THUNDER BAY — For more than six years, the family of Moses Beaver have been seeking answers to questions relating to how the gifted Indigenous artist’s life was cut short after being placed in custody, and with the inquest now concluded and a jury handing down more than 60 recommendations, the next stage in the healing journey can begin.
“Now that we have these answers, the family needs to take that next step toward healing and be able to close this part of their healing journey and move on toward hopefully looking for success and having these recommendations implemented,” said Caitlyn Kasper, senior lawyer with Aboriginal Legal Services, who represents the family of Moses Beaver.
After 20 days of evidence and testimony, on Friday the five-person jury released its verdict and recommendations in the coroner’s inquest examining the circumstances surrounding Beaver’s death in 2017.
Beaver died on Feb. 13, 2017 at the Thunder Bay Regional Health Sciences Centre after being transferred from the Thunder Bay District Jail where he was found unresponsive in his cell.
Evidence presented during the inquest revealed Beaver was suffering a mental health crisis in his home community of Nibinamik First Nation and medical transport was not available for several days.
Beaver was then arrested by Nishnawbe Aski Police Service and transported to the Thunder Bay District Jail. Several weeks later, despite efforts from family members to get him proper mental health care, Beaver took his own life.
The jury found the cause of Beaver’s death to be hanging but ruled the manner of death to be undetermined, a ruling Beaver’s family was seeking.
Kasper said one of the key issues for the family was that while Beaver had a traumatic and difficult life, he always emphasized to his community and his family that suicide was never a way out or a way of dealing with issues.
“When we look at that against what happened the evening of Feb. 13, it is the position of the family that that capacity to make that choice was gone because his mental illness had deteriorated so substantially,” Kasper said. “With that in mind, if you don’t have that requisite intent that you can choose suicide, that undetermined was absolutely the best category for manner of death.”
The jury also handed down 63 recommendations directed at the various parities with standing in the inquest, which includes the Ministry of the Solicitor General, Ministry of Health, Indigenous Services Canada, Nishnawbe Aski Nation, Nishnawbe Aski Police Service, the Ontario Provincial Police, Ornge, and the Ministry of the Attorney General.
The recommendations relate to access to mental health services, medical transportation, and policing in First Nation communities, training and education for health care and correctional workers, changes to health care delivery in correctional facilities, and a review of past inquests to identify obstacles in the implementation of past recommendations.
“This jury has worked very hard these last four weeks and we are very proud of the work they did,” said Julian Roy, counsel with the Office of the Chief Coroner Ontario.
“They were very attentive to the evidence, they worked very hard in their deliberations, and they have come up with a comprehensive set of recommendations that we are really hopefully will help to save lives in Northern Communities and Ontario’s correctional facilities.”
Some of the key recommendations include policing be deemed an essential service in First Nation communities under the Police Services Act and that it receives equitable funding and resources.
A committee consisting of representatives from local healthcare providers, non-healthcare providers as well as community members, should review cases on a regular basis where there is an adverse outcome relating to a treatment plan for a mental health emergency in remote communities.
Several recommendations relate to education and training, including NAN establishing a public health campaign surrounding stigma related to mental health, cultural awareness and mental health training for correctional staff and security staff, and up to date training for health care staff working in corrections.
Indigenous Services Canada is also encouraged to engage with First Nation communities to construct safe or secure rooms in or near nursing stations for people experiencing a mental health crisis.
Recommendations directed at the Ministry of Health include designating Meno Ya Win Health Centre in Sioux Lookout as a Schedule 1 facility to treat mental health conditions, that patients in remote communities not be required to be medically assessed in order to be transported to a schedule 1 facility, and additional funding to Ornge to expand its Mental Health Transport Team program to include two dedicated fix-wing aircraft with teams of one mental health nurse, primary care paramedic, and a security officer.
NAPS and OPP are recommended to devise written procedures with healthcare stakeholders to determine circumstances in which officers may assist Ornge with transportation of patients.
The jury is recommending the Ministry of the Solicitor General create a provincial agency under the Ministry of Health to directly oversee health care services in correctional facilities, create better access to medical records of inmates, and that there be a dedicated mental health wing at the new correctional facility under construction.
The final recommendation calls on the Office of the Chief Coroner to conduct an annual review of recommendations from past Ontario inquests dealing with mental illness and addiction issues experienced by First Nations persons.
“The jury has recommended we expand on that process and engage in analysis to really try and understand the progress of recommendations more generally in all of our cases to see how they are being implemented, are there patterns in terms of any obstacles for the implementation of recommendations our juries work so hard for us,” Roy said.
Kasper agrees with a review of past inquests and recommendations, saying it is something Beaver’s family fully supports.
“I am excited to see the outcome of that because I think ultimately that is going to show us what are the barriers for these recommendations being implemented,” she said.
“How do we get to a point where we stop having inquests dealing with these exact same issues and start getting toward actual real solutions and then evaluate how solutions are working on the ground. I am really looking forward to that review and what comes out of it.”
There is also the hope that the recommendations from the jury will prevent another family from having to deal with the same tragic loss of a loved one as Beaver’s family.
“We are all hopeful that [the family] will see this very important set of recommendations as a legacy for Moses,” Roy said. “We all hope that no family will have to experience what this family has experienced, the terrible tragedy that befell Moses and his community.
“The thoughtfulness and direction of those recommendations I think really speaks to the impact Moses had on everyone around him and certainly had an impact on the jury and they showed us that through the very carefully drafted recommendations they provided to the parties,” Kasper added.
“You need to have the education, tools, and resources in order for everyone to do a better job but the bottom line is a better job needs to be done.”