Ontario coroners told to improve communication during death investigations | CBC News

The recommendation was prompted by a father’s search for answers after the 2017 death of his son in Thunder Bay, Ont.

It also speaks to a larger issue, according to Anna Betty Achneepineskum — that coroners do not consistently communicate regularly with Indigenous families living in remote communities when they are investigating the death of loved ones.

“It just adds to the grief and loss if [family members] don’t know where or what’s happening with their loved one, and why they died,” said the deputy grand chief with the Nishnawbe Aski Nation, a political organization representing 49 First Nations across Treaty 9 in northern Ontario.

“We expect that an individual from Attawapiskat, from Fort Severn, Sandy Lake, Eabametoong, needs to be treated in the same way as if you were living in Toronto,” she said.

The recommendation is the latest call for Ontario’s chief coroner to improve communication and transparency with families, especially Indigenous people.

Dr. Dirk Huyer, Ontario’s chief coroner, told CBC News he already expects “regular and ongoing conversations between families and investigating coroners,” and work is ongoing to improve that communication.

Poor communication a longstanding issue

Jonathan Rudin, the program director for Aboriginal Legal Services, has represented many families during coroners’ investigations and inquests.

He said families often don’t know what a coroner does or even if they are involved.

“Our experience with families who live in more remote parts of northern Ontario on reserves, in those areas, they get their information sometimes second or third hand.”

Coroner reports are not often written in simple language, so families need help deciphering what a coroner finds, he added.

In 2008, an inquiry into Ontario’s pediatric forensic pathology system that was led by Justice Stephen Goudge found “many families who suffer the death of a child are left too much in the dark about autopsy procedures and even why their child died.”

In First Nations and remote communities, the inquiry added, “death scenes are seldom attended by coroners, let alone pathologists.”

In 2014, four-year-old Brody Meekis died in remote Sandy Lake First Nation of complications from strep throat.

Despite guidelines from the Office of the Chief Coroner, the coroner on the case, Dr. Wojciech Aniol, did not attend the death scene to investigate the boy’s death and chose to not call for an inquest.

The boys’ parents are now pursuing a lawsuit against the investigating and supervising coroners, and said in a statement issued in July 2021 that “the nightmare of [Brody’s] death was made all the worse by a system that doesn’t care and by coroners who don’t do their jobs.”

The final report of the national inquiry into missing and murdered Indigenous women and girls also found in 2019 that coroners not attending death scenes are an example of the difficulties Indigenous people have in accessing justice.

Communicating with families an ‘expectation’

It’s the coroner’s job to provide information to affected families about death investigations, including where the body is being transported, whether and why a post-mortem examination is being conducted, what that involved and when it is expected to take place.

Ontario’s chief coroner, Dr. Dirk Huyer, told CBC News that communication with families is a priority for his staff.

“Families should have as much information as possible. That’s their loved one that they lost and clearly a tragedy for them,” said Huyer. “And so there is the expectation throughout the organization that coroners are readily available and regularly communicating.”

Telling families about a change in investigating coroner is especially important, Huyer said, because that person is the contact point for family members.

Huyer said he has reminded senior members of his team about that expectation, and it’s regularly stressed to coroners and staff. 

They’re making those efforts, but it’s too slow.– Anna Betty Achneepineskum, deputy grand chief with Nishnawbe Aski Nation

But he acknowledged he does not know how often families are not kept informed about death investigations.

“We don’t have a specific audit or a followup to determine the exact frequency of that.”

Huyer said his office is also developing tools to improve clarity of expectations, and is working with organizations like the Nishnawbe Aski Nation (NAN) to develop an approach to improve death investigations and communication with families.

They are conversations Achneepineskum said she was involved in during a previous term as NAN deputy grand chief, from 2015 to 2018.

“They’re making those efforts, but it’s been slow,” she said.

Achneepineskum is calling for the development of a team of paid liaisons who can help facilitate that communication. She said she will bring that recommendation to a future meeting with Ontario’s chief coroner.

A father’s pursuit for answers

The recommendations from the Death Investigation Oversight Council were prompted by Ronald Chookomilin’s over four-year efforts to learn more about the death of his 25-year-old son.

Just after midnight on June 25, 2017, Marlan Chookomolin of Weenusk First Nation was found unresponsive and with serious injuries on recreational trail in Thunder Bay, Ont. 

A short time later, Chookomolin was taken off life-support and died in hospital.

While Thunder Bay police identified a person of interest in 2018, no arrests were ever made. The investigation is listed as continuing, a police spokesperson confirmed.

Ronald Chookomolin continued to seek answers, bringing the case to the Office of the Independent Police Review director, who later issued the Broken Trust report, which found evidence of systemic racism in the Thunder Bay Police Service.

He also brought his son’s case to the Criminal Injuries Compensation Board and the Death Investigation Oversight Council, which ultimately issued the recommendation in August 2021.

Chookomolin told CBC News he hopes the recommendation will mean families will receive more regular information directly from investigating coroners, something he said didn’t happen when his son died.

“I hope that we see results,” he added.