another company and on other occasions we may 24 use sched -- scheduled flights. 25 COMMISSIONER STEPHEN GOUDGE: Right.


1 Right. Thanks very much. Thanks, Mr. Sandler. 2 3 CONTINUED BY MR. MARK SANDLER: 4 MR. MARK SANDLER: Just one (1) other 5 question, Deputy Chief, before I turn to your fellow 6 panellists. We've heard that Nishnaw -- that NAPS 7 doesn't have it's own forensic identification unit. 8 Is that right? 9 DEPUTY CHIEF JOHN DOMM: That is correct. 10 MR. MARK SANDLER: So -- so in cases that 11 are suspicious deaths or -- or homicides, would -- would 12 those inevitably mean that -- that the OPP would -- would 13 have to be brought in to do the forensic identification 14 component of the investigation? 15 DEPUTY CHIEF JOHN DOMM: That's correct. 16 We do not have a full time forensic identification unit. 17 We have a number of trained officers that are called 18 Scenes of Crime Officers. And that's at a -- a lower 19 level of expertise. But they take photograph work and 20 impressions, the time that -- the proper handling and 21 collection of different types of evidence. So they are 22 and can be often dispatched to these type of incidents. 23 But when they're not available -- and 24 training can be an issue. I have a class running right 25 now for I believe seven (7) officers because we have a


1 sever shortage, and with thirty-five (35) communities 2 it's difficult to provide adequate levels of training and 3 -- or expertise in each of the thirty-five (35) 4 communities. So we -- we sort of pool it in some 5 instances and/or pick locations where there's high demand 6 and we'll try to train in those locations so we have the 7 resources available to us. 8 But when those conditions aren't met, yes, 9 we do quite often rely on the OPP to supplement our 10 investigations and provide forensic identification 11 services. And for any suspicious death or homicide that's 12 conducted we do rely on their full time identification 13 unit to attend our communities to augment the 14 investigation. 15 MR. MARK SANDLER: When a child is taken 16 to Toronto, for example, for -- for an autopsy -- and 17 we've heard that's where the -- the pediatric cases make 18 -- make their way, either to Toronto or -- or to Winnipeg 19 -- would the NAPS officer accompany the body to Toronto 20 or to Winnipeg if the OPP Forensic Unit is also involved? 21 Or would there be some combination of the two (1)? Or 22 can you help us out as to that? 23 DEPUTY CHIEF JOHN DOMM: It would really 24 vary on the specific case by case basis. Ideally one (1) 25 officer for sure, either a NAPS or an OPP officer. I


1 suppose it would come down to how much information that 2 OPP identification officer would actually possess. 3 So if it was a NAPS officer that was 4 conducting the investigation, was first on scene, made 5 certain observations, collected certain evidence, 6 interviewed key individuals off the get-go and received 7 certain, you know, key pieces of information from 8 individuals that NAPS officer would be more appropriate 9 to attend and relay that information to the attending 10 pathologist. 11 MR. MARK SANDLER: If I can turn to Chief 12 Gray-McKay. We're -- we're talking about the horror of 13 sudden and unexpected deaths of children in -- in 14 communities, and -- and unfortunately that -- that's an 15 event that's -- that's all too familiar to you, I know. 16 Could you describe what transpires in your 17 community when a child suddenly and unexpectedly dies. 18 And perhaps you could provide the Commissioner some 19 insight as to what barriers might exist to -- to the way 20 in which an investigation into those sudden and 21 unexpected deaths occurs. 22 CHIEF CONNIE GRAY-MCKAY: First of all 23 I'd just to acknowledge the creator, acknowledge the 24 drum, and also acknowledge the passing of one (1) of our 25 Elders in our community this morning. And I'm grateful


1 to be here to have some input into the discussions on the 2 traumatic loss of our children in our -- in our 3 communities. 4 One (1) of the things that -- that's very 5 clear to me in -- in the loss of a child or any -- any 6 loss is that we are talking about a foreign judicial 7 system that our people have to work within. So that is 8 one (1) of the challenges still for us as a people, is to 9 under -- is the implementation of a system that -- that 10 doesn't work for us, because it's a system that's 11 punitive, and it's a system that we have a very -- that 12 our culture and our ways of doing things in the event of 13 a death, and especially that of children, as traumatic as 14 it is, we have a very difficult -- difficult dealing 15 with. 16 And the reason why I say that is because 17 our ways, as you heard from the Elder, our ways are 18 different when -- when someone dies and -- and it really 19 points to the fact that one (1) of the barriers that I 20 see is that there needs to be a real education and 21 awareness around the system, and especially that of 22 investigations. 23 And that in itself is a barrier because 24 it's very pronounced when you -- when you talk about the 25 process that needs to be initiated when there's a death


1 of a child, or a death of anyone in the community, 2 because they're talking about a system that's here and -- 3 and our system. 4 And we know that there's a job that has to 5 be done. So there's a real need for an education and 6 awareness, and I think the only way that that an actually 7 be done properly is that you start to begin to capacity 8 build on the -- on the people that are in the 9 communities. 10 You build on those -- on those persons who 11 are capable, because we have people in our communities 12 who have the gifts that could provide supportive services 13 to the NAPS, because as you know, there is geographical 14 challenges, challenges with weather, challenges of 15 securing scenes. 16 And we all -- the serious assumption is 17 made that the services that are provided to Aboriginal 18 people, especially Northwestern Ontario, is that of all 19 Ontarians. 20 Well, truth be told, it isn't. As you 21 heard from the -- the Elder, and as -- from NAPS, many 22 times there is no attending coroner in our Communities. 23 I've been in leadership for thirteen (13) 24 years, and testimony from the former Chief, there's never 25 been any coroners. And in my community alone, I can


1 attest that since 1981, we've had two hundred and thirty- 2 three (233) deaths, and never has there been an attending 3 coroner. 4 So there has to be -- if we're talking 5 about fixing a system, that would be a mis -- a misguided 6 question, I guess. 7 We're talking about developing a system 8 that doesn't exist now. It's -- we need to develop a 9 system, within our communities, that provide supportive 10 services through the Coroner's Office, because we know we 11 have people in our communities who can do that job. 12 And especially in the fact that not only 13 is it police officers that are under-serviced, we're 14 under-serviced in many respects; nurses, doctors, 15 specialized services for children, in every respect. 16 And I think it's always been assumed that 17 we have all these services that the rest of Ontarians 18 enjoy. We don't, including all the other factors that 19 would affect the quality of life in our communities. 20 And the reason why I talk about to touch 21 on the quality of life is, if when you're talking about 22 investigations, one (1) of the barriers may be that in -- 23 in preventive services, prenatal care of the mother. 24 Was the child at risk before it was born? 25 So those are the kind of things that many people in other


1 -- in other towns and cities, take for granted. 2 We don't have the same type of prenatal -- 3 prenatal care that you have in -- in other communities, 4 because of the barriers of the -- the geographics, and -- 5 but that's -- those are some of the -- the thoughts that 6 come to my mind when you're talking about barriers. 7 There is many. There's cultural barriers. 8 In -- in a traumatic death in a community, one (1) of the 9 things that our culture really supports is -- life is the 10 ultimate most important thing, and especially that -- 11 that of a child. That's a gift to a community. 12 And one (1) of the things that needs to 13 happen for every person is -- is to take that time to 14 make the respect to the family. And many times in the 15 event of a death, everyone will go to that scene. 16 Everyone will want to be there with the family because 17 that's our way. 18 That's our way. Even if without words, 19 just to be there in presence. Even just to touch that 20 person, and shake their hand because in the shaking of 21 hands, there's a transmission of your expression of love 22 and compassion for that person, and that's the kind of 23 people we are. 24 And -- and that's one (1) of the things 25 that I strongly recommend, is that, you know, by


1 developing the people within the communities to be 2 investigative supports to the NAPS, that cultural 3 awareness needs to take place. 4 And the only people that are -- I really 5 believe that are -- have that ability to do that is those 6 who understand the culture. It needs to be a culturally 7 appropriate approach because we're talking about death in 8 itself is traumatic but even more pronounced, when it's a 9 death of a child. Meeqwetch. 10 MR. MARK SANDLER: Thank you, Chief. I'm 11 -- I'm going to turn to Chief Morris, and I'm going to 12 ask you a very similar question that I asked Chief Gray- 13 McKay and that is, could you give us your perspective on 14 the barriers that exist in the investigation of sudden 15 and unexpected deaths in a community such as yours? 16 CHIEF VERNON MORRIS: Chief Connie Gray 17 has made all the appropriate acknowledgements from the -- 18 from the onset of our gathering here. Thank you, Chief. 19 I would like to ask you to repeat that 20 question. Could you -- the last portion of it, I 21 couldn't hear. 22 MR. MARK SANDLER: Sure. I'd be 23 interested in -- in you describing, for the Commissioner, 24 what you see as the barriers that exist to an effective 25 investigation of -- of a death of a child in a community


1 such as yours. 2 CHIEF VERNON MORRIS: I guess it's a wide 3 open -- a wide open field for -- for coming to a -- 4 coming to describe certain barriers because of the fact 5 that, very much in the same way Chief Connie Gray has 6 stated, that we are not aware of any services that are 7 available that would work to that end in determining a 8 certain death -- investigating certain deaths within -- 9 within my community anyway. 10 If there was a service that ever did 11 exist, we were certainly not made aware that there was, 12 and we are not aware of it. So that is one (1) of the 13 barriers I see. One (1) of the barriers is communication 14 and the recognition -- the recognition of the fact that 15 First Nations, too, are very capable in participating and 16 giving support to services -- to services that could be 17 meant to, you know, to support life and quality of life 18 in their own -- in their own respective communities. 19 We -- we have -- we have challenges living 20 on -- there are many challenges in the north in all areas 21 of our development; in our social development, in our 22 physical infra-structural development and spiritual and, 23 you know, health and education and so on and so forth. 24 And there are a lot of barriers, even for 25 us at the community level. And, as a result, when


1 addressing these barriers, we have a lot of very capable 2 people who care about the communities and who care about 3 the quality of life in the communities. 4 And we have our own local people that had 5 come forth and have been identified prior to -- prior to 6 any event in the community. If there is an emergency or 7 a crisis, we have certain people in the community that 8 come forth and give -- and give support to the existing 9 services that we may have. 10 So in addressing barriers, we too, as 11 First Nations people, in our own communities, local 12 people, move towards giving support to our community. 13 Communication is a barrier. Communication 14 is -- and distance. Distance of the service provider 15 would -- would be a barrier, and, you know, the 16 culturally appropriate approach -- approaches to 17 addressing certain -- certain problems. And in this 18 instant, you know, the pediatric forensic death 19 investigations that I am not aware have existed or having 20 ever been in existence in my community, that is a 21 barrier. 22 So the different types of services that 23 are supposedly -- that do supposedly exist to support all 24 Ontarians, First Nations included, those types of 25 services that we are entitled to, that is a barrier.


1 The -- the communication, the awareness 2 and the education that is required to take -- to take 3 advantage and also to assist in -- in creating an 4 environment where the services are made readily available 5 for our -- you know, for my community, for other 6 Aboriginal communities like mine. 7 MR. MARK SANDLER: Thank you. Dr. Eden, 8 I think what -- what you're hearing is -- is somewhat of 9 a -- of a common theme, and -- and communication seems to 10 be a centrepiece of -- of some of the things that are 11 being said. 12 We -- we heard from the Elder that members 13 of the community don't want their baby cut up or -- or 14 autopsied, and -- and there may be communication issues 15 around when that should take place and -- and why it's 16 taking place. 17 You've heard from -- from two (2) chiefs 18 in Nishnawbe-Aski Nation that express concerns about 19 either the unavailability of services or lack of 20 communication about what services are available. 21 And of course, we've heard the 22 difficulties in -- in coroners not coming to -- to the 23 scenes when -- when deaths occur. What do you see the 24 appropriate response to those kinds of barriers or 25 concerns that have been articulated? What can we do


1 about these issues? 2 DR. DAVID EDEN: Now, first of all, I'd 3 like to thank the other panellists. I've been listening 4 closely. I had -- I was, of course, aware of these 5 issues, but I'm much clearer on them, and I look forward 6 to working with you in the future on -- on addressing 7 them. 8 But in a specific way, I think what's come 9 out in evidence, at yesterday's roundtable and today's, 10 is that circumstances of the north are materially 11 different from what occurs in southern Ontario. 12 And as the Dean of the medical school said 13 yesterday, the -- the way to deal with that is not to 14 take the sudden approach of an urban -- a society with 15 urban density and transplanted unchanged to the north. 16 It's to say, How do we address the needs of the 17 community? 18 And so to me, the -- and again, this is 19 something I mentioned yesterday, what we should be doing 20 is say, What -- is saying, What are the goals of what 21 we're doing, which is to -- and we go back to the -- the 22 Ontario Law Reform Commission report that founded the 23 Coroner's Office -- we are first trying to accurately 24 determine the facts surrounding a death. 25 And then -- and this a real strength of


1 Ontario -- if we look -- if we compare it to other 2 jurisdictions, we take those facts and say, What can we 3 learn to prevent future deaths? So the first step is to 4 accurately determine the cause of death and the manner of 5 death that they -- the question is then based on that, 6 see what we can do to prevent future deaths. 7 So the question to me would be how do we 8 do that while maintaining the same quality provincially? 9 And I think the goal should be that we are maintaining 10 the same quality, provincially, while recognizing that 11 the process we follow, the actual steps may be slightly 12 different. The goal is the same quality; not the same 13 process, but the same outcome of quality. 14 I -- I was moved by Elizabeth's 15 presentation. Children should not die before their 16 parents. It's devastating. It's devastating for the 17 parents, for the family, and for the community. 18 And as she mentioned, guilt is something 19 that follows a child's death whether or not the parents 20 did anything at all to cause a child's death. In every 21 society, parents feel guilty, and the broader family 22 feels guilty when a child dies, and I've seen that 23 myself. 24 I was passing a cemetery and saw a small 25 casket, and I felt guilty. We -- as a community, we all


1 feel responsible for the welfare of children, so that -- 2 that's the way we are as humans. 3 And she spoke very openly, as well, as 4 about -- about the consequences of a child's death. And 5 we know that the consequences of a child's death, besides 6 that guilt, can include mental illness like depression, 7 and it can include marital breakdown. 8 There's a lot of effects of a child's 9 death and certainly, our response to a child's death, as 10 a community, I would hope would be constructive to help 11 the family and the community through a difficult time, 12 and certainly, not to increase pain or increase the risk 13 of those other things which can follow. 14 The other thing I heard, though, is that 15 people do want to find the facts surrounding a death; 16 that parents do want to know what caused the child's 17 death and so do other people. 18 And as she mentioned and -- and everybody 19 is aware, that some, apparently, natural deaths of 20 children are not. They may be due to smothering. They 21 may be due to neglect. They may be due to homicide. 22 People know that. 23 And one (1) of the benefits of a well- 24 conducted investigation is that, at the far end of it, 25 there will be a reassurance to the family, and they can


1 reassure the community there has been a complete 2 investigation, and this child died of SIDS, and there was 3 no evidence that there was anything else that caused the 4 child's death. 5 So there's a value to a good death 6 investigation, and I think that should be maintained. 7 Another value is that when we do 8 autopsies, we sometimes find a medical condition in a 9 child which affects the health of the rest of the family, 10 and that's -- that's a benefit from autopsy. That's not 11 the primary reason we're conducting it, but it's an 12 important benefit that we get out of it that can help the 13 family's health. 14 There -- the concern I'm hearing relates 15 to communication and feelings. I -- I think I can 16 encapsulate to say that people do not feel they're always 17 being treated with respect. 18 And -- and I'm listening to this very 19 closely, and what I want to do as Regional Supervising 20 Coroner is work with First Nations communities to ensure 21 that there is good communication about what's happening, 22 and that there's certainly -- there may be a need for 23 further policy development here. 24 And, so that families are aware of why the 25 investigation is being performed, what the results are as


1 they come in, and -- and what those mean, in a way that 2 they can understand and work forward from. 3 As I mentioned before, we do not want to 4 gratuitously increase pain. This is a painful enough 5 time, so we have to be respectful of that. 6 That -- that's a factor in all pediatric 7 death investigations, but because of what happens in 8 Northern Ontario, because of transfers to distant cities, 9 and because of cultural language differences, I 10 acknowledge that this is a -- this is a -- an issue that 11 is greater in remote communities than in other 12 communities, and as such, requires being addressed as 13 much as possible. 14 But as we've heard, there can be weather 15 delays. There's flight routings and that. All of those 16 have to be taken into account, but it is useful if -- if 17 family knows on a day-by-day basis what's happening. 18 I -- I wouldn't want to be in a situation 19 where family haven't heard anything for a week. The 20 body's been moved. I -- I don't know if this has 21 happened, but I certainly wouldn't want to see it happen; 22 the family don't know on a regular basis what's 23 happening. And in addition to knowing what's happening, 24 they'll want to know what the results are, as I said, 25 throughout the investigation.


1 And taking into account burial practices, 2 is -- is very fair, and that's -- that's a -- a core 3 Ontario value; to -- to reper -- to respect that -- the 4 values of people. 5 Now the -- the autopsy decision is one (1) 6 that, in law, is made by the coroner, and in law, is made 7 by the coroner on the basis of public interest. 8 It -- it appears that there may be some 9 misunderstanding that the family can say there shouldn't 10 be an autopsy. The decision has to be made by the 11 coroner. 12 It does -- it should be made by the 13 coroner taking into account the family's wishes, but also 14 taking into acc -- account, the public interest. 15 And it's possible that may -- may be able 16 to develop policies there to assist people in 17 understanding the factors that go into the decision, and 18 to make sure that the decision is the appropriate one. 19 It -- it would not be right to order an autopsy where one 20 was not required. But if one is required, then we should 21 be doing it. 22 As I mentioned yesterday, having a person 23 on scene to investigate is valuable, and also from 24 Elizabeth's testimony, I think it's -- it's very valuable 25 to have a person on the scene to liaise with family about


1 the coroner's investigation. 2 I -- I am thinking about this. If my 3 child died, and my contact with the investigator was 4 exclusively over the telephone, it's not as good. I 5 would want to have somebody there who I could speak to. 6 Just in human grieving, personal contact is very 7 important. So I think part of our policy development 8 would be to see what we can do to ensure that there is a 9 personal contact for families. 10 With respect to Deputy Chief Domm's 11 comments, I -- I certainly respect the issues that he 12 deals with, and that as a investigating coroner, when I 13 go onto a scene of an infant death, there's usually been 14 about six (6) to ten (10) police officers involved. 15 There's a lot of demands, and those 16 demands, as he mentioned, include protecting the scene, 17 protecting the body, dealing with people who are 18 emotionally distressed, taking statements and so on. 19 There's a lot to be done, and again, this is an area that 20 we need to ensure is -- is appropriately addressed. 21 But as -- the -- infant death is common -- 22 or, sorry, is uncommon, and in a -- in a town -- in a 23 small town, it will be a rare event. So a police officer 24 serving a remote community will uncommonly see a child 25 death and that's something we have to take into account.


1 But as Deputy Chief pointed out, the 2 police officer can be in contact with a senior officer 3 who has more experience, as we -- as we do in the coroner 4 system, that a regional -- that an investigating coroner 5 who doesn't have much experience with child death 6 investigations can contact the -- the regional coroner. 7 One (1) issue that was mentioned was 8 pronouncement of death, and I wouldn't want that to 9 sidetrack us. In most cases in Ontario death is 10 pronounced before the coroner arrives. Death is 11 pronounced at the scene by emergency response personnel 12 which can include, in the north, a -- a nurse, a police 13 officer, or -- perhaps in consultation with a coroner, 14 but I'm not aware of any issues surrounding the logistics 15 of pronouncing death. 16 I -- I agree with Chief Mckay and Chief 17 Morris that there are issues surrounding education and 18 awareness of the coroner's system and how that meshes 19 with local communities. And I agree that's something 20 that we should work on together. 21 And the idea of using local capacity to 22 assist certainly makes sense to me. And one (1) way 23 would be, as I mentioned before, in the liaison with the 24 family about the unfolding of the coroner's 25 investigation, so there's somebody on scene who can


1 directly interact with the family would be very helpful. 2 The -- whether or not -- well we -- we 3 spoke yesterday about the coroner attending remote scenes 4 and the logistic -- logistic problems there. In the -- 5 in the questioning there and in my answer I was -- I 6 didn't -- I don't know whether I was explicit about this. 7 The question for me was how do we maintain the same 8 quality of investigation when the coroner can't be on the 9 scene? 10 Because the southern model is coroner goes 11 to the scene, and in remote communities there's 12 logistical barriers to having an experienced coroner on 13 the scene. So how do we get the same quality without a 14 coroner, and that is to have -- and my suggestion was 15 that there be police officers with training in specific 16 coroner's issues who would attend the scene. 17 The -- and that -- that to me is a 18 reasonable way to address it. The problem with having a 19 coroner on the scene who doesn't have training in volume 20 and background is an issue. 21 And I think it's important -- again saying 22 that our goal is to ensure quality death investigations - 23 - to make sure that there's somebody on the scene who has 24 the background, the training, the experience to do a -- a 25 sound coroner's investigation to the same quality that


1 would be done elsewhere. 2 And keeping those principles in mind, my 3 suggestion was a police officer with additional training. 4 We could look at other options, but I think it's got to - 5 - the -- the goal has to be quality. 6 To me it's -- it's not process. And if -- 7 if we're saying that they're -- that a coroner should be 8 at every death scene, I would say that that -- that may 9 not be logistically possible in that we can't 10 logistically get a coroner to every death scene. 11 But what we can do is ensure that the 12 investigation of a death at the scene will maintain the 13 same quality, bearing in mind that that may require 14 higher resources then it would in Southern Ontario. And 15 -- and I think there should be a commitment that the 16 quality will be the same even when it requires a greater 17 commitment of resources. 18 So in summary I -- I agree with the 19 concerns that have been expressed about communication 20 particularly, and I -- I wish to work with all the groups 21 involved to ensure that that is addressed as best we can. 22 And with respect to death investigations, my suggestion 23 would be that we aim for the highest quality of death 24 investigation and apply resources as necessary to achieve 25 that goal.


1 COMMISSIONER STEPHEN GOUDGE: Can I ask 2 Dr. Eden a couple of questions? How are the 3 responsibilities of your investigating coroners allocated 4 as between the communities across the north. That is, 5 where does the first responder call, I guess? Is there a 6 designated coroner that the first responder in a 7 community knows to call? 8 Is that the way it works? 9 DR. DAVID EDEN: Yes, they'll go to the 10 coroner in the nearest community and if that coroner 11 isn't available, they'll go to the next nearest community 12 geographically. 13 COMMISSIONER STEPHEN GOUDGE: And if I 14 look at the map and see where the yellow diamonds are, 15 you could really plot that out, I take it, for example? 16 DR. DAVID EDEN: Well, the -- the local 17 police will have experience. They'll have a -- 18 COMMISSIONER STEPHEN GOUDGE: They'll 19 know the line -- 20 DR. DAVID EDEN: -- existing coroner. 21 COMMISSIONER STEPHEN GOUDGE: -- of 22 communication. 23 DR. DAVID EDEN: Yeah, yeah. 24 COMMISSIONER STEPHEN GOUDGE: And as the 25 call comes in, is there any capacity in the coronial


1 service to get additional specialized backup from 2 coroners who may have had more experience? 3 Let's take the case of an unexpected 4 pediatric death, as you've said, not all investigating 5 coroners do that frequently. But is there a capacity for 6 the call to be routed or for advice to be obtained 7 elsewhere in the coronial system by the investigating 8 coroner and relayed to the -- to the first responder? 9 DR. DAVID EDEN: Absolutely. The -- the 10 investigating coroner can call the regional coroner 11 immediately. 12 COMMISSIONER STEPHEN GOUDGE: That's 13 where the call would go, I take it? 14 DR. DAVID EDEN: Yes, yes. And then this 15 being a specialized area, the regional coroner may call a 16 -- a person with more experience, such as a pediatric 17 pathologist, for further guidance. But the investigating 18 coroner is certainly not out there on their own. They -- 19 COMMISSIONER STEPHEN GOUDGE: Right. 20 DR. DAVID EDEN: They can and do call, 21 and I encourage them to call, for all infant deaths. 22 COMMISSIONER STEPHEN GOUDGE: And is it, 23 perhaps it's done now, but is it possible to think of 24 specialized training for the investigating coroners that 25 are on the frontline of the coronial response to the


1 death scene in these issues of communications, and so on, 2 that have been put forward? 3 DR. DAVID EDEN: I -- I would see that, 4 sir, as part of overall policy development. 5 And I think we should have a -- a flexible 6 system. In my limited experience already, I have met 7 some families who were quite happy dealing with me 8 personally over the telephone -- 9 COMMISSIONER STEPHEN GOUDGE: Right. 10 DR. DAVID EDEN: -- with a view to a 11 future visit sometime. Some families clearly preferred 12 to speak with someone in their community. And I would 13 say that, where possible, we should give the family 14 options and try to deal with that. And, certainly, 15 whatever education and training is necessary for 16 investigating coroners to carry out that function I would 17 agree should be provided. But I wouldn't want to say 18 that family must go to the coroner if the coroner can't 19 physically attend. 20 And I will say that my experience working 21 through a NAPS officer as liaison with -- with the family 22 has worked very well. I'm not saying that should be the 23 way it will be done all the time but it's a way that can 24 work. 25 COMMISSIONER STEPHEN GOUDGE: Thank you.


1 Thanks, Mr. Sandler. 2 3 CONTINUED BY MR. MARK SANDLER: 4 MR. MARK SANDLER: Deputy Chief Domm, 5 we've heard both today and in other roundtables and in 6 testimony that -- that the NAPS officers in the remote 7 north may serve as the surrogate for the coroner 8 attending at the scene. 9 And we've also heard today and on other 10 occasions that -- that there's a need for, whether it be 11 the coroner or -- or the police, to -- to have the 12 cultural sensitivity to deal with Aboriginal death 13 practices and to deal with all of the issues surrounding 14 the community response to -- to a death that has taken 15 place. 16 Do you see the need for additional 17 training of -- of your officers who are serving as the 18 first responders and sometimes as the substitute for the 19 coroner in these kinds of cases? 20 DEPUTY CHIEF JOHN DOMM: Thank you. We 21 do -- every new officer that is hired and comes to work 22 for our organization, we do an orientation with the 23 officer and it's usually about a week long following 24 their tenure at the Ontario Police College. And in that 25 session or orientation, we do try to cover as many areas


1 as possible and give them some background to the 2 communities, a history of the -- the NAN territory and of 3 its people, and some of the different considerations that 4 they need to take into account when -- when functioning 5 as police officers. 6 It's certainly by no means all inclusive, 7 and with thirty-five (35) different communities that 8 we're located in, there are differences from community to 9 community. 10 So in short, I would say yes, training is 11 always positive, and more training is -- is positive. As 12 -- as first responders, as quite often the only emergency 13 response in the community, they wear several different 14 hats, and the demands are quite significant upon them. 15 They are very varied and they require, you know, more 16 support, and more resources, and more training 17 ultimately, to be able to fulfill the roles that are -- 18 and demands that are placed upon them. 19 So I would agree that 1) you know, in -- 20 in part some cultural training would be of benefit as 21 well. We do -- or currently our workforce is only about 22 50 percent First Nation. We hire a lot of people from 23 urban centres across Northern Ontario, so our workforce 24 is quite varied, and diverse. So that -- it can be an 25 issue.


1 It can be -- there's definitely a need 2 that we need to improve upon as far as educating new 3 officers on the ways of the community -- the cultural 4 aspects of the community. 5 MR. MARK SANDLER: I'm going to ask you a 6 question that I'm going to ask all of the panellists at 7 this point, and -- and that is that we've identified some 8 of the issues, and challenges that arise in pediatric 9 death investigations in the north -- are there any 10 recommendations that you would urge the Commissioner to 11 make, or things on your wish list, that you'd like to 12 describe? 13 DEPUTY CHIEF JOHN DOMM: Nobody else is 14 jumping at this one, so I'll -- 15 MR. MARK SANDLER: Well, actually I -- 16 I'm directing it to you first. 17 DEPUTY CHIEF JOHN DOMM: You are still 18 directing it -- 19 MR. MARK SANDLER: I am. 20 DEPUTY CHIEF JOHN DOMM: Well, as I've 21 just mentioned, training is -- is key, and can help to 22 improve the flow of processes, the understanding of the 23 different complexities of the investigations, and 24 cultural aspects that we need to take into consideration 25 when -- when conducting investigations. So that -- that


1 is key. 2 I'm not so sure a protocol per se is 3 necessary. At times, they can be cumbersome. At times, 4 you can have too many protocols. I -- I generally try to 5 work those types of protocols, if you will, into policy 6 as a guide -- a guideline for officers on how to conduct 7 certain investigations, because protocols have a life to 8 them, a lifespan generally, and they need to be reviewed 9 annually, usually. And when we entrench things in 10 policy, it -- it tends to be more effective. But 11 something along that vein. 12 I guess, ultimately it comes down to 13 improved communication between different disciplines. 14 And what does this discipline need, and -- and how does 15 that interrelate with ours, and how do we ultimately 16 improve our operations. 17 The principle reality that we face across 18 Nishnawbe-Aski Nation, as far as the policing service, is 19 resources overall. Resources in -- in personnel, because 20 that is our key -- key issue. That's who we are. And 21 that's what a police service is; is human resources. And 22 it is a service industry and it comes down to meeting the 23 needs of the communities, then meeting the -- the demands 24 of our office through personnel. 25 And with so many communities, it's not


1 necessarily the size of the community, but it's the 2 number of the communities that we're policing. And then 3 being able to deliver a competent level of policing in 4 each of those communities is the challenge that we face. 5 This is one (1) aspect to policing; one 6 (1) of the -- one (1) of the many realities that police 7 officers must be able to perform, and hence it -- it 8 ultimately affects the quality of our service that we can 9 deliver. 10 MR. MARK SANDLER: Thank you very much. 11 Chief Gray-McKay, I'm -- I'm going to turn to you, and 12 ask you two (2) questions at the same time. I know that 13 you can handle them. 14 One (1) of them is that you indicated that 15 -- that you'd like the capacity of your community to be 16 drawn upon to address some of the barriers that we've 17 descried. And one (1) of the things that's been talked 18 about at this Inquiry is the possibility of having a -- 19 an Aboriginal liaison officer whose job it is to 20 coordinate communication between the Coroner's Office and 21 other components in the death investigation with the 22 community. 23 First of all, do you see that as a good 24 idea having a designated Aboriginal liaison officer? And 25 -- and the second question is the same that I directed to


1 Deputy Chief Domm, if -- if you had a wish list as to 2 what you'd like to see transpired to -- to im -- to 3 address some of the barriers that we've discussed today 4 and which will undoubtedly be discussed later today, as 5 well, what would be on your wish list? 6 CHIEF CONNIE GRAY-MCKAY: I guess it 7 would really depend on the definition of a liaison 8 officer because I think from, you know, looking at First 9 Nations people, we -- one has to understand that our -- 10 our history has that of an -- has that -- has been that 11 of a trauma. 12 And I think there's a real large bridge 13 that has to be built between First Nations and -- and a 14 non-native society going back hundreds of years, and I -- 15 I think we're talking about a foreign system, as I 16 mentioned before. To -- to bridge those kind of gaps, I 17 think it has to be a deeper route to be followed in order 18 to bridge those gaps that are -- are there. 19 And the reason why I say liaison officer 20 to me sounds like someone that's -- I would recommend, 21 more highly, people in our communities who could be 22 developed and trained that would help in an 23 investigations because we're talking about systems. Two 24 (2) systems meeting that don't understand each other, and 25 I think it's really important there has to be again that


1 awareness of -- of how the process is when there's a 2 death of anyone, especially that of children. 3 Because as -- why I always go back to the 4 history of trauma is that, you know, for many years our - 5 - our people didn't know their rights, and now that they 6 begin to know their rights, they want to be part. They 7 want to know what's happening in investigations, and 8 those are things that really need to happen. 9 And the only way that you begin to know 10 your rights is -- is to -- to have people educate you, 11 and that's why I really go back to the education and 12 awareness. Even the -- the coroner's services that are 13 virtually nonexistent, how do you begin to tell people 14 about -- that the service does -- that the service is 15 there, and the only way you can do that is by having 16 meetings, by having open houses. 17 And for people to know that, you know, 18 they have a right to ask these questions. For a long 19 time, our people didn't know that because it was a 20 suppressive -- suppressive en -- environment that our 21 people have gone through. 22 And there's actually a real huge mistrust, 23 and I know some bridges have been built -- have been, you 24 know, moved forward in terms of that trust, but there's a 25 great deal of work that needs to be done still.


1 And we don't -- our culture needs to be 2 incorporated into the -- the system of how we deal with 3 deaths in our communities, and the only way that can be 4 done is the consultation of our people and how you 5 conduct culturally appropriate investigations, and that 6 again can only be done by -- by those who understand it. 7 So one (1) of the things that I would 8 recommend in my wish list is that -- that there be 9 protocols with even the leaderships because, as -- as we 10 know, our leaderships, there have many challenges and -- 11 and many things that they deal with on a day-to-day 12 basis. 13 And one (1) of the things that 14 unfortunately we have to deal with, too often, is death, 15 and how do you keep the lines of communication open so 16 everybody's aware and how -- what is the process on 17 notifications when there is death? 18 So there is a real dire need on protocols 19 to be developed with the leadership, the people, the -- 20 the ones that are involved in the investigations, and the 21 coroner. There is that lines of communication that has to 22 be there and everyone in the on -- in -- involved has to 23 understand how that process works, the nurses and the 24 doctors. 25 And I think, too, there has to be --


1 there's a real strong need to educate people who come to 2 our communities about the history of Aboriginal people 3 and the effect of that traumatization of the history that 4 has occurred over the hundreds of years. 5 And I think, even for us, to understand 6 what has happened to us is -- is a learning thing because 7 a system that needs to happen when there's an 8 investigation is a further re-traumatization of -- but we 9 know it needs to happen. The investigation needs to 10 occur. 11 So if -- if people don't understand what 12 is happening, it re-traumatizes the -- the people. And I 13 think our Elder eloquently put that this morning when she 14 talked about people not knowing. Or why are they taking 15 my child? Or why are they taking my baby? Why did they 16 have to cut up my baby? 17 What she was talking about -- I felt what 18 she was talking about. I didn't hear it. I felt it, 19 because you hear that a lot. 20 So those -- those are my wish lists. 21 There's much work to be done, but I believe that this 22 Inquiry will come up with some real good recommendations, 23 and I think it's recommendations that come at a time that 24 Aboriginal people need to be heard, and they need to be 25 included in any process that's going to be developed,


1 especially when those services don't exist for our 2 communities. 3 And I'm grateful that I've had such a 4 small input in this -- in this area, and I'm grateful to 5 the Commissioner. I know that he'll do a good job. 6 Meeqwetch. 7 MR. MARK SANDLER: Thank you very much, 8 Chief. Chief Morris, I'm going to ask the same question 9 of you. 10 We've -- we've discussed briefly this 11 morning some of the barriers that exist. If you had a 12 wish list, what would be on your wish list? And I also 13 want to ask you a double-barrelled question at the same 14 time, and that is that one (1) of the things that's 15 obvious when one visits your community is how close-knit 16 the community is. 17 There's a lot of support in that community 18 for each other. So you, too, like -- like Chief Gray- 19 McKay indicated that the community should be involved in 20 -- in the investigative process. 21 So I'd be interested in your thoughts 22 about how you see your community being utilized to 23 address some of the concerns that have been identified. 24 CHIEF VERNON MORRIS: I guess in a -- in 25 a very broad sense maybe I can just share with you. I've


1 lived through the entire -- from the -- from the 2 beginning of Muskrat Dam to where it is now. 3 I have spent pretty much my entire life, 4 during that time, in the development of my community. 5 In the beginning we started out, and like 6 I say, with people with high spirits thought that we 7 would make -- we would develop a community -- we would 8 create a community; establish ourselves in that 9 particular territory. Throughout the years, we have not 10 access -- we have not had access to qualified 11 professionals. We have not had -- had access to any 12 services that the Province of Ontario provides. 13 So we have had to do with -- with the 14 talents, and the abilities, and the expertise of our own 15 people. And some ten (10) years ago, I started hearing 16 the term "para". Para what? Paralegal; para -- 17 paraprofessional, so on and so forth. 18 And we have had interested individuals in 19 the community take up that response -- you know, that 20 capacity. And it seems to have been working, you know, 21 for other areas of community development; in areas of 22 health, in areas of -- in areas of -- in -- where legal 23 assistance were -- were required; in -- in areas of 24 education, in areas of infrastructure, and you know, 25 community development in that sense.


1 You know, my wish list would say, Why not 2 -- why not train an individual, an interested individual, 3 in the area of investigations of -- of deaths, to assist 4 the coroner's office? 5 Each individual community should have an 6 independent investigator to work in partnership with -- 7 with Nishnawbe-Aski police services, or the Ontario 8 Provincial police. The idea of having a liaison person 9 that would cover a certain territory doesn't -- doesn't 10 really -- doesn't really do anything for me. 11 We have had similar -- we have had similar 12 arrangements in the past, you know, in terms of our 13 develop -- overall development in the north and they 14 really have not really served the purpose. So let's get 15 -- let's get this service on the ground at the grass 16 roots, at the First Nations grass roots, and that for me, 17 would be -- would be -- could be a reality. 18 It's not just a wish. It could very well 19 be a reality given the time and the resources to be able 20 to work with the service provider. 21 Thank you. 22 MR. MARK SANDLER: Thank you very much. 23 Dr. Eden, you're going to be continuing on other 24 roundtables this afternoon, so I'll give you the option 25 of either making some comments at this point or -- or


1 reserving them until we hear what else is said this 2 afternoon. 3 DR. DAVID EDEN: I can make -- make a few 4 comments now. And the -- the recommendations I've heard, 5 some to me are provincial in nature in that many of the 6 issues surrounding deaths in First Nations communities 7 that have been raised would apply equally in southern 8 Ontario as northern Ontario. 9 Some of them, and I would say more related 10 to service delivery, are specific to northern Ontario. 11 And I think I would summarize what I've heard on the 12 general issues surrounding deaths in First Nations 13 communities and -- and how those should be handled would 14 be to suggest that Ontario First Nations communities 15 should work collaboratively with the Coroner's Office, 16 police, and other agencies as appropriate to fa -- 17 facilitate high quality investigations and the 18 communication of results. 19 And one (1) of the -- one (1) of the sub- 20 text here is that the -- the Coroner's Office has a very 21 specific jurisdiction. It is simply to answer five (5) 22 questions and to make recommendations to prevent future 23 deaths, and that -- that is what the Coroner's Office is 24 -- is given the authority by the legislature to do. 25 I -- I think there may be a mis-impression


1 that the Coroner's Office controls every aspect of death 2 investigations including the medical consequences, the -- 3 the policing, and so on, and -- and that would be 4 incorrect; that the Coroner's Office has a very specific 5 job, and the -- and death can invoke a number of jur -- 6 of legal jurisdictions. 7 So the coroner is someone who responds to 8 a death. The police respond to a death. Ambulance 9 services and healthcare respond not only to the death, 10 but the healthcare system responds to the consequences on 11 the family afterwards, like depression or marital 12 breakdown. 13 The judicial system may be involved. 14 Professional governing bodies may be involved, and then 15 Ministry of Labour, Children's Aid. A lot of issues can 16 arise from a death, and I wouldn't want to suggest that 17 the Coroner's Office is in a position to direct other 18 agencies in how they should respond. 19 I think that we can look at our part of 20 things and ensure that it's done appropriately, and we 21 can work with other agencies to coordinate their 22 response, but I don't think it would be reasonable -- but 23 we just simply don't have a legal jurisdiction to 24 instruct other agencies about how to respond to a death. 25 And with respect to -- to service delivery


1 in the north, I would reiterate that we should look at 2 our goals and then look at how we can best deliver 3 services to ensure that those goals are met to the 4 highest quality. 5 MR. MARK SANDLER: All right, thank you 6 very much. Those are my questions. We're already 7 slightly over time, Commissioner. I understand Mr. 8 Falconer has some questions at the level -- 9 COMMISSIONER STEPHEN GOUDGE: How about 10 one (1) question, Mr. -- 11 MR. MARK SANDLER: Pardon me? 12 COMMISSIONER STEPHEN GOUDGE: How about 13 one (1) question, Mr. Sandler? We have a very full day 14 and we're already behind. 15 Mr. Falconer...? I just don't want to 16 take time away from other panels if I can avoid it. 17 18 QUESTIONED by MR. JULIAN FALCONER: 19 MR. JULIAN FALCONER: Thank you, Mr. 20 Commissioner. And thank you very much for the extremely 21 illuminating presentations. I am, of course, counsel for 22 Nishawbe-Aski Nation and Aboriginal Legal Services as a 23 First Nations coalition at -- at this Inquiry. 24 I wanted to direct, frankly, my questions 25 to the panel members, other than the Regional Chief


1 Coroner, and that's only because, Dr. Eden, Mr. 2 Commissioner has only given me one (1) question, so -- 3 and -- and I want to give -- 4 COMMISSIONER STEPHEN GOUDGE: It may have 5 parts, Mr. Falconer, but I really am anxious that we -- 6 MR. JULIAN FALCONER: Sure. 7 COMMISSIONER STEPHEN GOUDGE: -- move the 8 day along. 9 10 CONTINUED BY MR. JULIAN FALCONER: 11 MR. JULIAN FALCONER: That -- that's 12 fair. We, in the Inquiry process, of course, have 13 listened to evidence about these issues, and in 14 particular, the issue of -- of community resources and 15 relying upon the notion of a community-based 16 investigator. 17 And I wanted to ask you, Chief Gray-McKay, 18 and you, Chief Morris, and finally you, Deputy Chief 19 Domm, to address the -- the concern that I keep hearing 20 repeatedly, frankly, and I'd like to identify it, and 21 that is there is a -- there is a very significant concern 22 over the question of impartiality in small communities. 23 And I -- I thought that it's -- you know, 24 it's -- it's a legitimate issue because you have a very 25 small community and everyone knows everyone and the issue


1 is impartiality. And of course I heard Deputy Chief Domm 2 speak about some NAPS officers live in the community they 3 police. 4 So I was wondering if each of you could 5 speak to the issue of whether it's realistic to expect a 6 community-based investigator to be able to have the kind 7 of impartiality they would need to do the kind of work 8 you're talking about. Could each of you address that. 9 CHIEF VERNON MORRIS: I come from a small 10 community where everyone is related and everyone knows 11 everyone. So -- and we have a very -- a very progressive 12 community, very outgoing, and -- and we look forward to 13 the future in every respect. 14 We do -- as First Nations people or as 15 human beings in general, we have a belief system that 16 includes respect -- respect -- you know, -- respect, you 17 know, for each -- for each other. Other values and 18 beliefs that -- that are -- that we -- that we educate 19 our children on and ourselves, so on and so forth. 20 It's not very -- it doesn't have to be a 21 challenge to be impartial. It doesn't have to be a 22 challenge, you know, to -- to cite a conflict of interest 23 situation as a problem. In very many -- in very many 24 respects it can be -- the sharing of information can be 25 positive if -- if presented in that fashion.


1 So impartiality is something that, if you 2 want to keep a shroud a secrecy over a certain incident 3 or a situation then that could be a challenge in a small 4 community. If you want to keep a shroud of 5 confidentiality, like I said, it could be a challenge. 6 It doesn't have to be. Thank you. 7 CHIEF CONNIE GRAY-MCKAY: I mimic what 8 Vernon says because I think our communities, our way is - 9 - truth is one (1) of the virtues that we have. It's 10 very important for the truth to be known. And I think 11 our culture is based on having the creator who over -- 12 oversees us and then in the end of the day that's who we 13 have to answer to. 14 And I believe every -- our people can -- 15 can do the job just as well as anybody else. That the 16 inf -- the more information that's out there to bring the 17 truth out is healing. And it's -- it's a place that 18 we're -- we need to go as -- as a people, is the healing, 19 because for too long things have been hidden from us. 20 For too long we've been in a -- a guise of 21 darkness. And I go back to the histories again, it's the 22 same thing. But as our people begin to know their rights 23 and begin to know and set direction and to have a -- a 24 valued input, and the truth does come out. And I -- I 25 believe that the people can -- can do that.


1 And I think the more you -- these people 2 that you begin to educate and train that will all happen 3 because overall our values core based on our -- the one 4 that looks after us everyday then gives us our breath. 5 We acknowledge that. 6 And it's -- it's a core value that life is 7 sacred, and that -- and from the person that it's given 8 has all power over all of us. And I think it is innately 9 something that's -- a human sprit is that the truth -- 10 finding the truth is always important, that everyone -- 11 every culture strives for that truth, and every culture 12 has that -- it's a virtue. So with that, Meeqwetch. 13 DEPUTY CHIEF JOHN DOMM: And lastly, I 14 have no concerns with impartiality with our officers, 15 even if it is an officer that resides in the community. 16 There are other officers that participate in an 17 investigation that aren't necessarily directly connected, 18 so hence the -- that removes any concerns. 19 Furthermore, officers would excuse 20 themselves in any sensitive investigations that may occur 21 and they have done it and will do so in the future. 22 And lastly the fact that they're close to 23 the community only enhances the intimate information that 24 we can potentially garner from that particular 25 investigation. Thank you.


1 (BRIEF PAUSE) 2 3 MR. MARK SANDLER: Thank you very much. 4 Commissioner, that completes this roundtable. I want to 5 express my gratitude to all of the panellists who are 6 here. It's been a valuable exchange of information and - 7 - and I hope you'll be able to stay for the balance of 8 the day. Thank you. 9 Commissioner, if this would be an 10 appropriate time to take our fifteen (15) minute morning 11 break? 12 COMMISSIONER STEPHEN GOUDGE: What do you 13 think, should we try to shave a little time off that? 14 I'm in your hands -- 15 MR. MARK SANDLER: We can -- 16 COMMISSIONER STEPHEN GOUDGE: -- but I 17 really am anxious that we get full time with everybody 18 else too. 19 MR. MARK SANDLER: Why don't we aim for 20 ten (10) minutes then? 21 COMMISSIONER STEPHEN GOUDGE: Okay. And 22 let me before adjourn for ten (10) minutes then, on my 23 own behalf thank all four (4) of you very much for 24 coming. What you've imparted is very useful and I know 25 the thought you put into it, and so I am grateful. Thank


1 you for coming. 2 Okay. Well, lets break then if we can and 3 try to keep it to ten (10) minutes and then reconvene 4 with our next panel. 5 6 --- Upon recessing at 11:30 a.m. 7 --- Upon resuming at 11:45 a.m. 8 9 MR. MARK SANDLER: Commissioner, if we 10 can turn to roundtable number 2, which will examine the 11 limitations and impact of criminally suspicious 12 investigations in pediatric cases. And I'll call upon 13 Wally to introduce our two (2) panellists. 14 MR. WALLY MCKAY: Thank you very much, 15 Mr. Sandler. Mr. Commissioner, we have two (2) very 16 capable individuals on -- respected individuals in their 17 field of work in -- in this area. 18 First of all I'd like to introduce Mary 19 Jean Robinson, who completed a degree in political 20 science here in Lakehead, and followed by a law degree 21 from the University of Ottawa. She was called to a Bar 22 in 1989 and carried on a pra -- a private practice in 23 Thunder Bay until 2001. 24 And it's when she -- and then she joined 25 the staff of Nishnawbe-Ask Legal Services as Legal Aid


1 Area Director. She's also sat up and taught a third year 2 course in Aboriginal People and the Law at Lakehead 3 University. That is Mary Jean Robinson. 4 We also have Barbara Hancock, is -- who is 5 currently the Director of services for Tikinagan Child 6 and Family Services, working in Sioux Lookout, Ontario. 7 Tikinagan Child and Family Services provide child welfare 8 services to a third area remote First Nations affiliated 9 with Nishnawbe-Aski Nation. The agency received the 10 designation as a Children's Aid Society in April 1, 1987. 11 Barbara Hancock is a registered social 12 worker. She completed an honours bachelor in social work 13 from Lakehead University, Thunder Bay, 1980; Master of 14 Arts in Conflict Analysis and Management, Mediation 15 Certificate, University of Toronto. 16 She's the past chairperson of Trillium 17 Foundation, former chair of Keewatin District -- Patricia 18 District School Board, and former councillor of the 19 Municipality of Sioux Lookout. 20 Mark...? 21 22 PANEL 2 - CRIMINALLY SUSPICIOUS INVESTIGATIONS IN 23 PEDIATRIC DEATH CASES: 24 25 MARY JEAN ROBINSON


1 BARBARA HANCOCK 2 3 QUESTIONED BY MR. MARK SANDLER 4 MR. MARK SANDLER: Thank you, Wally, and 5 good afternoon. 6 Ms. Hancock, I'm going to start with you, 7 if I may. Your Child and Family Services engages in 8 activities that, I suspect, are very, very different than 9 your counterparts in Southern Ontario. 10 Can you give the Commissioner some sense 11 of -- of the role that you perform in the north and, 12 particularly, the kinds of activities that you'd be 13 involved in where a death has occurred of a pediatric 14 nature? 15 MS. BARBARA HANCOCK: Sure, thank you. 16 Tikinagan Child and Family Services has worked very hard 17 in the past twenty (20) years to develop a model of 18 service that is responsive to the communities that we 19 provide services in. 20 And, obviously, when we were first 21 designated, it was from more of a mainstream perspective. 22 And now, we have a service delivery model that we call 23 Mamow Obiki-ahwahsoowin, and that means everybody working 24 together to raise the children. 25 And our model is based on, not only the


1 mandate for the safety and well-being of children that we 2 get from the Child and Family Services Act, but it's 3 predicated on the inherent authority of the First 4 Nations. 5 So if we -- when we work with a family, we 6 receive our mandate jointly. We always work in close 7 collaboration with Chief and Council. Our workers, 8 before they begin to do their work, will go to the Band 9 office and will meet either with the Chief or the 10 Councillor with the portfolio for social services. 11 We also work closely not only with 12 families but also with extended families. And our case 13 conference scene under Mamow Obiki-ahwahsoowin will 14 involve case conferences that have representatives from 15 all of those different parties that we need to work with 16 in the community. 17 When there is a child death -- and I did 18 bring a few statistics just so that I could illustrate 19 the role that Tikinagan has when it comes to deaths, in a 20 community, of children -- we need to not only investigate 21 from a child protection sense if there's a child death, 22 but under the Ministry of Children and Youth Services, we 23 are required, under the directives for child death 24 reporting and review, to file a serious occurrence with 25 the Ministry and the Coroner's Office, and also to submit


1 a child fatality case summary report to the Coroner's 2 Office. 3 So to give you an idea of the number of 4 reports that we have submitted over the years to the 5 Coroner's Office, from 2003 to 2008, there have been 6 thirty-seven (37) child deaths. And these are just 7 deaths that involve Tikinagan. 8 And under the directives, it involves 9 Tikinagan by virtue of either the child who died was 10 receiving services from our Agency, or a child in a 11 family was receiving services from our Agency or an open 12 Family Services file. And even if the file was closed, 13 there's a window of twelve (12) months that we would need 14 to make these reports on. 15 So there were thirty-seven (37) child 16 deaths in the past five (5) years. Six (6) of those 17 deaths, the children were under the care of Tikinagan 18 Child and Family Services. And I must say that we will 19 have roughly five hundred (500) children in care at any 20 time, and we are rarely in court with a child protection 21 application. 22 Most of our work is -- the significant 23 majority of our work is done under Mamow through the 24 Chief and Council's declaration of a child in need of 25 protection. And we use an agreement that we call a


1 customary care agreement which is voluntary by all 2 parties. 3 So less than -- when we did something for 4 the Ministry of Children and Youth Services a year ago 5 under their ADR, Alternative Dispute Resolution 6 mechanism, less that 2 percent of our work is done in 7 court. And a number of those are status review 8 applications where we're looking to terminate Crown 9 wardship orders in favour of long term customary care. 10 So mainstream society has -- apprehends 11 more children. We do have a high number of children in 12 care for various reasons, but we do it collaboratively, 13 and in particular, with the First Nations. 14 And one (1) of the examples that I'm 15 giving when I'm asked to speak in other conferences is, 16 just imagine if you were in Thunder Bay or Toronto, and 17 every time you wanted to do any work, you had to go to 18 the Municipal office and see the Mayor; and the amount of 19 time that it takes to do that. 20 And yet that is part of how we work with 21 our First Nations. So it's six (6) children in care. 22 Thirty-one (31) of the child deaths were children who 23 were living at home, under the legal care and custody of 24 their parents, but we had an open family service file. 25 Of those thirty-seven (37) deaths, twenty-


1 one (21) of those deaths were suicides. And then there 2 were six (6) deaths of accidental drowning, and a number 3 of those were very young children under the age of five 4 (5). And then there were four (4) -- four (4) children 5 who died from illness. 6 Recently, two (2) very young children died 7 in a house fire, and then there were four (4) children 8 who died through other causes. 9 And I know that this -- the Commission is 10 looking into criminally -- criminal -- were there 11 criminal charges, and I must say that in the twenty (20) 12 years that I've been revolved -- involved in working in 13 the north, and in all of our thirty-seven (37) cases, no 14 parent was criminally charged. 15 So I'm not speaking from that perspective. 16 In one (1) case, foster parents were criminally charged 17 in the death of a child. 18 So I think the amount of time that we work 19 with the community, the emphasis that our workers place 20 on working collaboratively with families and other 21 service providers; and if I could speak to the role, when 22 there is a child death, I think, is unique. 23 We have -- since the year 2000, we have 24 worked very hard to de-centralize our services. We were 25 more centralized prior to that in our administrative


1 office in Sioux Lookout. 2 We now have ten (10) Regional Branch 3 Offices, we call them, in communities. And we have 4 worked very hard to have a presence in every one (1) of 5 the First Nations that we provide services in, so on-the- 6 ground workers from those communities. 7 Our workers, when there are deaths, -- our 8 -- our primary and first responsibly is to ensure the 9 safety and well-being of children. I mean that's -- 10 that's the overall purpose of the Act, and that's what we 11 must do, but we do it in ways that we involve the family 12 in those decisions. So we do our safety assessments. 13 But most frequently, whether or not the 14 children come into care, or can remain out of care, we 15 work with the extended family, if necessary, to find 16 supports to go into the family to ensure child safety, or 17 we find extended family members who can look after the 18 children, either privately or with our assistance. 19 And -- and we strive very hard to keep 20 them in the community, and -- and involved in the family. 21 If we have children placed -- if we have siblings that 22 are placed outside of the community, we bring the 23 children home. That's a given. 24 We frequently receive requests to bring 25 extended family members home. Our workers buy groceries


1 for the families. Our workers go in and cook meals for 2 the families. 3 Many times our workers are requested, by 4 the family, to speak at the funeral, to talk about the 5 life of the child, or to talk about the involvement, 6 because they're community members as well. 7 And I'm not aware of many other Children's 8 Aid Societies that play such an active role, both in the 9 community and in the arrangements. 10 When children are in care, we have 11 assisted in paying for aspects of the funeral. So that 12 we do many things that are required in our communities 13 that maybe fall in a very grey area when it comes to 14 delivering child welfare services. 15 MR. MARK SANDLER: Thank you. I just 16 want to follow up and ask you, Ms. -- Ms. Hancock, based 17 upon the extent of your involvement in these communities 18 to describe the -- the impact that a child's death has as 19 -- as your agency observes it. 20 Could you provide the Commissioner with 21 your insights in that regard? 22 MS. BARBARA HANCOCK: Sure. I'll try. 23 And -- and from the perspective that I've been involved 24 in twenty (20) years, but in some ways, I'm still an 25 outsider, so a lot of what I'm talking about is what I've


1 seen in my job as a Director of Services, which means 2 supporting a staff, and supporting the communities, and - 3 - and debriefing, and spending an awful lot of time 4 listening to staff who work in the communities, and deal 5 with it on a day-to-day -- on a day-to-day basis. 6 When -- when a child dies, and I think 7 Chief Connie Gray-McKay, and Chief Morris spoke to it. 8 It -- it is viewed as a tremendous tragedy, and when you 9 think of so many of the deaths that we're talking about 10 are unexpected, yes, and -- and the children are taking 11 them by their own hands because so many of the deaths 12 that we deal with are suicide. 13 And then the -- the tragedy of -- of young 14 children drowning; it's -- it's hard to describe the 15 depth of emotion, but I'm sure anyone who's a parent can 16 begin to comprehend that. 17 However, also added to that is the fact 18 that the families know each other. The families are 19 related to each other. And so when -- when death 20 happens, it -- you know, it touches all -- all aspects of 21 the community and it touches all aspects of the service 22 providers, right? I mean, some of our staff at Tikinagan 23 are probably related to -- to the family or to the child 24 who dies. 25 If -- if it is a death where criminal


1 charges may be laid, then we're looking at families being 2 split along family lines and -- and people not knowing 3 who do you provide -- who do you provide support to. 4 Along with that, we -- we've talked about 5 the lack of clarity and the la -- lack of reliable 6 information, so that leads to a lot of rumours and 7 speculation involved with shock and grief and -- and 8 blame. 9 You know, we've talked -- we -- you've 10 heard testimony that speaks to the -- that parents don't 11 know where the body is and -- and the -- the fear that 12 comes along with that, and that was talked about by the 13 Elder. 14 From a Tikinagan perspective, because we 15 are one (1) of the largest service providers in these 16 communities, there is an expectation by families and by 17 Chief and Council that Tikinagan workers should have the 18 answers. Tikinagan workers should somehow be able to say 19 where has this body gone, or what was the cause of death, 20 or where is the status of the -- the investigation, and 21 our workers -- our workers don't know these things. 22 Yes, they may be with our Child Protection 23 investigation working with the officers in -- in a 24 criminal investigation, but we're not -- because we're 25 not the legal guardians, we're not privy to a lot of that


1 information, and yet the -- the community members and the 2 families, they want it from somebody. 3 One (1) of the -- the themes that today -- 4 I heard this morning, that was hinted at, that I'd like 5 to stress that's there is relationships and time which 6 are missing, right? They're missing with the -- when 7 onsite come in or with the Coroner's Office relationships 8 take time to develop. 9 Tikinagan has been twenty-five (25) years 10 at working at relationships and establishing protocols 11 with the leadership of the First Nations and with other 12 service providers. It takes time. 13 And one (1) of the things that isn't 14 happening when there's a tragedy is relationships and 15 time, so the families are left to support each the best 16 they can with very little information unable to make 17 funeral arrangements because they don't know when the 18 body is coming back. 19 There's no debriefing services available 20 for families or community service providers or for -- or 21 for victims if it's been a homicide or something like 22 that, and it traumatizes the whole community. 23 There's also difficulties with 24 interpretation. So we're dealing with technical 25 information, and English may or may not be spoken well,


1 especially -- and you heard the Elder talk about 2 grandparents and the relationship of grandparents to 3 children. 4 Well, that heightens language 5 difficulties, so who's going to do the interpretation 6 that balances the words, especially the technical words, 7 with expertise with English and Ojibway or Oji-cree? So 8 that's frequently there, and sometimes our workers need 9 to do translation, and I know that that puts a great 10 burden on them. 11 And sharing of information is always 12 difficult. If I could just finish with one (1) example 13 with the Coroner's Office, and it's -- it's not to lay 14 blame, but it did happen and I was personally involved. 15 And it was a child death in the community of Mish, where 16 Chief Connie Gray-McKay is from. 17 And a child died and the body was returned 18 to -- to the community for burial and our staff 19 participated. And, you know, we're there afterwards, as 20 well -- our staff in the communities -- to help the 21 families and to deal with the difficult issues of child 22 protection; so to provide support, but also talk about 23 some very difficult issues if due to grief the children 24 aren't safe in the home and how do we ensure child 25 safety.


1 A number of months went by, and then I got 2 a phone call from the Regional Coroner, Dr. Legge, and he 3 was quite apologetic, but he said to me, We have the 4 brain here of this -- this infant that was buried a few 5 months ago. 6 And I was quite shocked. We -- we thought 7 that -- we thought that the -- all of the body had been 8 returned. We thought that the -- the burial had been 9 done with -- with all of the body. 10 And now I was confronted and being asked 11 to, Well, now how do we turn -- return the brain of this 12 infant to the community? In the end, the -- the remains 13 were -- were couriered to Sioux Lookout, and I personally 14 went to the funeral home to -- to retrieve the -- the 15 brain of the infant. 16 Meanwhile, some staff that I supervised, 17 from the community, went and got the young mum. We were 18 the ones who informed the community. And they brought 19 the young mum to my office, and I had to give her the 20 rest of her child. And our staff drove her, and she sat 21 in the back of a van with a little box, holding it and 22 then went back to Mish to do a second funeral. 23 You -- you can't necessarily blame 24 anybody, but I really wanted to bring this story forward 25 because I think it brings home some of the difficulties


1 with communication, with information sharing, with 2 relationships, and with spending time in the community 3 with the people. 4 MR. MARK SANDLER: Thank you. I'm going 5 to come back to you in a few moments, Ms. Hancock. If I 6 -- if I can turn to Ms. Robinson, and I want to start 7 with the basics. Could you describe for the Commissioner 8 what NAN legal is and what it is that you do here? 9 MS. MARY JEAN ROBINSON: Good morning or 10 afternoon. Nishnawbe-Aski Legal Services has existed for 11 about eighteen (18) years. It started out as an area 12 office of Legal Aid Ontario, primarily issuing Legal Aid 13 certificates, providing duty counsel, and -- and 14 developing a system of community legal workers. 15 Since that time, there's been significant 16 expansion, and we also provide restorative justice 17 workers for matters that are durv -- diverted out of the 18 Euro-Canadian court system. We have a talking together 19 department which works between families and child welfare 20 agencies where children are the subject matter of the 21 Child Welfare Act. 22 And Tikinagan is one (1) of the agencies 23 that we work with, but I believe I provided a map and -- 24 and some materials -- I won't go on too long because I've 25 also provided pamphlets for the Commission with respect


1 to all of our various projects. 2 But my personal role is as Legal Aid Area 3 Director, so in that respect, I issue Legal Aid 4 certificates, supervise the panels of lawyers, including 5 panels of lawyers who provide assistance for very serious 6 cases in which this would be the subject matter of this 7 Commission; community legal workers; restorative justice 8 workers; talking together workers; crime prevention 9 workers. 10 We have a staff of approximately forty 11 (40) people. Our community legal workers are organized 12 by tribal council area, so each of them is responsible 13 for very specific communities so that they develop a 14 rapport between NAN Legal Services, the Euro-Canadian 15 justice system, the -- all of the other agencies. 16 The community legal workers are the 17 liaison to the actual community on the ground, with one 18 (1) exception, a person who is in a drive-in community, 19 they all have language. We are linked into four (4) 20 jails by video, so people can communicate with us either 21 to apply for Legal Aid, to ask what's happening, to 22 complain about their lawyer, whatever assistance they 23 need. If they are in custody, they can communicate right 24 into our office. 25 MR. MARK SANDLER: Let's take a


1 hypothetical, Ms. Robinson, that we've -- that parallels 2 some of the cases that we've been dealing with here. 3 Let's assume that -- that in an Aboriginal community in 4 Nishnawbe-Aski, an individual was charged with the death 5 of a child; very serious matter. Pathology evidence was 6 being relied upon by the prosecution in support of its 7 case. 8 It may very well be the kind of case in 9 which one would want to ensure that the defence counsel 10 is -- is skilled in challenging the science, and may 11 indeed want to retain a pathologist to address the issues 12 up here. 13 Can you take us through what your role 14 would be in -- in addressing those needs, and how 15 successful you feel you can be in -- in this jurisdiction 16 in addressing those needs? 17 MS. MARY JEAN ROBINSON: I don't have a 18 lot of experience because in my twenty (20) -- eighteen 19 (18) years of practice, I've only seen one (1) case. 20 And in that situation, the foster parents 21 were co-accused. My role would be -- the -- the 22 community legal worker would be the first point of 23 contact. 24 They would contact me with a very serious 25 case. In this one, it developed over time, but if


1 something was immediate, we would immediately put a 2 lawyer into the community. 3 If the person wasn't arrested, we would 4 charter a lawyer into the community to -- to assist. In 5 a situation where there's been some investigation, and 6 the charge isn't laid until later, that would come 7 through the community legal worker. 8 We have -- I manage a pa -- all of my 9 panels, and one (1) of my panels is very serious cases, 10 and so I have a list of lawyers who take very serious 11 cases; generally speaking, criminal specialists. In a 12 case like this, that's prob -- you would be looking for 13 that. 14 Once a certificate is issued, the lawyers, 15 receiving certificates, are told if this case is likely 16 to move forward, then it needs to come into big -- what 17 we call "big case management". 18 The lawyer then provides us with all of 19 the information; what's avail -- what they have in -- by 20 way of disclosure; who the Crown will be calling as 21 experts, and what they require. 22 And then we sit down, and have a big case 23 management meeting. And in this particular instance, 24 there was a pathologist -- and I think there were maybe 25 two (2) pathologists involved in that case.


1 I've never seen a case where I was asked 2 for an expert, and -- and they were denied; and 3 particularly in this case. 4 The pathologist would be provided -- in 5 this particular instance, the pathology -- pathologist 6 for the defence came from Winnipeg, and one (1) defence 7 counsel was from Winnipeg, and one (1) from Kenora. 8 And -- 9 MR. MARK SANDLER: Do -- do you have 10 difficulties in securing senior experience counsel in -- 11 in serious cases in Nishnawbe-Aski? 12 MS. MARY JEAN ROBINSON: No, actually. 13 We -- we have just a wonderful pan -- people who -- who 14 work in this area, and we have senior counsel, criminal 15 specialists, right across the territory. 16 It's a little more difficult on the 17 Timmins eastern -- eastern side, because we also have the 18 James Bay Coast within the NAN territory. 19 So occasionally we would have to bring a 20 specialist from Sudbury, or North Bay, on a particular 21 case. But we have criminal specialists who are -- who 22 are -- who do our duty counsel in the remote north. 23 COMMISSIONER STEPHEN GOUDGE: How do you 24 explain that, Ms. Robinson? We heard in Southern Ontario 25 of the difficulty that exists now in getting senior


1 counsel to do defence work on Legal Aid certificates. 2 You have got a much better record up here, 3 and what is the explanation? 4 MS. MARY JEAN ROBINSON: I think that -- 5 COMMISSIONER STEPHEN GOUDGE: I mean 6 the -- 7 MS. MARY JEAN ROBINSON: -- speaking from 8 my own experience, it's -- it's something you -- it's 9 different from the traditional practice of law. 10 And the people who -- who are there are 11 there because that's the way they want to practice, and 12 these are the people and the issues that they want to 13 address. 14 And I don't -- can't say otherwise. The 15 other thing that we do have, although I don't think this 16 impacts on specialists, is we have something called a 17 guaranteed daily rate because if some lawyer is going to 18 go into a community, when his matter is over before the 19 Court, he can't -- he can't zip back to the office. 20 They're stuck there until the plane is 21 ready to go, and everyone's ready to go, and on occasion, 22 you might be stuck there for several days. So there's a 23 flat rate which is -- has made a difference to my ability 24 to recruit lawyers and do -- keep my panel. 25 And some of it is being available for the


1 panel. 2 COMMISSIONER STEPHEN GOUDGE: Right. But 3 would you say that you have, on your panel, the senior 4 defence counsel looking across the region? I mean, is 5 that what I hear the experience being up here? 6 MS. MARY JEAN ROBINSON: Particularly in 7 the centre which is the Thunder Bay -- 8 COMMISSIONER STEPHEN GOUDGE: Right. 9 MS. MARY JEAN ROBINSON: -- communities, 10 and the west which are the communities north of Kenora. 11 It's a little more difficult, but not impossible on the 12 Timmins James Bay coast side, but with respect to 13 pediatric issues, it doesn't come up. I say there's been 14 one (1) in eighteen (18) years. 15 COMMISSIONER STEPHEN GOUDGE: Right. 16 MS. MARY JEAN ROBINSON: But if I were 17 faced with that, I would not have difficulty. 18 COMMISSIONER STEPHEN GOUDGE: Thank you. 19 20 CONTINUED BY MR. MARK SANDLER: 21 MR. MARK SANDLER: And just one (1) last 22 question for now, Ms. Robinson, and that is that one (1) 23 of the issues that has been raised is whether people who 24 defend Aboriginal clients have the cultural sensitivities 25 and language capacities in order to do that.


1 How is that addressed? 2 MS. MARY JEAN ROBINSON: No, not yet. 3 Cultural sensitivity is something that we're constantly 4 having to work on. All of our community legal workers 5 have language, and they provide the translation for 6 defence counsel. 7 They do not translate for the courts, and 8 they do not translate for the police. They do -- they 9 translate for the individual who is being -- who is under 10 suspicion or -- or being charged or -- or even through 11 the court system, often the defence witnesses won't have 12 good command of English language. 13 And this is one (1) of the areas where I'm 14 trying to train everyone to say, Don't ask people, do you 15 speak English, because 90 percent say yes they do, and 16 maybe 75 percent actually can function in a very 17 technical way. So what we've been working at, and I've 18 also been working with the correctional officers in the 19 jails to say, Ask people what language do you prefer. 20 And that's the language we offer our 21 assistance in. 22 MR. MARK SANDLER: Thank you. I'm going 23 to turn back to Ms. Hancock. Could you describe, in a 24 little more detail, what interplay there is between your 25 agency and the Coroner's Office, and what interplay there


1 is between your agency and the Paediatric Death Review 2 Committee which we've heard about in these proceedings? 3 MS. BARBARA HANCOCK: Well, as you can 4 see from our statistics, we have a lot of paper interplay 5 with the Coroner's Office, because all of the deaths we 6 have to submit extensive documentation. 7 The case -- the child fatality case 8 summary report is the narrative that a Children's Aid 9 Society submits to the Coroner's Office, and ultimately 10 goes to the Paediatric Death Review Committee. 11 And it is a narrative where we have to 12 explain the role of Tikinagan in that family and with the 13 children from the very first contact our agency might 14 have had with that family to the point of the child 15 death. 16 And we have to show, within that 17 narrative, how we have functioned not -- not from a 18 cultural perspective or not from our situation at 19 Northall (phonetic), that's woven in there, but how have 20 we complied with the standards contained under the Child 21 and Family Services Act for delivering services to 22 families. So the provincial standards and regulations. 23 So the narrative -- so we submit this case 24 fatality report to the Coroner's Office. It is reviewed 25 at the Coroner's Office and then there is an option which


1 99 percent of the time, it happens with our cases, where 2 we receive notification by writing from the Coroner's 3 Office to state that we then need to hire an outside 4 consultant to do an internal society review. 5 So we then have to -- out of our 6 resources, hire a consultant, along with myself -- I 7 write all of the child fatality case summary reports for 8 the agency, so I've written most of them. And then -- so 9 there's the consultant and myself and then I draw two (2) 10 or three (3) staff from whichever community or unit 11 office, branch office, that the child death occurred. 12 And we sit down and go over the case and 13 look at the Society's interventions in dealings with the 14 family and providing services to the child within that 15 framework of Ministry legislation. And then that goes 16 back to the -- to the Coroner's Office, most frequently, 17 again, to the PDRC. 18 This, itself, could take a span of four 19 (4) -- four (4) to five (5) months after the death to get 20 -- to get all of that done. The coroner's warrants for 21 seizure of our files has dramatically decreased since the 22 new directives came in several years ago. 23 Prior to that, it was a less of a 24 narrative and so it was almost an automatic that we would 25 receive a coroner's warrant for -- for our files,


1 childcare files, Family Service files. We'd have to 2 replicate them and courier them to Toronto. 3 And so then the case is reviewed by the 4 Paediatric Death Review Committee, and we have no way of 5 knowing when their report is coming back. It's usually a 6 minimum of a year that we'll get the -- the final report 7 back with the series of recommendations from the 8 Coroner's Office. 9 One (1) of the difficulties that our 10 Agency has with the recommendations that come back from 11 the Coroner's Office is that it's our feeling that many 12 of the recommendations that are given to us are outside 13 our scope and mandate of a Children's Aid Society to 14 address, and it's causing us a great deal of difficulty 15 and energy. 16 And by that, I mean there are 17 recommendations that are fair, and they are 18 recommendations on how we could perhaps intervene with 19 families in a more effective way to prevent future -- 20 this occurring in the future. 21 We also get quite a number of 22 recommendations that may be directed at the Ministry of 23 Children and Youth Services to take a look at our 24 funding, say. And now there's a new Ministry. Is it 25 Aboriginal Affairs? I believe. So the latest one (1)


1 that just came in within the last couple of months, they 2 were mentioned in there. 3 Another one (1) that we got was that we 4 should run swimming programs -- swimming -- or public 5 awareness programs on water safety in all of our thirty 6 (30) communities. Those are impossible, and they're not 7 what a Children's Aid Society is funded to do or has the 8 human resources to do. 9 Yet, all of those recommendations remain 10 open with the Ministry of Children and Youth Services 11 forever, or it feels like forever, because the Ministry 12 will not sign them off until we have completed the 13 recommendations. So the recommendations that we are 14 unable to do, they just languish. 15 However, as an agency, we're still held 16 accountable for them, and every six (6) months, I have to 17 submit a written report to the Ministry of Children and 18 Youth Services and to the Coroner's Office on what we've 19 done. 20 And so we -- at times, we're caught in 21 this no win. It uses an awful lot of our financial 22 resources, staffing resources, senior administrative 23 time, and, certainly, we get at some -- some meetings 24 with chief and councils, they accuse us of spending more 25 time doing that than we do trying to help them in their


1 situations with -- with the families that they're dealing 2 with. 3 MR. MARK SANDLER: I'm going to switch 4 topics, if I may, and ask you another question, Ms. 5 Hancock, and that is that what we heard in Toronto is 6 that when there is a ongoing criminal case, there's 7 sometimes a lack of understanding between the police and 8 Children's Aid or unevenness as to what information 9 should be shared, should not be shared in the course of 10 an ongoing prosecution. 11 Now I know that you've indicated that the 12 experience with pediatric death prosecutions is rare, but 13 I expect that you do -- you do get involved in criminal 14 investigations that don't involve death on occasion. 15 Could you describe that interplay between 16 the police, Crown, and your agency? 17 Is there an understanding of how 18 information and to what extent information should be 19 shared? Help us out as to that. 20 MS. BARBARA HANCOCK: It's hard to 21 remember everything. You know what? It goes up and 22 down. I think for the main, let me first speak with 23 police services, and we deal primarily with Nishnawbe- 24 Aski Police Services and with the Ontario Provincial 25 Police.


1 There is a protocol in place. There is an 2 older protocol that was -- was drafted, it has to be, I'm 3 sure, eight (8) years ago -- eight (8) to ten (10) years 4 ago now. And it's a regional protocol for the Districts 5 of Kenora and Rainy River. And so signators to that 6 protocol are all the Children's Aid Societies, Aboriginal 7 and mainstream, and all of the police services of which 8 NAPS and OPP are part of it. 9 And it speaks to the relationships when 10 there is investigations and child welfare is -- is 11 involved. The -- the proto -- we have -- we have also a 12 working relationsh -- protocol with NAPS. So that 13 information, especially at the beginning of an 14 investigation, is -- is shared very effectively and -- 15 and in a timely manner, for the most part 16 We -- we know that our -- our intake unit 17 investigators, we know we have to call the NAPS office, 18 and NAPS knows that if there's something involving 19 children, you know, they call us. And -- and we do joint 20 investigations. Now, obviously, investigations can get 21 out of step between a child protection investigation and 22 a criminal investigation as it proceeds. 23 And in -- sometimes if there's tension and 24 difficulty in information sharing, it's probably as 25 you're getting, you know, a little bit down the line, and


1 our workers are coming and going, and NAPS' offices are 2 coming and going, and it gets a little murkier and a 3 little more difficult. 4 However, when it comes to who's in the 5 community, usually two (2) of the key people in the 6 community are the Tikinagan worker and the NAPS police 7 officer. And so that I would say again, going back to my 8 theme on relationships, if the relationships are strong 9 in the community, between those two workers, information 10 flows quite effectively. 11 If there is strain or they don't know each 12 other that well or it's outside, then it is more 13 difficult and -- and it -- isn't handled as well. We do 14 not have a lot to do with the Crown attorney's office, 15 per se. Our contact is more with the police, with the 16 individual officers. I -- we've had some recent 17 difficulties with the Crown attorney's office in Dryden. 18 I think that it sometimes -- the 19 difficulties arise from not understanding the mandate of 20 a chil -- Children's Aid Society because there is an 21 expectation that we can alleviate or provide resources to 22 give the children counselling, and that's not within the 23 strict boundaries of our mandate. 24 That's a children's mental health issue. 25 And that causes great difficulty. And then -- and also


1 another area of concern that can arise with -- 2 particularly with individuals that are not familiar with 3 the remote north and how Tikinagan's service delivery 4 manual, is that we do not remove children from families 5 in these situations to the same extent that a mainstream 6 society does remove them. 7 And so we will be criticized for not 8 taking the children out of the home when we feel that we 9 have, along with the community and the extended family, 10 adequately addressed the safety issues of the children. 11 And they may be placed with the grandparents, privately. 12 However, housing as it is, there may be 13 contact with someone who is criminally charged. We're 14 not always told, in a timely manner, from the Crown's 15 office if there's a -- restrictions on supervision. And 16 we've just had an incident where we were supposed to 17 supervise any access, but we weren't told that for six 18 (6) months -- till six (6) months afterwards. 19 So I mean there are, you know, those 20 sorts of ups and downs in the relationship. 21 MR. MARK SANDLER: I'm going to ask you 22 both this question, based upon your familiarity with the 23 north, and -- and your expertise in your respective 24 fields. We heard earlier today -- and we also heard from 25 Ms. Hancock a few moments ago -- about some of the


1 communicative issues that arise in death investigations; 2 the families not knowing various aspects about -- about 3 the death investigation. 4 And we've heard a variety of suggestions 5 both today, yesterday, and during the course of the 6 Inquiry about how the communicative issues might best be 7 addressed. 8 So I'll ask each of you whether you have 9 any suggestions as to how one might enhance communication 10 between the communities in which you work and -- and the 11 investigative process, whether it be the coroners, 12 police, or -- or participants. Ms. Hancock and then Ms. 13 Robinson. 14 MS. BARBARA HANCOCK: Well, I think 15 probably a lot of things have already been talked about. 16 Communication -- effective communication, I believe, 17 requires people in the community, in whatever form that 18 takes, because what happens when there's no presence from 19 the Coroner's Office, and we have investigating officers 20 from outside of the community who are doing the 21 investigating, then we really are left with no one in the 22 community that can answer any questions. 23 Also, and I think that -- you -- you kind 24 of spoke to it, that people are very polite, and you 25 know, maybe other individuals in a mainstream agency


1 would pick up the phone, and would start to -- to yell 2 over the telephone. 3 I think many of our families wouldn't know 4 where to call, and also would not feel comfortable 5 calling; so to -- to -- and -- and not even sure what a 6 coroner is. And -- and you've talked about all of that. 7 So to kind of say, Well, call this phone number, most 8 people aren't going to call that phone number. 9 Some people don't even have long distance 10 on their telephone. So that if -- if the recommendations 11 don't begin to address how there is a presence in the 12 community, how does that information get shared in a way 13 and a language that people can understand, and -- and 14 with -- by someone that they're not afraid to ask 15 questions. 16 And, so to me that means that it does need 17 to be done -- the discussions on finding a way to do this 18 has to be done in collaboration with the Chief and 19 Council of the community. 20 And we have to acknowledge that if there 21 are thirty (30) communities, there are thirty (30) ways 22 of doing things -- thirty (30) different ways of doing 23 things. That's a challenge of setting up protocols in 24 the remote north. It's not a homogeneous approach. 25 So it would also have to be a protocol in


1 a manner that's flexible enough that while it captures 2 consistency and quality, it recognizes the unique aspects 3 of each community, and what their systems are in that 4 community, and how information is shared in that 5 community. 6 And I think that's the great challenge 7 that you have before you. 8 MR. MARK SANDLER: Thank you very much. 9 Ms. Robinson? 10 MS. MARY JEAN ROBINSON: I agree that 11 communication -- it has to be with someone that the com - 12 - that the person, and the community, trusts. It can't 13 just be someone who comes in who is the Aboriginal 14 liaison person, because they won't be any further ahead 15 than anyone else. 16 So trust is a huge piece of whoever is 17 going to improve the communication. And when you look at 18 the fact that this is also a trauma -- and the Summer 19 Beaver plane crash is the one (1) that comes to my mind, 20 when there was this huge tragedy for this community. 21 The majority of their band council were on 22 that plane, and a child, and all of a sudden, the lawyers 23 are all running around, and people are drafting 24 statements of claim and -- things are happening all over 25 the place.


1 Nay, stop. You guys can't go up there. 2 You can't go up there unless you're invited. You can't 3 go up there without Chief and Council. And if you're 4 going to go forward up there, you're going to need a 5 liaison person on the ground. And, so it -- you had to 6 bring everything to a halt, and start over again, and say 7 -- and -- in fact, it was Chief Vernon Morris who was the 8 liaison person throughout that. 9 And they -- it -- it all got diverted, and 10 there was no litigation other than the approving the 11 child matters. So trust is huge. 12 And it's not just trust. It's respect for 13 the fact that you're coming into someone else's space. 14 Education. I would love to have someone 15 from the Coroner's Office come to one (1) of my community 16 legal worker training sessions, and provide the community 17 legal workers with information about this is what the 18 Coroner's Office is, this is what they do. If there's a 19 problem -- if one (1) of the people, in one (1) of your 20 communities, raises a problem, who do you call? 21 And they can be that -- that intermediary, 22 they can help out in that respect. So I think the 23 community legal workers can offer some assistance here in 24 improving communication because we do get calls about a 25 child having been removed.


1 They don't know where it went. A number 2 of things happen and our community legal workers don't 3 know -- neither do I, quite frankly -- know as much as we 4 should around the whole Coroner's Office and autopsies. 5 And when we talked the other day, just 6 very quickly, there was a suggestion of -- find my note 7 here -- there being some sort of an Aboriginal liaison or 8 -- or maybe it was around having one (1) place where 9 autopsies are done so there's not this issue of did -- 10 did the -- is it being done in Winnipeg, is -- where 11 people chasing around, and Sudbury was mentioned. 12 Thunder Bay is the hub. Sudbury may work 13 for the James Bay Coast better, but trying to get from 14 Sandy Lake to Sudbury is probably three (3) or four (4) 15 planes and the communication isn't -- isn't great because 16 once you get down into Sudbury, you're not going to have 17 our language base. 18 Across NAN, there are three (3) dialects, 19 so the people from -- from one (1) area, for example, 20 would -- a community legal worker working in Sandy can't 21 translate in Fort Severn, so there are those kinds of 22 communication issues, as well. 23 But I certainly would -- would appreciate 24 some training session for -- for our community legal 25 workers, and also cross cultural maybe, for some of our


1 panel lawyers who were involved, as well. 2 And certainly, virtually all the lawyers I 3 know, need cross cultural training. 4 MR. MARK SANDLER: Thank you very much. 5 That sounded like a little bit of an entree to my last 6 question for each of you, which is are there any 7 recommendations that you'd like to urge upon the 8 Commissioner, and I -- I heard a few in your last 9 comments, Ms. Robinson. 10 Is -- is there anything else that you 11 wanted to add? 12 MS. MARY JEAN ROBINSON: No, if I can 13 remember to turn the mic on, there's one (1). I think we 14 underestimate the skill and ability in the communities, 15 and we could make more of -- use of people on the ground. 16 I can't stress enough, you have to get 17 past the issue of trust. There's a vist -- Connie's 18 pointed out there's a long, long history of mistrust, and 19 it's a long road back, and if you want to be effective, 20 there has to be a trust element. Whether that's the 21 community legal worker or a liaison person, however 22 that's done, the best trust is in the community itself 23 because that person is one (1) of that group. 24 MR. MARK SANDLER: Thank you very much. 25 Ms. Hancock...?


1 MS. BARBARA HANCOCK: I -- I think I've - 2 - I've probably said most of -- most of what we would 3 like to see already. The one (1) last comment I'd like 4 to make, and it probably comes from years of experience 5 and also from having testified before at -- at an 6 inquest, and that I hope the recommendations take into 7 account the financial resources required. 8 Because what I've seen happen in the past, 9 is that you see onetime project money coming down, and 10 it's supposed to address systemic issues, and you improve 11 the capacity at the community level a touch, you imploo - 12 - you improve coordination, but more than that, you know 13 what, you give hope. 14 And just when things start to improve, 15 there's no more money. There's no more coordinator, and 16 it's all gone again. And -- and so the -- you know, the 17 co -- whatever happens, I hope the recommendations take a 18 look at how can it be ongoing and how can it be systemic 19 so that the communities once again don't think there 20 might be a solution and then it just disappears. 21 MR. MARK SANDLER: Thank you very much. 22 I believe, Commissioner, we have one (1) or two (2) 23 questions from Ms. Esmonde. 24 COMMISSIONER STEPHEN GOUDGE: Ms. 25 Esmonde...?


1 2 QUESTIONED BY MS. JACKIE ESMONDE: 3 MS. JACKIE ESMONDE: Good afternoon. I 4 introduced myself to you yesterday, but for those of you 5 who don't know me in the audience, my name is Jackie 6 Esmonde, and I'm going to ask you some questions on 7 behalf of Aboriginal Legal Services of Toronto and 8 Nishnawbe-Aski Nation. 9 And I'd like to begin with you, Ms. 10 Hancock. You were speaking earlier about the importance 11 that your agency places on meeting with Chief and Council 12 whenever you go into a community and the development of 13 protocols in that regard. 14 Can you perhaps elaborate on that and what 15 is the value added and what is the importance of meeting 16 with Chief and Council before you go into a community? 17 MS. BARBARA HANCOCK: Well, as I said, 18 one (1) of the foundational pieces to Mamow Obiki- 19 ahwahsoowin is the inherent authority of the First 20 Nation. And Chief and Council are the leadership of the 21 First Nation and represent the First Nation. 22 So we cannot make any decisions, as a 23 Children's Aid Society, without speaking with them. So 24 we speak with them at the beginning. We ask them to 25 attend case conferences, and we go back and speak to them


1 again when it comes to planning for the safety of 2 children and our interventions in the family. 3 So in -- in no way for us is it a token 4 consultation. They are there every step of the way. 5 They will go with us to families to speak with them. So 6 they -- they're part of how our workers are expected to 7 work within that community. 8 Now, we have eight (8) signed protocols 9 with eight (8) First Nations, and in that, it lays out 10 the roles and responsibilities. And it includes roles 11 and responsibilities and our expectations for the First 12 Nation, as well as the First Nation's expectations for 13 Tikinagan Child and Family Services and how we will work 14 in the community. 15 When it comes to placement of children in 16 the home, we get a safe home declaration from the Chief 17 and Council. So besides doing home assessments like 18 other Children's Aid Societies would do, first step a) is 19 the First Nation has to sanction that in to them, this is 20 an adequate home to care for the -- for the specific 21 child that we're dealing with. 22 So they're involved in all aspects. 23 Tikinagan has a three (3) day annual assembly, and we 24 bring forward, for the year, reports and updates and seek 25 direction from the Chief's within our area as well on our


1 projects and initiatives. 2 MS. JACKIE ESMONDE: Thank you for that. 3 My last question is for both of you. I'm interested in 4 hearing from you, on your views, on the strengths of 5 having workers based in the community and how your 6 agencies deal with questions about impartiality when you 7 have workers that are so closely linked to the community? 8 MS. BARBARA HANCOCK: Well, that's always 9 a difficult one. We don't quite get to declare conflict 10 of interest the same way that other people do. We -- we 11 have approximately two hundred and fifty (250) staff at 12 Tikinagan. And we've just centralized our services so 13 that we have 70 percent of those staff in the First 14 Nation communities. 15 And I think, the last I heard, we were 16 running between 80 and 85 percent of our staff are from 17 the communities. So our -- our staff live and work in 18 those communities. If we have a branch office, we have a 19 bit of ability to have some flexibility so that if it's 20 an immediate family member, we can have another staff 21 person do it. 22 We're also -- when we hire, even if we 23 only have two (2) workers, we attempt, if we can, to 24 maybe hire from the different family groupings in the 25 community. And we have just now gone to -- I think we've


1 almost managed to succeed to having two (2) frontline 2 workers in every community. 3 And while they play different functions 4 between child care workers or family service workers or 5 investigators, at least we can then, if we need to, have 6 a second person. Or we'll bring them in from a satellite 7 community, a surrounding community as well. 8 It's difficult, but I think I echo some of 9 the remarks that got made from the first roundtable, 10 which is the -- the hallmark of -- of truth and -- and 11 dealing with these things as they arise, and not 12 hesitating to say -- and this is where Chief and Council 13 is so valuable too if there's a conflict of interest -- 14 you can have another person there that will ensure 15 objectivity, that will ensure that people are not being, 16 you know, rough -- run -- run over or that there's an 17 allegation or perception of favouritism. 18 And so if -- if we only have a worker 19 there, that's a great value that Chief and Council 20 provide for us, which is they will send a designated 21 person to be with our staff so that there -- there is 22 objectivity and the community can feel comfortable that 23 we're not ignoring things or placing children at risk. 24 MS. JACKIE ESMONDE: Thank you. 25 Ms. Robinson...?


1 MS. MARY JEAN ROBINSON: Can you give me 2 an example of -- I'm not quite sure where you're going 3 with your question? 4 MS. JACKIE ESMONDE: Well one (1) of the 5 concerns that's been raised in these proceedings is the - 6 - the issue of if investigators are based in the 7 community, that they may be so closely linked with family 8 members or neighbours that they won't have the 9 impartiality that they need to conduct an investigation. 10 The -- the models that your organizations work with rely 11 there heavily on having people who are connected to the 12 community. 13 So I'm interested in how you address those 14 kinds of concerns, or if they are concerns for you? 15 MS. MARY JEAN ROBINSON: Thank you. Put 16 the context of an investigation around it and it helps me 17 a bit. Where -- where we would hit a conflict of interest 18 within Nishnawbe-Aski Legal Services, we would just shift 19 community legal workers. 20 Or if an application comes into the office 21 and the person is closely related -- because everybody is 22 related -- if they're closely related to someone in the 23 office we would pass it outside to one of the other area 24 offices. 25 We are -- from Legal Aids point of view, a


1 defence side service and so our role is really the 2 individual rights. And the individual rights sometimes 3 come into conflict with the collective right in the 4 community and we just try to work within that. Over time 5 that should work its way through. As we expand on the 6 Aboriginal side, the Euro- Canadian side should contract 7 a bit, maybe a lot. 8 But we would address a conflict of 9 interest as it came up, and we're not investigators, so. 10 MS. JACKIE ESMONDE: Okay. Thank you 11 very much. 12 MS. MARY JEAN ROBINSON: That would be 13 more your area. 14 MS. JACKIE ESMONDE: Thank you. 15 COMMISSIONER STEPHEN GOUDGE: Thanks, Ms. 16 Esmonde. 17 MR. MARK SANDLER: Thank you very much. 18 That completes the questioning for this roundtable. I 19 want to thank each of your for your valuable contribution 20 and -- and insights. 21 And Commissioner, if that'd be a 22 convenient time, I suggest we break until 1:45. 23 COMMISSIONER STEPHEN GOUDGE: 1:45. Do 24 people have to go to the restaurant or are we -- 25 MR. MARK SANDLER: Yes, they'll have to


1 go to the restaurant, that's why -- 2 COMMISSIONER STEPHEN GOUDGE: Is that 3 enough time? That's an hour. 4 MR. MARK SANDLER: I guess we'll find out 5 if it is. 6 COMMISSIONER STEPHEN GOUDGE: Okay. 7 Let's -- 8 MR. MARK SANDLER: Let's -- 9 COMMISSIONER STEPHEN GOUDGE: Lets try 10 for an hour and let me thank both of you immensely for 11 what you've been able to give to us. It's very helpful, 12 so thank you both for coming. 13 Well adjourn then until 1:45. 14 15 --- Upon recessing at 12:45 p.m. 16 --- Upon resuming at 1:51 p.m. 17 18 COMMISSIONER STEPHEN GOUDGE: Mr. 19 Sandler...? 20 MR. MARK SANDLER: Thank you, 21 Commissioner. Good afternoon, everyone. We're about to 22 turn to roundtable number 3 entitled "Community 23 involvement with pediatric death investigations", and I'm 24 going to ask -- prevail upon Wally yet again to introduce 25 our panellists.


1 MR. WALLY MCKAY: Thank you very much, 2 Mr. Sandler. Mr. Commissioner, we have with us James 3 Morris, from Kitchenuhmaykoosib Inninuwug, or what is 4 know as Big Trout Lake. 5 Big Trout Lake turns out a lot of fine 6 leaders who have made an impact in the development of our 7 area and Jim is one of those exceptional people. 8 He has began his career in education and 9 communications. He's one (1) of the leaders that 10 developed the Wawatay Communication Society and sort of 11 was involved in Anishinabe communications with the 12 Northern Native Broadcast access program with the 13 Department of Secretary of State then in 1984 and 1988. 14 And between 1988 to 2000 James was one (1) 15 of the long -- longer serving Deputy Grand Chiefs of 16 Nishnawbe-Aski Nation and who had the Health and Social 17 Services folly -- portfolio. Since 2001 he has been the 18 Executive Director of the Sioux Lookout First Nations 19 Health Authority. Welcome, James. 20 Of course we've already introduced Dr. 21 David Eden. He still remains Dr. David Eden. 22 23 PANEL 3 - COMMUNITY INVOLVEMENT WITH DEATH 24 INVESTIGATIONS: 25


1 JIM MORRIS 2 DAVID EDEN 3 4 QUESTIONED BY MR. MARK SANDLER: 5 MR. MARK SANDLER: Thank you, Wally. 6 Mr. Morris, if I can ask the first series 7 of questions to you. First of all, could you outline for 8 the Commissioner what is the Sioux Lookout First Nations 9 Health Authority and what are the kinds of things that 10 you do, just to provide some context to the discussion 11 that will follow? 12 MR. JIM MORRIS: Okay, thank you very 13 much. The Sioux Lookout First Nations Health authority 14 is a Chief's organization. It's a Chief's Regional 15 Health Organization that serves thirty-two (32) 16 communities in -- in north of Sioux Lookout and in and 17 around Sioux Lookout. 18 It was based on the recommendation from 19 the Scott-McKay-Bain Health Panel. The McKay stands for 20 Wally McKay. And there -- it was -- the recommendation 21 was to create an Aboriginal health authority that ult -- 22 that would ultimately take over all the health services 23 in -- in the region. 24 And we're still in the process of doing 25 that. Right now we have three (3) main programs: one (1)


1 is we -- we run client services, whereby we an -- we 2 organize, arrange, and coordinate transportation, 3 accommodations, translation services for clients coming 4 down out of the north to access health services in Sioux 5 Lookout, Thunder Bay, and Winnipeg, and wherever else. 6 We also have -- we've been in the process 7 of a MOG (phonetic) meeting, an organization that was 8 called Northern Counselling that provided mental health 9 counselling for adults in the area. That was funded by 10 the Federal Government. And CFI, Child and Family 11 Intervention Services. 12 Up until then there's never been any 13 children's mental health services per se, in -- in the 14 region. The province had a program called ISNC, 15 Integrated Services for Northern Children, but there was 16 a clause in there that said, except for status Indians 17 living on reserves, so that was another program that -- 18 where the kids fell through the cracks. 19 Originally the money came from Tikinagan 20 to create what they call a -- a family counselling unit, 21 and it was supposed to work with families in general. 22 But about 2000 I guess they discovered that the work was 23 not focussing on the kids who needed help so they 24 discontinued it. And then in 2000 we created a group 25 called the Intergovernmental Committee on Aboriginal


1 Youth Suicide. It consisted of about eleven (11) 2 provincial ministries and about six (6) or seven (7) 3 Federal ministries. 4 And it was created partly in response to 5 an -- an inquest that was done into a young girl who 6 committed suicide from Lansdowne House. Her name was 7 Selena Sakanee. 8 And they asked us to amalgamate those two 9 (2) resources. And so since 2002 we've been in the 10 process of creating a comprehensive mental health agency 11 for children and their families, and we're still in the 12 process of doing that. It's been a long process of 13 amalgamating two (2) different practices, changing and 14 upgrading staff who don't want to change, and we're 15 getting there, but we're not there yet. 16 If you were ask -- to ask me today, or if 17 you were to ask Tikinagan do we have a children's mental 18 health agency in the area, they'd say no, because we're 19 just not quite there yet. The majority of the clients 20 that Northern deals with now are adults, and we're just 21 now starting to deal with -- provide some long term 22 counselling for -- for children. 23 The other thing that we do is we -- in the 24 whole area of developing First Nations capacity to take 25 over our health services, we've had a number of projects


1 that were designed to do that. 2 One (1) is we give out a district health 3 plan we called Anishnabe Health Plan and that lays out a 4 plan for the next five (5) to ten (10) years to develop 5 First Nations capacity and take over more and more 6 services that are currently being run either by the 7 Government or other groups. 8 The latest development is that we've been 9 in negotiations all this year with the Federal Government 10 who currently pays all the fees for the doctors that work 11 in the area. But as of April the 1st, the payment of the 12 physicians fees will be done by the province, like it's 13 done everywhere in Canada. 14 So the chiefs recently approved a bridging 15 agreement they call it, whereby as of April 1st the 16 province will pay for the physicians fees and the Federal 17 Government will pay for the ancillary fees, like travel, 18 flying time I guess, accommodations for doctors because 19 they have to go up north. 20 And the health authority will be -- be the 21 -- the paymaster. And we'll also use this year to 22 increase our capacity to be able to run these services. 23 So that's the process -- it's an organization that very 24 much in transition building in our capacity to run our 25 own health systems.


1 MR. MARK SANDLER: Mr. Morris, would -- 2 would the health authority have -- have any involvement 3 in -- in cases that involve pediatric deaths, either in 4 counselling the families involved or in relating to the 5 Coroner's Office? 6 Can you help us out as to that? 7 MR. JIM MORRIS: I think only in the 8 counselling part. Whenever there's a death in the 9 community, either by suicide or other tragic deaths, 10 Northern is called in to send in crisis teams, and also 11 we -- we send in clinicians to provide counselling to the 12 immediate family, and then whatever resources are 13 available to the family surrounding the victim. Like 14 everybody is related, but we try to focus on key people 15 like boyfriends and girlfriends and stuff like that. 16 I think in the -- we've started keeping 17 clear, accurate statistics on youth suicide since 1986. 18 And I forget how many there have been in 19 the -- in the entire region. I think it's about two 20 hundred and seventy-six (276) the last time I counted. 21 And a lar -- a large majority of those very young people 22 are under the age of sixteen (16). But there's only been 23 one (1) inquest on them. That was the Selena Sakanee 24 Inquest. 25 And surprisingly what happened is that


1 when -- when the Intergovernmental Committee went through 2 those recommendations, they -- they assigned a whole 3 bunch of them to the Northern to implement, so. I'm 4 involved in that way, so. People hold an inquest and 5 then they tell me to do it. 6 And then -- but they don't have -- like 7 Barb said, there wasn't money there to -- for me to do 8 it. I've had to develop measures to deal with them and 9 then go begging money for what was to do it. 10 MR. MARK SANDLER: Dr. Eden, I'll turn to 11 you for a moment. 12 As you know, we've been wrestling this 13 morning, and -- and at various times throughout the 14 Inquiry with -- with the best model for addressing all of 15 the resourcing issues, and logistic issues in death 16 investigations in the north. And that's generated some 17 discussion this morning as well about community 18 involvement, or community representatives be involved in 19 the investigative process. 20 And I know you spoke to this issue a 21 little bit yesterday, but perhaps I -- I'll ask you to -- 22 to comment on it again this afternoon with a view to 23 addressing some of the issues that have been raised in 24 the course of the various roundtables, up and to this 25 point in time today.


1 (BRIEF PAUSE) 2 3 DR. DAVID EDEN: I think the -- you know, 4 the discussion yesterday was about who should be on-scene 5 at a death investigation, ans that that does seem to be 6 an area that's being looked at in -- in considerable 7 detail. 8 The -- the suggestions I had yesterday 9 factored -- sorry, centred around the skill set of the 10 person who is on-scene. And in my view, the person who's 11 on-scene requires a complex skill set, and I mentioned 12 investigative skills; familiarity with examining a body; 13 knowledge of the law, and the ability to make difficult 14 decisions that involve application of law; documentation, 15 and taking into account that that documentation may be 16 used in Court; and the ability to conduct self 17 professionally, and impartially; and a word that I didn't 18 use yesterday, but in retrospect I should have, is 19 independently; and also the ability to communicate with 20 people who are under tremendous emotional strain. 21 So those were the -- the skill set. And 22 taking into account where will this decision making go, 23 and this is very much what this is Commiss -- what this 24 Commission is about. 25 When decisions are made in pediatric


1 pathology, they have tremendous ramifications down the 2 road. And a -- a decision about whether or not to order 3 an autopsy, what tests should be ordered, and so on, may 4 end up in the courts, and may end up with either a person 5 ending up convicted inappropriately, or not convicted 6 inappropriately. And both of those, of course, have 7 great consequences for the entire community, not to 8 mention the individual. 9 So in my view, these are very important 10 decisions. And it's critical that those decisions be 11 made by people who have the appropriate background, and - 12 - in general terms, and that specific skill set. 13 Again in -- in listening to Mr. Morris, 14 what he's described to us is that there are service 15 delivery issues in Northern Ontario. And what his 16 organization has done -- and I -- I think it's -- a very 17 sensible approach -- is to say how do we achieve the same 18 level of quality and accessibility of care as exists 19 elsewhere, but taking into account the way we are here in 20 northern Ontario. 21 So I -- I endorse the idea of taking a 22 flexible approach in which quality and accessibility are 23 -- are paramount. How exactly that's applied I think 24 would be different depending on the service. 25 And we -- we heard today about social work


1 being community based, and that's something that -- that 2 I agree with. The social worker, for instance in 3 Children's Aid, is working directly with the child and 4 family. They are not expected to be independent of and 5 impartial of. It's their role to be involved with the 6 family and to help them through difficult times. 7 The -- the worker who -- the -- the legal 8 -- the criminal law worker is an advocate for the 9 accused. They are not meant to be independent, they are 10 meant to be on the side of their client. 11 The role of the coroner, in my view, is 12 materially different from the role of the social worker, 13 or the defence counsel, or -- or someone working in -- in 14 the same role as the defence counsel, because the 15 Coroner's Office is serving a broad public interest, part 16 of which is to liaise with family. And we've heard that 17 there are concerns about the way liaison occurs with 18 families and you -- you've heard my recommendations 19 about how that should be enhanced. 20 But the cor -- the Coroner's Office is 21 performing a public interest job, it is not acting for a 22 specific member of the public. 23 And I will get this, I'll get a family 24 member saying, Dr. Eden, I want you to issue a warrant 25 for this. And of course in law I can't say, Well, I'm


1 not their lawyer acting on their instructions, I am a 2 public official and my role is to interpret the law in 3 the public interest. And if it's in the public interest 4 for me to warrant that I'm going to, but if it's in their 5 private interest, for instance, if they wanted that for a 6 civil litigation, then no, it would be inappropriate for 7 me to warrant it. 8 So just to summarize, go back to the same 9 thing, what's our goal, answering five (5) questions, 10 making recommendations: 11 Are there issues about delivering service 12 in northern Ontario? Absolutely. 13 And how do we maintain the same quality? 14 We ensure that the investigator at the scene has a 15 general background of the specific skills to carry out 16 the work to the same level of quality as it would be 17 expected anywhere in Ontario. 18 COMMISSIONER STEPHEN GOUDGE: If you 19 shifted, Dr. Eden, and you spoke a little about -- well, 20 more than a little, about this yesterday -- but if you 21 shifted to the communications dimension of the coroner's 22 work, that is contact with the family and communities -- 23 we've heard a good deal about that this morning -- is 24 there a role in that context for community liaison people 25 that can serve as an associate of the coroner,


1 communicating with the kind of trust we heard about this 2 morning being important to explain what's going on in the 3 death investigation? 4 DR. DAVID EDEN: From our point of view, 5 absolutely. It's -- and -- and again, this is not a 6 First Nations specific issue. There's many communities 7 that I deal with and have dealt with where a person may 8 want to bring a priest, or a nurse, or an Elder, or they 9 may wish to have somebody else speak to me on their 10 behalf without them present. 11 From my point of view what's important is 12 that they get the information in a way that they can 13 understand in a way they're comfortable with, and to have 14 a person in the community who has an existing tie with 15 the Coroner's Office and can act in that role would be 16 valuable. 17 My -- my caution on that, though, would be 18 that families who wish it should have the option to go 19 through other methods, which would be to speak on the 20 phone to the coroner, or to the regional coroner, or to 21 somebody else if they wish. 22 COMMISSIONER STEPHEN GOUDGE: Right. I 23 mean the uniqueness of the north is the remoteness 24 problem, whereas you've outlined the logistical 25 difficulties of the coroner actually being physically


1 present in these communities from time to time, where the 2 community liaison capacity might be of considerable 3 assistance, absent the coroner being him or herself 4 present. 5 DR. DAVID EDEN: I agree, sir. 6 7 CONTINUED BY MR. MARK SANDLER: 8 MR. MARK SANDLER: I'm just trying to get 9 my head around, we've been talking about two (2) very 10 different functions: we've been talking about an 11 investigative function, and I'll come back to that in a 12 moment, and right now we're talking about how to enhance 13 communication. 14 And -- and what you also heard from -- 15 from some of the other panellists earlier today is that 16 the combination of mistrust and also remoteness has 17 caused some of those panellists to be suggesting that -- 18 that there ought to be someone in each of the communities 19 that performs this communication role, as opposed to 20 someone who might represent the Coroner's Office or 21 address communications issues across the region. 22 So break that down, if you would, and how 23 would you see a model? 24 I mean, we all seem to agree that -- that 25 there's some need to enhance communication and that it


1 may well be that there be some benefit to having someone 2 who's got some skills and expertise in that area. 3 Should those kinds of people come from 4 individual communities or would you suggest some other 5 models? 6 DR. DAVID EDEN: Ideally, I would see 7 both sides. I would see that it would be useful to have 8 somebody in each community for the reasons that have been 9 so well articulated, that it is good to have somebody in 10 your community with that link with the Coroner's Office 11 who knows -- who knows the people on the coroner's 12 investigation side of things and knows the community. So 13 there's an advantage there. 14 I also see an advantage to having a -- an 15 Aboriginal liaison officer with the Chief Coroner, or 16 working with the Chief Coroner, whose role would not be 17 so much direct liaison but would be in coordinating the 18 efforts -- because there would be, I would think, on the 19 order of thirty (30) such people, at least thirty (30) to 20 fifty (50) people in individual communities who would be 21 working with the -- would be acting in that capacity to 22 liaise between families and the coroner. 23 And if we had an Aboriginal liaison 24 officer that person could be involved in education, in 25 setting up best practices, in providing advice over the


1 phone for difficult situations and so on. 2 So it would be a province-wide resource 3 for all those people who are carrying out a very 4 difficult job. Because it's -- this will be a difficult 5 job and I -- it would be a job that somebody who 6 volunteered for it would be doing it maybe once a year, 7 once every two (2) years, and they're going to be 8 extremely busy and extremely stressed during the time 9 they do it, and I think they should have support outside 10 the community to help them through that time. But I 11 could see it working. 12 MR. MARK SANDLER: All right. Mr. 13 Morris, I'm going to ask you for your comments, because 14 what Dr. Eden is really suggesting to -- to address some 15 of the communications issues that we've heard a lot 16 about, is a combination of having an Aboriginal liaison 17 officer attached to the Coroner's Office that would -- 18 would deal with the larger issues associated with 19 communication and provide support for people within each 20 community that could also provide some level of 21 communication. 22 I'd like to draw upon your knowledge of 23 the communities and -- and your expertise. What do you 24 think of that idea and what do you see the role of the 25 community playing in dealing with the things that we've


1 discussed on death investigations? 2 MR. JIM MORRIS: Okay. Well, first of 3 all, you have to remember that the people who live in 4 those communities don't consider themselves to be remote. 5 You know, that's their home, and you're the guys who are 6 remote. We can't talk to you. 7 If you want to -- if you want to improve 8 communications then you put people in the communities so 9 -- that people can communicate with, because it's a very, 10 very different world than what you're used to. 11 Just to give you an example, these -- 12 these communities we're talking about, they range in size 13 from fifty (50) to two thousand (2,000). Everybody is -- 14 they're like little villages, and they're all extended 15 families; everybody is connected. 16 For example, in Big Trout Lake where I 17 come from, my mother is ninety (90) years old and she's - 18 - she's still alive. She's at the extended care in Sioux 19 Lookout. But she has -- the last time I counted -- we 20 did a count in December. She has a hundred and forty- 21 five (145) grandchildren, great-grandchildren and great- 22 great-grandchildren, and there's been more born since 23 then. Ninety percent of those people live in Big Trout 24 Lake. And then the children, based on the clan system, 25 who can marry in Big Trout, do marry, you know.


1 Otherwise, they marry outside but they come and live. 2 So I'm basically related to 90 percent of 3 Big Trout Lake. I couldn't -- I don't know if I could 4 perform a function like this in a community like that, 5 because I know everybody. 6 And -- and when somebody dies, when a 7 child dies, as you've heard it, it -- it traumatizes the 8 whole community. I've dealt with whole communities when 9 young people have committed suicide, you know, two (2) in 10 a row or four (4) in a row, where the whole community has 11 just shut down. 12 I've gone into communities where chief and 13 council, who are usually the first people to be contacted 14 when something happens, they couldn't talk, no. 15 Nevermind doing investigation, or talking to a coroner, 16 they couldn't do that. 17 So we had to send in crisis teams to look 18 after the parents. And I think and I didn't send in 19 other program to watch the kids for three (3) months, 20 because the community became totally functional. 21 But there are people today in the 22 communities who could perform the functions that -- that 23 you're talking about. For example, the community health 24 representative, CHRs. Now those people are meant to be 25 public health. That's -- that's all they're supposed to


1 do. 2 But I think during the Scott-Mckay-Bain 3 hearing, they discovered that these people were being 4 required to do a lot of work that was not like in their 5 mandate. They were actually doing, what, primary care, 6 right. They were giving needles and x-rays, setting 7 bones. 8 But I think because of the liability 9 issues that's gone -- back now, and so we're now more -- 10 they're -- they're doing more of the public health work 11 at this -- I think they still do DOTs, the direct 12 observed therapy, for people that have TB. They have to 13 make sure they take their medication, right. They 14 perform that function in the communities. 15 But they're there, and they're very 16 experienced people. They know the community. They know 17 the people, and they're more trained than -- than other 18 people. 19 We also have the mental health workers. 20 The need ap. (phonetic) workers, the dog -- drug abuse 21 workers. There's a whole range of workers -- people in 22 the communities that -- that we see could be formed into 23 a team to -- to look after that function, if you could 24 call it that, to be responsible for their thing. 25 I think it would be very unrealistic to


1 expect one (1) person in the community to do that. It 2 would be too -- too traumatic, because you know 3 everybody. 4 And everybody also knows in the community 5 when something happens. When something happens in the 6 community, everybody knows, okay. You can't hide 7 anything. We -- we talk about -- we push the -- the 8 concept of confidentiality, and -- and we use it in our 9 work, but it's -- it just doesn't work, because it's a 10 small community, and everybody knows everybody and 11 everything, really. 12 So, that's why a lot of the clients that 13 we work with come to Sioux Lookout. And -- and the 14 Federal Government spends a lot amount of money bringing 15 people out, because they don't want counselling in the 16 home, they -- they want it in -- in Sioux Lookout because 17 it's -- it's away from everybody, and it's private. 18 They're very diverse, and on top of that, 19 each community is different. There are some communities 20 that are very traditional that follow their -- the -- the 21 Anishinabe way of life. And the -- when you ask Elders 22 about our culture, you ask them what is our culture? 23 They don't -- they don't talk to you about hunting, and 24 trapping, fishing, having snowshoes. They talk you -- to 25 you about the values by which you life: truth and


1 honesty, love and compassion, and respect for all living 2 things. I mean, respect for everything. 3 So how you approach people, especially 4 kids who die, in a Native community is very different, 5 no. You -- you respect that person and you honour that 6 person, and you would never do anything to that body that 7 would not respect it. Very different from western 8 training, where western train -- medical people are 9 trained to think that this is just flesh and blood and 10 bones. 11 And I guess you need that training to be 12 able to, you know, perform the functions that you need to 13 do on the bodies, but to try and do that in a Native 14 community, it's pretty near impossible. But there are 15 people who can be trained to -- to deal with stuff like 16 that. 17 The method that we use for teaching people 18 on how to operate competently in a Native community, and 19 also to teach First Nation people not to overwhelmed by 20 outside technology, is called competency training. And I 21 would -- I -- that -- one (1) of the recommendations I 22 would make for anybody working in First Nations 23 communities is to -- to take that. 24 Because if you -- if you take competency 25 on a scale, on one hand you have cultural proficiency,


1 which is like my late dad. He raised seven (7) of us 2 totally on the land, so -- his skills as a hunter and 3 trapper and teaching us how to live, and no outside -- 4 never spoke -- never spoke English, didn't need to. 5 Never got outside help. 6 I -- I don't think he -- I don't think he 7 got any government help until he retired and got his old 8 age pension. That's the first time he ever got 9 government help for -- to live. Then on the other hand, 10 you have what would be culturally destructive, like the - 11 - the residential school syndrome would be culturally 12 destructive. 13 Cultural competency is one (1) step down 14 from that. Me, I consider myself culturally competent 15 because I'm not as proficient as my Dad was. I couldn't 16 support myself on the land, but I know enough about the 17 culture to know that when I go into a community, any one 18 of the fifty-nine (59) communities that exist up north, 19 how I should behave, who I should talk to, and how I 20 should treat the people who live in that community. 21 And that's what -- that's what all these 22 parties need to learn to do. And that's how you break 23 the ice and that's how you gain the trust that Connie was 24 talking about. And it has to be a team approach, that's 25 what I'm saying.


1 MR. MARK SANDLER: Dr. Eden, we've been 2 talking about community health representatives as serving 3 a function to address some of the needs that have been 4 identified. And again, I'm -- I'm breaking this out into 5 two (2) different needs. 6 The -- the first is one that we've been 7 spending some time talking about, which is the need to 8 improve communications within an environment that fosters 9 trust and -- and confidence. 10 Do you see community health 11 representatives as -- as being the right fit to perform 12 that role within the community? 13 Does that make sense to you? 14 DR. DAVID EDEN: That -- that seems to me 15 to be getting to a level of detail that -- that I 16 wouldn't be qualified to give an opinion on about. In 17 light of the evidence that I -- I've heard from others, 18 it seems to me that each community may have it's own 19 optimal approach. 20 And some communities may say -- and this 21 might be larger ones, for instance -- we have qualified 22 people within the community who could look after this. 23 Other communities might say, we really need to leave the 24 community or bring somebody in. 25 And I think that if we look for a central


1 theme it would be -- it would be useful if each First 2 Nation's community appoints a person or agency who will - 3 - who services will be offered in liaison with the 4 Coroner's Officer. So that's known in advance. 5 And then how each community does it would 6 depend. And it might be the community health 7 representative. It might be a -- a police officer. That 8 -- that can be decided by the community. Or is it 9 someone from a more central place like Sioux Lookout. 10 But that would be the first recommendation. 11 And then the second recommendation would 12 be that there should be an Aboriginal liaison officer who 13 would act as a central resource for those persons and 14 agencies. 15 MR. MARK SANDLER: Let me ask you now, 16 Dr. Eden, turning back to the -- to the second issue that 17 again has been spoken about at some length in the course 18 of our Inquiry, but we're -- we're kind of flushing some 19 of these things out to -- this afternoon. 20 We know that from Dr. Butt and others who 21 have testified at the Inquiry that -- that there is use 22 of non-doctor investigators in other jurisdictions. And 23 I believe Alberta was one (1) of the jurisdictions that 24 was cited. 25 Have you looked at the use of, for


1 example, nurses or non-doctors to perform the 2 investigative functions in other jurisdictions? And -- 3 and does that have any application here? 4 And I'm mindful that -- that you've 5 already spoken to the -- to the -- what you see as the 6 optimal situation, which might be well trained, well 7 resourced police officers performing that -- that role. 8 But I'd be interested in your comment on what apparently 9 is going on in other jurisdictions as another model and 10 whether that has any application to what we're talking 11 about. 12 DR. DAVID EDEN: I haven't -- I haven't 13 had the benefit of doing a formal study of other 14 jurisdictions, but I work with other jurisdictions and 15 know that there are various types of coroners and -- and 16 medical examiners out there. 17 I -- I'm certainly aware of the system 18 that's used in Alberta. The nurse -- the nurses there, 19 to my understanding, particularly on complex cases, work 20 under very close supervision of the medical examiner. 21 And that is to say they're not acting as independent 22 investigators for more complex cases, although the -- the 23 degree of independence varies depending on the type of 24 case. 25 There -- there's a number of models used


1 throughout North America and throughout the world. 2 You'll find that each of them, well, really -- really 3 takes into the accounts of the characteristics of the 4 jurisdiction in which they're located, what resources are 5 available, and how best those should be used, but of 6 course is historical, as well. 7 The -- I've been working in a medical 8 coronial system and the strengths of it to me have a lot 9 to do with the fact -- and it goes back to our 1971 10 Ontario Law Reform Commission report -- it has to do with 11 our approach in Ontario that the point of the Coroner's 12 Office is not -- is not simply to determine the facts of 13 death. That's a very important job. But what the 14 creators of the Act spent a lot of time doing was saying 15 this is about prevention of future deaths. 16 We, in Ontario, think it's very important 17 and you don't see that as much in other jurisdictions. 18 Our Coroner's Office, I would say, is more 19 actively involved in prevention than most other 20 jurisdictions. And in fact some jurisdictions have death 21 investigation systems that are almost entirely uninvolved 22 in the prevention of future deaths. And that's an area 23 in which medically trained coroners can be of enormous 24 value because that's a core part of -- of the medical 25 philosophy is prevention.


1 The -- I could see nurses in a general 2 sense -- so I -- I've seen forensic nurses working in 3 jurisdictions and I -- I believe it -- it could work. 4 The issue for me, for nurses in the rural communities, is 5 that there is -- there are only one (1) or two (2) nurses 6 in a rural commu -- community and they will necessarily 7 have existing therapeutic relationships with families 8 there, and that's -- that would pretty well preclude 9 during -- doing a death investigation. That -- that's an 10 inherent conflict of interest to do a death investigation 11 on your own patient. 12 So I would go back to the -- the skill set 13 that I laid out of the investigative skills, the 14 professional skills, and so on, and say, you know, that 15 there's a variety of groups that could provide it. We 16 would look at the resources we have and my suggestion 17 would be that physicians and police officers have those. 18 Are there other people? There could be. 19 MR. MARK SANDLER: Wally has some 20 questions for Mr. Morris, so I'll turn it over to Wally. 21 MR. WALLY MCKAY: Thank you, Mr. Sandler. 22 James, just to follow up on what has been presented by 23 the panel members, the issue of Aboriginal liaison 24 people. And just recall Chief Connie Gray-McKay's 25 statement that, you know, yes, you know, that's good, but


1 it is not enough. You know, we need -- we need more than 2 that. 3 And Chief Morris stated that, you know, 4 suggested the idea having some people in the communities 5 trained to do this. Right now we're not getting -- a 6 statement was made, we never see a coroner up there, you 7 know, and -- and so basically you have this legislation 8 and -- that our communities up north are not being 9 accessed or provide -- a service being provided from the 10 Coroner's Office, just looking at -- just the history -- 11 I want to frame my question with a -- background 12 information. 13 I remember a number of years ago we 14 started a Justice of the Peace program because we weren't 15 getting enough courts in our communities. So we started 16 working with the government, and so we said, Okay, let's 17 find a way of doing and then Justice -- Peace of the 18 program came in and now we have some of the finest cour - 19 - Justice of the Peace that go regularly and carry all 20 the function holding courts there. You know, we have a 21 number of other things that have gone on over the years. 22 And so I'm wondering, you know, from your 23 experience, James, in being involved in so many areas 24 what I would -- you know, I don't know -- the coroner 25 talks about there is five (5) questions you have to


1 answer, you know. 2 Do you presume, or do you think that we 3 can go further than Aboriginal liaison officers? And I 4 just want to add, liaison officers is -- is not a good 5 term to use for us, you know, because in -- we refer to 6 them as messengers, you know. When somebody doesn't want 7 to send -- deliver a good message, you send a liaison 8 officer, you know. So -- so we beat up that guy, you 9 know. 10 But if -- if the First Nations decided to 11 establish a program, wouldn't the coroner's mandates and 12 things like that, work with the Government, things like 13 that, do you think -- you know, how long do you think 14 would this come about, or you know, that we would have 15 trained people in place? 16 You know, from your experience, from, you 17 know, putting into place the other things that will be 18 done. 19 MR. JIM MORRIS: Okay, before I answer 20 your question directly, I have rather a simplistic way of 21 viewing policy and program development. 22 To me, a policy reflects a community need 23 and before you can find out what that need is, you have 24 to talk to people at the community to find out what the 25 nature of that is, and then your policy is based on that.


1 And then the program that you design is supposed to meet 2 that need. 3 So when you talk about, like a liaison 4 person, I don't know where that came from. You know, is 5 that just something that you guys cooked-up that you 6 think might be a good idea? Or did you actually talk to 7 the people in the communities, and did they say, Yeah 8 that's a good idea, let's do that, or that's what we 9 need. I don't think so. 10 I think you have to spend more time 11 talking to the people to see if your policy and program, 12 if -- if it doesn't meet the needs of the people in the 13 communities. And it sounds like to me it isn't. Then I 14 think you need to, you know, do it in a more 15 comprehensive way to find out exactly in what way the 16 people in the communities want to access your services 17 and then -- and then they'll tell you how it can be done. 18 I don't think you're there yet. 19 I don't think these hearings are going to 20 generate that information. It'll give you some ideas, 21 but you really need to talk to the people in the 22 communities at some point in time. I -- I know you've 23 been to some communities already, but there's -- there's 24 fifty (50) communities out there and they're all very 25 different.


1 In terms of developing people, or persons, 2 in the communities who could perform this function, 3 because we have such a lack of resources in -- in our 4 communities, we've always been -- we've always had to 5 build what's already there. So if you're asking me how 6 long would it take to develop these people, I wouldn't 7 start there, I would look at the people that are already 8 there to see how they could be used. 9 Now, just to give you an idea of some of 10 the people that become -- that become activated when 11 somebody dies, like a child, right now. In a community 12 where there is a nurse, usually it's the Chief or Council 13 who get the first call, right. They're involved. The 14 second person to get the call would be the nurse, if 15 they're in there. If there's no nurse, the CHR gets the 16 call, and then the police. 17 So in a situation where we've got young 18 people that have hanged themselves, which has been a lot, 19 it's usually the -- the CHR, or the police, that take the 20 -- the people down. 21 But there are also mental health workers 22 in -- in some communities. Each community has money to 23 hire mental health workers. They become very involved 24 very -- very quickly to -- to help those people who are 25 affected, or traumatized by the incident. Some


1 communities have justice workers. And then there are the 2 child welfare workers that Barb was talking about. 3 They're -- they're in every community. 4 Also there are Elders. There -- there are 5 people in our communities who are expected to perform 6 certain functions. For example, I remember when somebody 7 had drowned, we all participated in dragging the lake to 8 -- to look for the body. But when we found it, we were 9 asked not -- not to bring it up. 10 There was two (2) men, two (2) of the 11 older people in -- in another boat who were there for the 12 express purpose of handling the body and bringing it out 13 of the water. That -- that was their job and they were 14 expected to perform their function. 15 In some communities there's also a person 16 who's expected to organize the funerals. They make the 17 coffin that -- that's their skill set. They make the 18 coffin, they dig the grave and they -- they perform the 19 whole -- like a -- like an undertaker. It's not a paid 20 position, it's just a -- something that the whole 21 community agreed that this -- this is what this person's 22 going to do and -- and there is universal acceptance for 23 that person to do that work. 24 And then the police officer. One (1) of 25 the problems that some officers have is they usually know


1 the people in the community and that makes it difficult 2 for them in some cases to deal with these situations. 3 The community nurse -- in Sioux Lookout 4 right now there are two (2) physicians practices that are 5 based in Sioux Lookout that work in the communities. 6 Right now though they only go into -- one (1) group 7 consisting of sixteen (16) doctors, only go into the 8 communities five (5) days a month. That's -- that's the 9 amount of time they spend in the community. But where 10 they're in the community when something happens, they -- 11 they become involved very quickly. 12 So the health and met -- mental health 13 resource people, also from tribal councils, the health 14 authority and Northern, become very involved at -- it you 15 were to spend some time looking at the people who are 16 already involved in these types of situations, we believe 17 that you could you know, create a community investigation 18 team group from -- from that -- that group. 19 But I think it's unrealistic to think that 20 one (1) person can do it, or having a liaison person 21 sitting in a desk in Toronto is going to do anything. 22 It's -- you're way, way short there. 23 MR. MARK SANDLER: All right. What I'm 24 going to do, as I always do, is invite each of our 25 panellists to make any concluding remarks and then we'll


1 canvas whether other counsel have any questions. 2 So, Mr. Morris, are there any other 3 concluding remarks that you'd like to make? 4 MR. JIM MORRIS: You were talking a lot 5 about -- when I was listening this morning to you people 6 talking about a liaison person, it may be a good idea, 7 because I've seen it done elsewhere, but I think you need 8 to go beyond that. 9 And I think you need to talk to the 10 communities about the idea of selecting a group of people 11 who would act as a team to perform that function in the 12 community, and then train them on what -- whatever it is 13 that a coroner wants them to do when a death happens. 14 MR. MARK SANDLER: Thank you very much. 15 Dr. Eden...? I seem to always be asking 16 you if you have any concluding remarks, so. 17 DR. DAVID EDEN: I -- I'll say that I -- 18 I agree with Mr. Morris. This is a -- a challenging 19 issue and we should look at a -- a flexible response 20 which might be one (1) person, might be a number of 21 people, might be in the community, outside the community 22 or some combination. 23 The -- the one (1) thing I would say 24 though is that I could -- my -- I didn't say it and I 25 should have, my view is certainly not the Aboriginal


1 legal officer -- or liaison officer being the -- being in 2 Toronto. My view is that that officer should be in 3 Thunder Bay or certainly in a northern venue. That's the 4 appropriate place. Still providing provincial oversight, 5 because there are First Nations throughout Ontario, but I 6 think Thunder Bay would be the logical place for -- for 7 that officer. 8 There -- there's really two (2) sides of 9 the coroner's investigation that we've been looking at. 10 The one (1) is the investigation of the body and the 11 other is the communication of the investigative findings 12 to the family. 13 And those to me are quite separate 14 functions and should be maintained as separate issues to 15 be dealt with. I -- I have concerns about Mr. Mckay's 16 evidence in that -- it -- it sounded to me as if the five 17 (5) -- the answers to the five (5) questions are 18 elementary and they're not. And this in fact has -- 19 what's occupied a great deal of time at this Commission 20 is -- is the struggles that investigators and 21 pathologists, police, and ultimately the courts had over 22 deciding how and by what means a child came to his or her 23 death and the consequences of an incorrect finding there 24 are enormous. 25 And so from my point of view, in that I


1 certainly would not like to see that happen again, it's 2 critical that the decisions made are made according to 3 the -- the highest quality. 4 And how exactly that's done I think is 5 something that needs to be looked at further. We do have 6 the issue of coroners not being able to attend the scene. 7 How we should address that, I think, as I said, could be 8 discussed further, but it's got to be a quality scene 9 investigation, the highest quality, as expected elsewhere 10 in Ontario. 11 And Ontario, in my view, is a world leader 12 in the investigations we do at death scenes. And to do 13 it right, we have to have it conducted by someone who is 14 skilled and who does the investigations on a regular 15 basis. 16 The -- I -- I hear about a -- a lay 17 investigator in a small community -- and even leaving 18 aside the issues of impartiality and the independence 19 issue -- and, certainly, counsellor for NAN has spoken 20 about how important independence of the coroner is, 21 another point -- it's important that the investigator 22 have enough cases to maintain skills. And in a town of 23 five hundred (500) or a thousand (1,000) people, volume 24 is an issue. 25 So I can't say I know what the right


1 answer is. I -- I've given suggestions in that regard 2 but I will say that the important thing is quality and 3 that quality has to take into account the very serious 4 downstream consequences of decisions made very early in 5 the investigation. 6 And, again, operationally these are 7 decisions made in the first few hours of an investigation 8 that can have significant consequences in the criminal 9 courts. 10 MR. MARK SANDLER: Thank you very much. 11 Commissioner, I understand Mr. Falconer 12 has a few questions. 13 COMMISSIONER STEPHEN GOUDGE: Mr. 14 Falconer...? 15 16 QUESTIONED BY MR. JULIAN FALCONER: 17 MR. JULIAN FALCONER: Mr. Morris, Dr. 18 Eden, good afternoon. I'll reintroduce myself just for 19 the purposes of process. It's Julian Falconer, counsel 20 for Nishnawbe-Aski Nation and Aboriginal Legal Services 21 of Toronto. 22 I -- I found Mr. Morris's caution to look 23 at what community is asking for, how are they expressing 24 their need, to be very illuminating and, frankly, a real 25 lesson in going back to basics. And I want to start with


1 that lesson for a moment, if I can, to canvass, to 2 understand the issue. 3 Dr. Eden, can you speak to the question of 4 how, in the urban centres, a doctor as an investigating 5 coroner works with a police officer, in brief terms? 6 Just going back to basics, how it works in 7 an urban centre. In other words -- and if I can put it 8 in another way, can you explain how it works when it 9 works the way it's meant to under the Act? 10 DR. DAVID EDEN: The -- the coroner will 11 attend at the scene with the police officer and they -- 12 and there will be a discussion at the scene. The coroner 13 has their jurisdiction and the police have theirs, and 14 depending on the nature of the case, that maybe the 15 coroner or the police were the lead investigator. 16 But I think the point here is that the two 17 (2) attend together, are viewing the scene and the body 18 simultaneously and the coroner is making decisions with 19 that. 20 MR. JULIAN FALCONER: And I guess where 21 I'm going with this dis -- asking you this, is it is -- 22 we're kind of past the point, in terms of navel gazing, 23 of hearing from community that the Coroner's Office isn't 24 present in -- in -- in -- in First Nations communities in 25 -- in these communities, that is that because of the


1 hurdles or barriers discussed before. 2 So whereas you have that dual 3 relationship, a -- I'll call it lay investigator because 4 it's a medical investigator. You have a doctor working 5 with a police officer. You have that dual relationship 6 operating in urban centres. You don't have that dual 7 relationship operating in First Nations communities. 8 And I'm wondering if you could speak to 9 that, because I'm -- I'm suggesting, for the sake of 10 discussion, that that's the part that's missing. 11 Does this make any sense what I'm raising? 12 DR. DAVID EDEN: We do have that but the 13 coroner isn't present. But the coroner is in 14 communication with the -- with the police. So there -- 15 there is still an investigation going on that involves 16 both agencies, but the coroner isn't present at the 17 scene. But I wouldn't want that to mean that the police 18 are taking over the coroner's role or making decisions on 19 behalf of the coroner because that is not happening. 20 MR. JULIAN FALCONER: And that -- that's 21 helpful. And so -- what the -- the issue that -- that 22 appears to be being grappled with is in a number of 23 different jurisdictions they use lay investigators. And 24 the lay investigator that Dr. Butt talked about, it could 25 be a nurse, in a jurisdiction he was referring to, or it


1 could be other healthcare professionals. 2 And obviously, doctors, for example, would 3 have to get the training in law that you referred to 4 before that's part of the coroner's system. There'd be 5 certain training that the -- whatever that the lay invest 6 -- whatever the medical investigator gets -- you referred 7 to whole number of things they have to be trained in 8 outside of medicine. 9 And doesn't that happen with coroners now? 10 Isn't that what's happening with investigating coroners? 11 They get trained in law or other aspects of their 12 decision making that is non-medical? 13 DR. DAVID EDEN: That's correct. I -- I 14 spoke it -- about the general background that we look for 15 in investigators or that I would recommend for 16 investigators and then the specific knowledge and skills 17 for the coroner. 18 MR. JULIAN FALCONER: As the Executive 19 Director of Sioux Lookout, Mr. Morris -- Sioux Lookout 20 Health Authority, can you identify, Mr. Morris, who you 21 see as an existing health -- community-based health 22 resource that would represent potential training 23 candidates that would be amenable to training around the 24 importance of independence, or training around the 25 importance impartiality, and training around decision


1 making along the lines -- and communications with family, 2 and decision making along the lines that Dr. Eden talked 3 about. 4 In other words, are there resources out 5 there that can -- that can potentially represent that 6 beginning? 7 MR. JIM MORRIS: I think the only -- the 8 only healthcare professional -- professionals that are in 9 the communities for any length of time are the -- the CHR 10 people. Everybody else is a transient worker. 11 The nurses -- I think the longest period 12 of time that the nurses stay in the community is nine (9) 13 months and then -- and then they're circulated. Some of 14 these nurses only get outpost training, what they assume 15 to be a jack-of-all-trades, otherwise the rest are just 16 contract nurses from certain hospitals. 17 But if you were to look at the CHR -- not 18 -- first of all, the CHRs are band employees, okay. I -- 19 I don't have any control over CHRs. I don't know -- only 20 each -- each individual community controls their CHRs, so 21 if we were to -- wanted to propose anything for those 22 guys then you would have to consult with the chiefs 23 collectively to see if -- if -- to consider any proposals 24 that may be proposed for them. 25 But the CHR are the only people who are


1 there for any length of time. As I said, they know the 2 people, they know their medical history and social 3 history. They see people in the communities. In many 4 places, this is -- this is one (1) person who is trusted 5 by families because they -- they look after them on a 6 regular basis. 7 When something happens, the CHR's one (1) 8 of the people that provides comfort to the families. And 9 they know their culture, they're from the community, and 10 they know the language. 11 They know little things about people like 12 bruises; they know the difference between somebody having 13 a -- a bruise and a birthmark, stuff like that. They 14 know their people well, you know, personally, like that. 15 They're familiar with the community norms. 16 They are aware of any genetic illnesses that may be in 17 the community. They also understand the religious and 18 spiritual orientation of different groups in the 19 community, and they vary quite -- quite widely in some 20 cases. 21 And they can provide the -- the accurate 22 language interpretation that -- because language is very 23 important because -- and we learn this through work -- in 24 working with our doctors, because I have observed a 25 doctor talking to my mother one time and my niece was


1 interpreting. 2 So here's the doctor talking to -- to my 3 mother, and giving her the diagnosis and all that, and 4 there's my niece who wasn't a trained interpreter talking 5 to my mother. But I noticed that my niece only 6 interpreted what she understood, which wasn't everything 7 the doctor said. 8 So after the interview, the doctor says to 9 my mother, Do you understand, and my mother said, Yes, I 10 understand. But we realized that she only understood 11 what she was told, and there's a big block of information 12 that was missing. 13 CHRs can deal with that because they're -- 14 they're medically trained people. Some other cons is 15 that the CHR is probably related to everybody. 16 And if things don't turn out right, and -- 17 say in an investigation, they could get impacted 18 negatively if there's controversy over an investigation 19 or something. That sort of thing. 20 But the CHR is a key person. But as I 21 said, that's something that would have to be negotiated 22 with the Chiefs, collectively. 23 MR. JULIAN FALCONER: Thank you very 24 much. 25 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr.


1 Falconer. 2 3 (BRIEF PAUSE) 4 5 MR. MARK SANDLER: Sure. Thank you very 6 much to both of you. As you've gathered from our 7 roundtables earlier on today, we've been wrestling with 8 the -- with the issue of how to deal with the 9 communication issues, and the investigative issues that 10 are raised in the community. 11 And you provide some -- some new insights 12 to -- to what's been a question that has been discussed 13 throughout the day, and will undoubtedly make it's way 14 into submissions later in the piece. 15 So thank you both. 16 COMMISSIONER STEPHEN GOUDGE: And let me, 17 for my part, thank you both as well. You have both added 18 a great deal to our storehouse that we have to figure out 19 how to use. So thank you for coming. 20 MR. MARK SANDLER: Commissioner, we want 21 to reconfigure for the next roundtable and do that fairly 22 quickly. 23 So perhaps we could just break for five 24 (5) minutes and reassemble? 25 COMMISSIONER STEPHEN GOUDGE: That is


1 fine. 2 3 --- Upon recessing at 2:50 p.m. 4 --- Upon resuming at 3:00 p.m. 5 6 MR. MARK SANDLER: Mr. Commissioner, if 7 we can turn to our fourth roundtable, and we've entitled 8 it Improving Communication Between Aboriginal Communities 9 and the Chief Coroner's Office. 10 And if I can introduce our panellists. To 11 your far left, is Nathan Wright of the Chiefs of Ontario. 12 Mr. Wright is a member of Six Nations. 13 He is the Justice Coordinator for the 14 Chiefs of Ontario, and he has responsibility for 15 coordinating and facilitating justice issues on behalf of 16 a hundred and thirty-four (134) First Nations in Ontario. 17 Welcome, Mr. Wright, and thank you, 18 because I know you were pressed into service on 19 relatively short notice, so we're very grateful that 20 you're here. Thank you. 21 Beside him is Deputy Grand Chief Alvin 22 Fiddler. Deputy Grand Chief Fiddler was born in Sioux 23 Lookout, Ontario, and raised in Muskrat Dam First Nation. 24 At the age of thirteen (13), he left his 25 community to attend high school in Sioux Lookout and


1 Thunder Bay. He studied business management at the 2 University of Lethbridge in Alberta. 3 In the early 1990s, he helped his family 4 establish a fly-in fishing and hunting camp in their 5 traditional territory in Two Rivers. 6 After working as the first executive 7 director of the Tommy Beardy Memorial Family Treatment 8 Centre in Muskrat Dam, he served as his communities 9 Deputy Chief from 1993 to 1998. He served as NAN's 10 Health Director from 1998 until he was first elected 11 Deputy Grand Chief of NAN in 2003. 12 Deputy Grand Chief Fiddler was re-elected 13 to a second term in 2006. Welcome to you. We have Dr. 14 Eden back again, and we also have back with us Dr. Bonnie 15 Porter, the Chief Coroner of Ontario who was appointed 16 Regional Coroner for Niagara -- in Niagara in 19 -- in 17 January of 1991 and Deputy Chief Coroner of Inquests in 18 May of 1996, and she became the Chief Coroner in 19 September of 2007, and welcome again, Dr. Porter. 20 21 PANEL 4 - IMPROVING COMMUNICATIONS BETWEEN ABORIGINAL 22 COMMUNITIES AND THE OCCO: 23 24 NATHAN WRIGHT 25 ALVIN FIDDLER


1 DAVID EDEN 2 BONITA PORTER 3 4 QUESTIONED BY MR. MARK SANDLER: 5 MR. MARK SANDLER: Well, ladies and 6 gentlemen, you've heard in the course of the day there's 7 been much talk about communications and the need to 8 improve communications as between First Nations 9 communities and the death investigation team including 10 the Chief Coroner's Office. 11 So rather than go back over ground that's 12 already been tread, I'm interested in hearing from each 13 of you as to what specific suggestions that you might 14 make that could address the communications issues that 15 we've talked about today and previously at the Inquiry. 16 And I know part of the focus of that 17 discussion will be on protocol, so I'm going to turn to 18 the Deputy Grand Chief first and ask you to comment on 19 the need for a communications protocol between First 20 Nations and the Office of the Chief Coroner of Ontario? 21 DEPUTY GRAND CHIEF ALVIN FIDDLER: Thank 22 you. Good afternoon, Mr. Commissioner, and ladies and 23 gentlemen. As part of our presentation here today, we 24 also submitted a discussion paper to the Commission which 25 outlines a process which we think would work in terms of


1 improving the -- the -- the system in Ontario as it 2 relates to our communities in -- in the Anishinabe 3 Nation. 4 And it -- it talks about -- or it 5 references the -- the commitment that was made by this -- 6 by the government of Ontario back in 19 -- or back in 7 2005. Their commitment to establish a new relationship 8 with -- with First Nations to -- and that relationship 9 should be based on cooperation and -- and respect, and 10 that's what we're putting forward here today, is a 11 process. Some people may call it a protocol, but our 12 relationship with First Nations, with Anishinabe Nation 13 and the coroner services to -- to be based on that, to -- 14 to -- for us to -- to have -- for us to sit down and have 15 a meaningful dialogue and to involve our communities from 16 -- from the grass roots, from -- from our members, from 17 our -- from our leaders in our communities to -- to sit 18 across the table in partnership with the -- with 19 provincial representatives for us to -- to define what 20 that would look like. 21 And -- and that's what the paper outlines. 22 MR. MARK SANDLER: All right. And I 23 should say, Commissioner, that we were provided the 24 discussion paper and there are hard copies of it 25 available on the table behind you for those who have not


1 already received one, and we will post it electronically 2 when we -- when and if we get back to Toronto. 3 But perhaps I'll ask you, Deputy Grand 4 Chief Fiddler, I see at page 10, that -- that it has been 5 suggested that the protocol could have certain features. 6 And -- and I -- I wonder just for the 7 benefit of those who are listening as well, if you could 8 just highlight, for the Commissioner and -- and the 9 listeners, what you regard as some of the key features 10 that would make their way into a communications protocol 11 such as you've advocated? 12 DEPUTY GRAND CHIEF ALVIN FIDDLER: Well, 13 I think first of all -- first of all, I think in order 14 for -- for -- for this to work, I think there has to be 15 an acknowledgement of who we are, and I referenced the -- 16 the -- the provinces and commitment earlier that the 17 commitment that -- that they made to First Nations back 18 in 2005, and one (1) of the developments that came out 19 from that is the creation of a new Ministry dedicated to 20 First Nation or Aboriginal affairs and there's a new 21 Minister that was appointed following the -- the election 22 in the fall. 23 And we've met with the -- with Minister 24 Bryant on -- on a few occasions now. And every meeting 25 that we've-- we've met with him, he talks about the


1 relationship that -- that he envisions that the province 2 needs to establish with First Nations. 3 And he talks about a government-to- 4 government relationship; that everything we -- that we do 5 and every issue that we need to address should be based 6 on that. And that's what the -- the protocol that we're 7 proposing, you know, that -- that's what we were basing 8 it on. That it shouldn't just be, you know, Anishinabe 9 Nation is not -- we are not service providers. We are 10 not stakeholders. We are not part of an interest group. 11 We are a nation, and we are a government 12 and -- and this is based on the treaty that we signed 13 with Canada and Ontario a hundred (100) years ago. So 14 that -- to me that's -- anytime we want to talk about the 15 relationship with the province, it should be based on it, 16 and -- and to me, that's -- that's the -- the basis of 17 this proposed protocol. 18 And there's some details there that -- 19 that we outlined that would be a part of that and -- but 20 to me, it's about respect. It's about having that -- 21 acknowledging that -- who we are and -- and working 22 together on that basis. 23 MR. MARK SANDLER: Mr. Wright, I know 24 from personal experience how much work you've done in the 25 -- in the past and continue to do on issues relating to


1 the existence of protocols, so -- so I'd be interested in 2 -- in your views from a Chiefs of Ontario perspective on 3 what the Deputy Grand Chief has had to say. 4 And I know you've had an opportunity to 5 have a quick look, at least, at the discussion paper and 6 -- and some of the contents that are being proposed for 7 communications protocol. Your comments? 8 MR. NATHAN WRIGHT: Thank you, Mr. 9 Sandler. I echo the comments of Deputy Grand Chief 10 Fiddler in terms of the -- the notion of a protocol 11 should speak to the -- the improvement or the -- the 12 strengthening of the relationship between First Nations 13 all across Ontario and the -- the Government of Ontario. 14 I think that, in my past work, and as you 15 are aware, that's one (1) of the items that we push for 16 in other inquiries, such as the Ipperwash. I think the - 17 - the point I want to underscore on that is that as we 18 move forward, the relationship cannot be defined by the 19 Province of Ontario or its agencies as we move forward. 20 It can't be a prescribed relationship. It's got to be a 21 relationship built on mutual respect and trust on both 22 parties. 23 When -- when we look at the relationship 24 between -- in the past, it -- it's been very colonial, 25 very parentalistic in -- in the approach by the Crown


1 governments in right of Ontario and right of Canada. 2 And when we -- when we move forward, I 3 think protocols -- in any protocols, for it to be 4 successful, there has to be that groundwork laid out in 5 terms of respect for First Nations in terms -- and 6 recognition in terms of the inherent rights. 7 Also, linked in with the respect and 8 reconciliation of those rights is the need for equal 9 capacity on both sides. We heard a number of speakers 10 this morning that -- that spoke of the -- the inadequate 11 capacity of service providers to provide adequate service 12 to the citizens within their communic -- communities. 13 And I just want to underscore the -- the 14 notion by NAPS in terms of the need for them to increase 15 their capacity and also for recognition. They go to -- 16 they go through the same training as the OPP -- as an OPP 17 officer and yet don't get the same recognition by 18 individuals, as well as the Canadian policies that they 19 have to operate under. 20 So for -- again, just on the score, for 21 protocols to be successful, those are some of the 22 elements that -- that need the strength that -- we need 23 to strengthen in tandem for protocols of communication to 24 be successful. 25 MR. MARK SANDLER: And -- and just


1 following up for a moment. Would you envisage protocols 2 as between the Chief Coroners Office, and -- and the 3 Chiefs of Ontario, and NAN? Some combination? 4 Could you help us out on some of the 5 dynamics of -- of how that could be organized? 6 MR. NATHAN WRIGHT: Just to put this in 7 the context, I'll -- I'll go over some of the political 8 structure of how First Nations operate in Ontario. 9 For the benefit of those in Ontario, there 10 are three (3) -- what we call three (3) distinct Nations. 11 And they are the Mushkegowuk, the Anishnawbek, as well as 12 the Haudenosaunee in the south. 13 Those nations, through common interests 14 and shared common realities of the day, decided to enter 15 into agreements with the Crown governments over time. 16 And I'm -- I'm just giving a historical 17 context here. They entered into treaties, such as Treaty 18 9 and Treaty 5 for the -- for the -- the NAN territory, 19 as well as a number of other treaties. 20 They've formed treaty groups such as the 21 Union of Ontario Indians, as well as Grand Council Treaty 22 3, and there's also the Association of Iroquois and 23 Allied Indians which is a collective of eight (8) First - 24 - sorry, twelve (12) First Nations that have common 25 interests.


1 So in tandem with that, there's also 2 twelve (12) First Nations which deem themselves 3 Independent First Nations; autonomists, and don't 4 affiliate themselves with any political or -- 5 organization, yet still meet as a collective to discuss 6 collective issues. 7 So the Chiefs of Ontario, what's formed by 8 these organizations back in 1978, I believe -- that's the 9 year I was born. 10 So -- and the -- the -- 11 MR. MARK SANDLER: You remember that, do 12 you? 13 MR. NATHAN WRIGHT: -- the thinking at 14 the time was they needed an organization to discuss 15 common issues that all these Nations had in -- in common 16 across Ontario. 17 So that's the function of our office, is 18 to facilitate and coordinate common issues for First 19 Nations all across Ontario. 20 And we meet on an annual basis, through 21 our annual assemblies, and leadership comes together to - 22 - to pass resolutions that give us our direction. So if 23 that can help in terms of the context. 24 Now getting to the question, my views at 25 this point is that the pro -- protocols should be with


1 those organizations that represent those common views. 2 Like the -- the NAN, Nishnawbe-Aski 3 Nation, as well as the Unit of Ontario Indians, AIAI, and 4 Grand Council Treaty 3, and the Chiefs of Ontario's role 5 would be to facilitate the common principles, if -- if 6 we're required to, and if the Chiefs, in assembly, deem 7 that to be our role within it. 8 MR. MARK SANDLER: Thank you. That's 9 very helpful. 10 Dr. Porter, I know that the communications 11 issues that are raised in draft protocol extend not only 12 to some of the issues we've been dealing with but beyond. 13 But I'd be interested in your -- your 14 general reaction to both the idea of the communications 15 protocol with the Office of the Chief Coroner, and 16 perhaps some of the features of the protocol that have 17 been identified, at page 10 and following, of the 18 discussion paper. 19 DR. BONITA PORTER: Well, thank you. I've 20 had an opportunity to -- to briefly review the document, 21 and I think there's certainly a lot there that can be the 22 beginning of discussion. 23 But I think one (1) of the biggest things 24 that has contributed to improving communications is -- is 25 the ability to network that we've been able to -- to 26 begin today.


1 And the other thing that strikes me is, is 2 that it -- it seems that there's not going to be one (1) 3 solution that's going to fit all of the -- the 4 communities. 5 And in the past, the Office of the Chief 6 Coroner has undertaken different processes to improve 7 communications. In the early '90s, Dr. Young actually 8 hired a consulting firm from Six Nations to look at the 9 issue of communications with the Aboriginal communities 10 in the north, and a study was done, and there were a 11 series of meetings that were held where coroners visited 12 communities. 13 Aboriginal community representatives came 14 and met coroners. And I think that probably went away to 15 -- to deal with some of the -- the concerns about not 16 understanding the roles. 17 Clearly that was a long time ago, but that 18 is one (1) way that -- that improving communication can 19 be accomplished. It's just by getting together and to 20 discuss things. 21 And that -- that may be a circumstance 22 where you can't get a protocol that is going to meet 23 everyone's needs, but the important aspect is is that you 24 meet, you know who to call. 25 And what you find in coroner's work is 26 that you're never going to be able to put down on paper


1 something that's going to meet every circumstance because 2 the types of tragic deaths that we sometimes are asked to 3 investigate are not ones that we've ever experienced 4 before. 5 So it's tragic for the community. It's 6 tragic for the family. And there isn't a road map. And 7 you have to be able to work together to discuss with 8 those who have some expertise and who have done tragic 9 deaths before but maybe not the same circumstance. 10 So I don't think we're going to be able to 11 get a protocol on paper that's going to meet everyone's 12 needs, but I think there are a number of ways that we 13 could improve our relationships; the kinds of things that 14 were started in '91. 15 I've -- I've had the opportunity to meet 16 Deputy Grand Chief Fiddler earlier in 2007 to start 17 working on a protocol. Some of the things that I think 18 are here might be addressed by the issues we discussed. 19 Some are missing, and some were -- were added in the 20 other -- the other version. And -- and yet there is a 21 circumstance where we did -- we were able to develop a 22 protocol. 23 In late 1998, I convened a group meeting 24 in Toronto of Aboriginal community members, the 25 Cemeteries Branch, members of police services, to deal 26 with what -- what happens when you find remains, human


1 remains. How do we determine what's First Nations and 2 what isn't? And if we are able to determine they are 3 First Nations, who do we call to ensure that they're 4 returned to their community? 5 So I guess what I'm saying is, there are 6 many different ways we can improve communication 7 relationships. I think we've heard some of them today. 8 There are some that we have initiated in the past that I 9 think will work well again if we reinitiate them. 10 There may be some circumstances or issues 11 that you can develop -- a piece of paper if you like -- 12 where it's written down what you will do when the 13 circumstance occurs. But, unfortunately, I think there 14 are some where you can't. And what's important is the 15 respect that we've talked about, knowing who to call, 16 knowing what the roles are. 17 I think we share common goals and that is 18 to deal with tragic circumstances in really the only way 19 you can, and that is to support people through them and 20 to try to learn from them. 21 So I think we've got a lot of information 22 here that we can go forward. 23 MR. MARK SANDLER: I'm going to go back 24 to -- to you, Deputy Grand Chief Fiddler, and I focussed 25 in my initial question to you on protocols. But you've 26 also had the opportunity not only to hear what's been


1 said today, but I know that you've followed, with some 2 interest, the work of the inquiry. 3 Are there any other strategies that -- 4 that you'd like to propose to the Commissioner that could 5 be utilized to enhance communications with the Office of 6 the Chief Coroner? 7 DEPUTY GRAND CHIEF ALVIN FIDDLER: Well, 8 one (1) of the -- I think the -- the key message I've 9 heard throughout this process right from the -- right 10 from the beginning, even when the Commission visited two 11 (2) of our communities in the fall, and the testimonies 12 that have been given over the last few months and, again, 13 yesterday and today, is that the -- the system, as it 14 currently exists, and as it -- as it currently is 15 designed, isn't -- is not working; that it's -- it is 16 failing our communities. 17 And the relationship that should be there 18 to -- to make that system work -- the relationship 19 between the Coroner's Office and the First Nation 20 leadership in the communities -- is non-existent. 21 And I think that's why we're proposing 22 this -- this relationship. It's our way of reaching out 23 to the Coroner's Office and say, We're willing to work 24 with you. You know, this -- these are some of our -- 25 some of our ideas on paper and -- and for us to -- to 26 work together as partners to -- to see what we can build


1 that's going to work for -- for our communities. 2 MR. MARK SANDLER: All right. And I'll 3 ask the same question. Mr. Wright, do you have any 4 suggestions -- and I know you haven't been as -- as 5 involved in the same way as the Deputy Grand Chief in -- 6 in what has been transpiring at the Inquiry -- but are 7 there any additional comments that you'd like to make 8 about how communications can be enhanced over and above 9 the existence of protocols? 10 MR. NATHAN WRIGHT: Well, I think I'm 11 going to answer that in a very practical way, and I -- 12 I'm just going to pick on -- pick up on the comments made 13 on the earlier presentation by Mr. Morris is that the 14 Chief Coroner's Office should -- well, I don't want to 15 prescribe this, but it would be very beneficial for them 16 to go out to the communities on a very personal basis, 17 and to -- to start that education and awareness of what 18 the Chief Coroner's Office does in relation to the 19 investigations and their principles and their values. 20 And have that understanding and that face- 21 to-face talk with communities. That may require getting 22 on -- on a plane and starting that process and working 23 through with the communities and having that 24 understanding of how they operate. And also at the same 25 time, the communities would be able to -- to relate to 26 them their cultural values and how they deal with these


1 situations at a community level. 2 MR. MARK SANDLER: Dr. Eden, I'll -- I'll 3 turn to you because you've heard, and we've discussed it 4 together in another context, the -- the fact that coroner 5 aren't attending the -- the communities for -- for scene 6 investigations. 7 But what's suggested is that perhaps as 8 part of a renewal of the relationship or creation of a 9 new relationship, would involve the coroners, whether 10 local or -- or the Regional Supervising Coroners 11 attending a number of the communities in -- in the north 12 to -- to build trust and to build relationships. 13 So I'll ask you to comment, as -- as the 14 new man in town, on that. 15 DR. DAVID EDEN: It's one (1) of the 16 disadvantages of choosing cor -- coroner as a career path 17 that one doesn't get a whole lot of invitations for 18 speaking engagements, and I'm, as you've seen, quite 19 happy to speak. And any community that -- organization 20 that wishes to hear from me or wishes to engage in a 21 discussion about coroner's issues, I'll be very happy to 22 -- to attend. 23 MR. MARK SANDLER: All right. I'm going 24 to -- I'm going to do what I do all the time. Those of 25 you who are familiar with my questions, they'll be used 26 to this. I'm going to go -- go down the panel, and I'll


1 start with Dr. Porter, and I'll invite any final comments 2 or any recommendations that you'd like the Commissioner 3 to -- to consider. Dr. Porter...? 4 DR. BONITA PORTER: Thank you. As I 5 mentioned yesterday, we are working very hard on being 6 able to put something that's very practical and detailed 7 to the Commissioner to consider. 8 And as we prepare that document, we 9 certainly will include some of the issues that we've 10 heard today, but I would like a bit more time to consider 11 the -- the discussion paper in order to be able to -- to 12 put something together. 13 So I would like to defer to the -- the 14 recommendations we'll make through our submission. 15 MR. MARK SANDLER: Dr. Eden...? 16 DR. DAVID EDEN: I've got nothing to add. 17 Thank you. 18 MR. MARK SANDLER: Deputy Grand Chief 19 Fiddler...? 20 DEPUTY GRAND CHIEF ALVIN FIDDLER: Thank 21 you. Just to -- I guess as a way of closing off, first 22 of all, I just want to express my thanks to the 23 Commission for giving us the opportunity to -- to have 24 our voices heard through this process. I think we have a 25 lot to say, and we have a lot of issues and concerns that 26 need to be addressed, and we're -- we're grateful for the


1 opportunity. 2 What I wanted to say is that a lot of 3 times in the past, we have been told that whenever we ask 4 for resources, whether it's in education or healthcare, 5 or in policing, that we are told -- our chiefs are told 6 that you're communities are too remote, that your -- your 7 communities are inaccessible, that it's too expensive to 8 deliver that service or that program in your community. 9 But if you flip -- flip it around, 10 whenever there's a -- a discovery made in -- in our 11 territory whether it's gold or diamonds or potential 12 sites for energy, millions and millions of dollars are 13 spent building roads and building airports to get at 14 those resources. 15 And one (1) of the most recent examples 16 that I can think of is -- is in Attawapiskat where a few 17 years ago there was a discovery that was made. There -- 18 there was diamonds that were discovered just outside of 19 the community, and Ontario and Canada worked hand-in- 20 hand, you know, jumping through hoops and jumping over 21 hurdles and -- and the next thing you know the mine is 22 there. 23 It's being built, and it's going to be -- 24 begin operations next year, and yet the community has 25 been asking for a new school for many, many years and -- 26 and the children in Attawapiskat they're still attending


1 that same school. 2 So I think what my point is that -- you 3 know, that -- that excuse isn't -- is not acceptable 4 anymore -- that if we're going to be building a service, 5 whether it's -- it's the Coroner's Services, improve the 6 Coroner's Services in our communities that -- and I heard 7 the testimony, today and yesterday, that it's too 8 expensive, that we cannot go to the remote communities 9 because -- because of the cost, or that we're too remote, 10 or that we're too inaccessible, and that shouldn't be. 11 So I just want to -- I guess my 12 recommendation to this Commission is to look at what 13 we're putting forward, to work with us as partners, and - 14 - and putting it together and -- and making it work. 15 MR. MARK SANDLER: Thank you very much. 16 Mr. Wright, last word to you. 17 MR. NATHAN WRIGHT: My -- my final 18 comments will again speak to the need for that improved 19 and stronger relationship between Ontario and First 20 Nations. And there needs to be -- for that to continue 21 to be a strong relationship, there needs to be an 22 understanding of the uniqueness in the diversity of our 23 First Nations. 24 Like I mentioned, there's three (3) 25 distinct nations in Ontario and NAN -- NAN's issues are 26 certainly a lot different than the issues of say Six


1 Nations down in -- down in the south. 2 So when we speak of developing protocols, 3 I think there needs to be an understanding that from 4 these protocols might -- might stem on new policies 5 around the -- around the issues of investigation. 6 For those policies to be successful, there 7 needs to be joint -- a process for joint policy 8 development between the two governments, First Nation 9 governments and the Government of Ontario, for those 10 policies to be successful and also the strength and the 11 communication protocol, so those are -- I'll just -- I'll 12 just leave that with you right there. 13 MR. MARK SANDLER: Thank you very much. 14 Counsel for two (2) of the parties have some brief 15 questions. 16 Mr. Gover...? 17 18 QUESTIONED BY MR. BRIAN GOVER: 19 MR. BRIAN GOVER: I'm going to be very 20 brief, and I'm going to turn to Dr. Porter, and Dr. 21 Porter, we've heard from others, including Dr. Eden, 22 about the potential for having a person who would be 23 responsible for assisting in liaison functions with 24 Aboriginal communities, and -- and I won't call that 25 person a liaison officer in -- in light of the views of 26 the gentleman to my right. I'll call that person a


1 liaison coordinator, perhaps. 2 Do you see any scope for having someone 3 who had the liaison coordination function between the 4 Office of the Chief Coroner and those communities 5 attached to the regional senior -- Regional Supervising 6 Coroner's Office here in Thunder Bay, for example? 7 DR. BONITA PORTER: I certainly would see 8 the value of it in -- in an area where there are unique 9 needs that perhaps are not elsewhere in the province, so 10 I would say, Yes, I could certainly see that there would 11 be a role for someone to fulfill. 12 Interestingly enough, we've also, in part 13 of our preparation for a submission to the Commissioner, 14 identified that there perhaps is a need for everyone who 15 has experience with the Office of the Chief Coroner or 16 the need to communicate that we should have a family 17 services or a family information person for the whole 18 office so that anyone can sort of approach one (1) -- one 19 (1) person, one (1) contact, so I guess the answer to 20 that is -- is yes, but I would say it extends beyond the 21 north. 22 I think that we have identified that there 23 is a need for anyone to have one (1) point of contact for 24 family information. 25 MR. BRIAN GOVER: Thank you. 26 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr.


1 Gover. 2 MR. MARK SANDLER: Mr. Falconer...? 3 4 (BRIEF PAUSE) 5 6 QUESTIONED BY MR. JULIAN FALCONER: 7 MR. JULIAN FALCONER: Good afternoon. 8 And for -- I realized, as I was listening to Dr. Porter, 9 that I had neglected to congratulate you on your 10 appointment as Chief Coroner, so let me start by doing 11 that. I -- I remind you again, I'm counsel for -- of 12 Nishnawbe-Aski Nation and Aboriginal Legal Services of 13 Toronto at these Inquiry proceedings. 14 I wanted to ask -- you can tell I was 15 planning to ask Dr. Porter the first question, because I 16 made sure I sucked up first in her direction. 17 DR. BONITA PORTER: It didn't work, Mr. 18 Falconer. 19 MR. JULIAN FALCONER: Dr. Porter, I 20 wanted to ask you a matter that -- that I think you're in 21 a unique position to speak to as Chief Coroner for the 22 province. At page 2 of the discussion paper, Nishnawbe- 23 Aski Nation and ALST refer to the Ontario government 24 policy paper -- the policy document entitled "Ontario's 25 New Approach to Aboriginal Affairs." 26 And -- and cited in the next page are just


1 two (2) basic, very basic principles on how the Ontario 2 government, starting in 2005, which is the origin of the 3 policy paper, a few years ago, is re-committing to how 4 government agencies are going to relate to Aboriginal 5 peoples. 6 I -- I wanted to ask you to -- if you 7 could, to comment on how this statement of relationships 8 has played or is going to play a role, or it may have 9 already played a role in terms of how the Office of the 10 Chief Coroner is delivering services to First Nations? 11 DR. BONITA PORTER: Can you refer me to 12 the specific part on the page, the statement that you 13 want me to -- to speak to? 14 MR. JULIAN FALCONER: Well -- 15 DR. BONITA PORTER: Is there -- are there 16 a few lines that I could read quickly? 17 MR. JULIAN FALCONER: Sure, the -- at 18 page 3, you'll see a reference to a commitment to a 19 significant and fundamental shift in the way the 20 government agencies relate to Aboriginal peoples. 21 And of course, I'm including the Office of 22 the Chief Coroner as a government agency. And it says: 23 "It means change in the way Ontario 24 conducts its relationships with the 25 different Aboriginal communities and 26 organizations across the province.


1 Change that reflects differing 2 Aboriginal priorities, and change that 3 gives Aboriginal peoples more say in 4 shaping decisions that affect their 5 lives. We need our Aboriginal partners 6 to work with us to create a better 7 future for Aboriginal children and 8 youth bringing their insight and 9 experience to develop strategies that 10 respond to the real needs of different 11 communities." 12 And what I was inquiring of you, as the 13 Chief Coroner for the province, is to what extent this 14 statement of commitment, this statement of policy by the 15 Ontario provincial government starting in 2005, has 16 informed how the Office of the Chief Coroner delivers 17 services to First Nations. 18 DR. BONITA PORTER: Okay, thank you for 19 that clarification. One (1) of the things that is 20 important as a -- a foundation is to be able to identify 21 how many of the deaths that we do investigate are in 22 Aboriginal and First Nations people, and we did not have 23 a way of doing that prior to about a year or so ago when 24 we added an involvement code so that if the coroner is 25 aware that the deceased person is Aboriginal or that the 26 family is Aboriginal, we have a way of identifying that.


1 So I would see that as being the starting 2 point of being able to -- to address this. And the -- 3 the other thing that comes to mind very quickly is the -- 4 the outreach that -- that we made to establishing a 5 protocol in June of '07. 6 That there was a concern that was brought 7 to my attention that there appeared to be some 8 misunderstanding and a need for cross-cultural dialogue, 9 and I initiated that process, and I'm committed to seeing 10 it through. 11 MR. JULIAN FALCONER: And could I then -- 12 thank you, Dr. Porter. Could I then ask Deputy Grand 13 Chief Fiddler on the -- sort of -- if -- and -- and I 14 don't mean to leave out Chiefs of Ontario, or Mr. Wright 15 or anything else, so I encourage others to answer the 16 same question. 17 Can you assist me, Deputy Grand Chief 18 Fiddler, just expounding from your perspective, to what 19 extent this statement of policy is in play now, and what 20 you see as the role of this policy statement? 21 DEPUTY GRAND CHIEF ALVIN FIDDLER: Well, 22 first of all, we were -- I think we welcome the 23 announcement. The governments announcement to establish 24 this new relationship that -- that they want to work with 25 us on -- you know, based on government-to-government but, 26 you know, to be a respectful relationship, to be a


1 cooperative relationship. 2 And it's not just the -- the government 3 itself that we're looking at. We're looking at all its 4 agents, all the -- the -- the organizations, all the 5 service providers that fall under that government, 6 including the Chief Coroners. 7 And that's what we're hoping to establish 8 is -- is -- is a relationship with -- with the -- with 9 the Coroner's Office to be based on a -- on -- on what we 10 understand that -- that -- that policy to be. 11 MR. JULIAN FALCONER: Did you want to add 12 something to that, Nathan? 13 MR. NATHAN WRIGHT: Yes. Just being my 14 role as -- as -- as the, I guess for lack of a better 15 term, "the brown bureaucrat" with -- with the Chiefs of 16 Ontario, is that I've -- I've been trying to monitor how 17 I see this policy in action. 18 And it's with disappointment today that I 19 say that I don't think this policy is -- well, the way 20 this policy has been rolled out, it hasn't -- it hasn't 21 translated into the improved relationship up and to this 22 point for a number of reasons. 23 One (1) is that the agencies, as well as 24 the Ontario government, do continue to prescribe the 25 relationship which that -- that's a fundamental point 26 that needs to be changed by the Government of Ontario.


1 And further to that, that it's still 2 interpreted without First Nations' content or First 3 Nations' voice being heard within the Government of 4 Ontario as it rolls out. They do use the -- the policy 5 to their own advantage when a few of their commitments 6 actually please the First Nations. 7 But for a roundabout way, I don't think 8 the policy is being rolled out or being implemented as it 9 stands right now. 10 MR. JULIAN FALCONER: And one (1) final -- 11 thank you, Nathan. 12 One (1) final question I -- I wanted to 13 ask you, Dr. Porter, there's been a lot of discussion 14 that you were party to all day, as was I, about the issue 15 of usage of investigators as alternatives to police 16 officers or doctors, for lack of a better word, lay 17 investigators or assistants to lay investigators. 18 What I was wondering is, as we get close 19 to the end of making submissions and everything, what 20 lawyers are going to do and legalize or trialize a 21 process; if we were going back to roundtable thinking, 22 discussions, systemic discussions, is there research in 23 the Coroner's Office about how this process of usage of 24 lay investigators in other jurisdictions has succeeded or 25 failed? 26 In other words, we know that there's a


1 large number, percentage-wise, of jurisdictions outside 2 of Ontario. In other words, somewhere around eight (8) 3 or nine (9) of the other jurisdictions are using them in 4 Canada. 5 I'm just wondering, is there research, 6 within the office of the Chief Coroner for Ontario, on 7 how those lay investigators are working out? 8 DR. BONITA PORTER: I'm not aware of any 9 initiative within our office to look at changing our 10 fundamental system. And I would say that that's because 11 I personally believe that it's still the best utilization 12 of physicians to deal with the primary purpose of what 13 the Coroners' Act says we are about, and that is to learn 14 what happened in any individual death, and to try to make 15 recommendations to prevent it in the future. 16 And I think it's important to remember 17 that we only request or order autopsies in about a third 18 of the cases that we actually investigate. If we did not 19 have physician coroners, that percentage would -- would - 20 - would increase dramatically. 21 So I would -- would not personally see any 22 benefit in -- in looking at a change to the fundamental 23 role that we have or that we -- how -- how we fulfill 24 that role because I believe that the fact that we have 25 physician coroners is one (1) of the greatest strengths 26 of our system. And that the intrusion that we -- we


1 initiate into a family's death when they are dealing with 2 -- a family when they are dealing with a death, is 3 minimized because we have physician coroners. 4 So I don't see that there's any benefit to 5 looking at alternative systems. I believe there are 6 things we can improve on in -- in the way we investigate 7 death in Ontario; ensure that we can -- can deliver a 8 quality investigation, an inquest where appropriate, that 9 we communicate well with families and the other members 10 of the death investigation team and the courts, but I 11 fundamentally believe that one (1) of our strongest 12 strengths is that we have physician coroners. 13 MR. JULIAN FALCONER: And Deputy Grand 14 Chief, did you want to address that at all? 15 DEPUTY GRAND CHIEF ALVIN FIDDLER: Well, 16 that's -- I think that's another reason why we -- why we 17 developed a paper is just to present what we've heard 18 from our -- from our leaders, from our own communities on 19 -- on how we can improve the system that -- to design a 20 system that's going to work for us. 21 To -- to utilize the -- the knowledge of - 22 - of our members and -- and our leaders and -- I think 23 I'm a bit -- I'm a bit discouraged when I hear that the 24 system is more or less -- that it's more or less working 25 in Ontario. That may be so, but what we're saying that 26 in our communities, it's -- it's not working.


1 And when a proposals or proposals are 2 being made to get more police officers or -- or to 3 utilize doctors, we're having a hard time as it is to 4 recruit doctors to come to our communities to -- to treat 5 our -- our patients, to begin to alleviate the -- the 6 high rates of -- of diabetes and cancer and -- and to 7 address public health in our communities. 8 It's -- it's very difficult as it is now. 9 And I'm just not sure how feasible it would be to -- to 10 base or to develop a system based on -- on more doctors. 11 I'm not really sure how that would work. And that's why 12 we're saying, you know, as part of our discussion papers, 13 what -- you know, we want you to work with us to create a 14 system, to develop a system that we know is going to work 15 for us. 16 MR. JULIAN FALCONER: Thank you. 17 COMMISSIONER STEPHEN GOUDGE: Thanks, Mr. 18 Falconer. 19 MR. MARK SANDLER: Commissioner, that 20 completes the questioning for this roundtable. I want to 21 thank each of the participants, as we always do, for 22 their valuable contributions. I also want to take the -- 23 the opportunity as -- as one (1) of the final words to -- 24 to thank those who made our journey to Thunder Bay a -- a 25 valuable one. 26 And that includes, in particular, the work


1 that was done in -- by ALST, NAN, and the Chief Coroner's 2 Office in facilitating a number of the speakers that -- 3 that we've had today, and -- and we're very grateful for 4 that. And particularly the attendance of -- of people of 5 importance in -- in the community to speak to the various 6 issues of concern to us. 7 So I wanted to mention that, and I -- I 8 think Wally had a closing comment as well? 9 MR. WALLY MCKAY: Thank you very much, 10 Mr. Sandler. And thank the -- the panel for their 11 contribution and your statements. 12 Mr. Commissioner, we have heard this 13 morning, from the Elders and the various Aboriginal panel 14 members, putting forth a picture of what happens out 15 there, especially the trauma involved in the passing away 16 of the children. 17 I had mentioned that the community views 18 the birth of children as a gift to the community. When 19 we say in our language (OJI-CREE LANGUAGE SPOKEN), my 20 relations, it's just not a saying, it's a reality where 21 we're all related. 22 And whenever one (1) -- one (1) thing 23 happens to one (1) of those relations is a fact that 24 impacts the community so much. And I think when we look 25 at the -- what has been discussed here, we look at the -- 26 we look at the changes that are needed, and we have seen


1 the Deputy Grand Chief of Nishnawbe-Aski Nation putting 2 out an option for consideration to bring healthy 3 relationships amongst the entities in Ontario for a 4 better relationship. 5 You often think about the law governing 6 the Office of the Coroner and what may have been under -- 7 misunderstood or understand that there is not enough 8 monies to enforce or comply with laws because we are too 9 far up north. 10 When we look at these things, as 11 Aboriginal people, if it cannot be done, if it's in law, 12 then it's a bad law for us. And to me -- we've had to 13 contend with so much bad law in our history, and I think 14 we have an opportunity -- and the Deputy Grand Chief's 15 proposal with that is another attempt to make it right 16 and make it better at this stage. 17 So I'd like to thank -- the opportunity 18 for being here, to listen to, and thank you very much for 19 the opportunity. 20 Yes, for the -- 21 MR. MARK SANDLER: You go ahead. 22 MR. WALLY MCKAY: For the closing I'd 23 like to call upon an Elder from Mishkeegogamang First 24 Nation. James Bottle is going to say a closing prayer 25 for us and then Jeff -- Jeff Neecan is going to come and 26 do the closing with the drum and a song.


1 COMMISSIONER STEPHEN GOUDGE: They should 2 have the last word, Wally, but before they have the last 3 word let me on behalf of the Commission thank the 4 panellists for once again contributing a great deal to 5 our storehouse of knowledge. The presentations have been 6 very thoughtful. 7 I'd also like to echo Mark's thanks to the 8 organizations for what I know was a lot of hard work, 9 both on the part of ALST-NAN and behalf of the Chief 10 Coroner's Office. So I think that's gone into making 11 these two (2) days very fruitful for us. 12 I'd like to thank you, Wally, for your 13 role in cofacilitating it with Mark, it's been very 14 helpful, and to our support folk for all the work I know 15 they've put in to get us onto the internet over the last 16 two (2) days, we're grateful for that, as well. So thank 17 you, all. And now our closing. 18 MR. MARK SANDLER: Yes, Commissioner, 19 just as -- as the Elder proceeds up, I also did want to 20 acknowledge, Ms. Murray was to be on the panel today and 21 an illness in the -- in her family has prevented her from 22 coming up here, but she was of enormous assistance in 23 putting together this program. So I want to acknowledge 24 that and -- and thank here -- she's undoubtedly watching 25 by web -- and extend the thank you's on behalf of the 26 Commission.


1 MR. WALLY MCKAY: Thank you very much. 2 Elder James Bottle...? 3 4 (INTERPRETED BY CHIEF CONNIE GRAY FROM OJI-CREE TO 5 ENGLISH) 6 7 ELDER JAMES BOTTLE: He says thanks to 8 everyone that's here that have different roles and given 9 different job descriptions for being here together. 10 We've all come together in our -- our 11 different jobs to come to -- to come to some conclusion 12 on a common goal and a common vision for some -- for this 13 topic to come to a conclusion based on a consensus 14 building and building something together. 15 16 (INTERPRETATION CONCLUDED) 17 18 CHIEF CONNIE GRAY-MCKAY: And now he's 19 going to close with prayer using the language that he has 20 been given to give us safe journeys back to our 21 communities and wherever we came from. 22 23 (CLOSING PRAYER) 24 25 (CEREMONIAL DRUM CLOSING) 26


1 --- Upon adjourning at 4:00 p.m. 2 3 4 5 6 Certified Correct, 7 8 9 ___________________ 10 Wendy Warnock, Ms. 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25