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Mamakwa and McKay inquest concludes as jury prepares for deliberation

The coroner’s inquest into the deaths of Don Mamakwa and Roland McKay, who died while in police custody, concluded with closing submissions by counsel on behalf of involved parties before jury prepares for deliberations on Friday
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Don Mamakwa (left) and Roland McKay died while in the custody of the Thunder Bay Police Service. (File).

THUNDER BAY — After 16 days of testimony, the coroner’s inquest into the deaths of Don Mamakwa and Roland McKay, who died while in police custody, came to an emotional end as counsel on behalf of all involved parties delivered closing submissions, imploring the jury to deliver recommendations that will prevent similar incidents from happening again.

And while all counsel agreed Mamakwa and McKay’s death were tragic and the result of numerous failures on the part of various institutions, there was disagreement regarding the manner of Mamakwa’s death and whether it should be considered homicide, an accident, the result of natural causes, or undetermined.

The inquest opened three weeks ago before presiding coroner Dr. David Cameron and saw more than 30 witnesses testify before the four-person jury.

The purpose of the inquest is to examine the circumstances surrounding the deaths of Mamakwa and McKay, who died in the lockup of the Thunder Bay Police Service headquarters after being arrested for public intoxication.   

Mamakwa, 44, of Kasabonika First Nation died on Aug. 3, 2014. McKay, 50, of Kitchenuhmaykoosib Inninuwug First Nation, died on July 19, 2017.

The jury will now be charged with formulating recommendations for the various parties involved in an effort to prevent similar incidents from happening in the future.

All the parties agree that the cause of McKay’s death was hypertensive heart disease and the manner of death was natural causes.

The cause of Mamakwa’s death was determined to be ketoacidosis and complications from diabetes, chronic alcohol abuse, and septicemia. However, the jury must decide on the manner of his death as either homicide, accident, natural causes, or undetermined.

Kate Forget, counsel on behalf of the coroner, began her closing by acknowledging the families of Mamakwa and McKay, who attended every day of the inquest.

“Your presence, every day at this inquest, has changed the feeling in this room,” she said. “It has reminded us daily of your love and commitment to both Don and Roland and why we are all here together.”

Forget asked the jury to keep in mind the concept of truth and reconciliation, echoing the remarks of retired Senator Murray Sinclair, saying without truth there can be no reconciliation.

“Inquests require us to look backwards, which can be an incredibly painful and heartbreaking process,” she said. “We are recounting events that we know end in tragedy and grief. But it demonstrates why inquests are so necessary. We have all had to learn and unlearn, learn hard lessons and unlearn things we thought we knew.”

Throughout the inquest, the jury heard details of how Mamakwa had interactions with police and paramedics on the night of Aug. 2, 2014 and asked to go to the hospital. Police believed paramedics cleared him to go into custody and he was placed in a cell.

While in the cell, he stopped breathing and was found hours later by the jailer. No physical checks in the cells had been done for nearly five hours.

Forget said Mamakwa advocated on behalf of himself several times that night, including the first time he asked to go to the hospital.

“The most painful truth of all is that Don, if he had been transported to the hospital that night, he wouldn’t have died alone in cell 13 and likely would have survived,” Forget said.  

“He was ignored. We have to ask ourselves why. Was it because he was Indigenous? Was it because he was intoxicated? Because he was homeless? Was it compassion fatigue, racism? We have to ask ourselves why.”

On July 20, 2017, McKay also had an interaction with the Thunder Bay Police Service and Superior North EMS.

Evidence showed McKay’s vitals were elevated when assessed by paramedics, but he did not want to go to the hospital. After being placed in a cell, he was found unresponsive and officers started CPR. He died in hospital later that night.

“The harsh truth is that Don was advocating for himself and Roland needed someone to advocate for him on the night of their deaths,” Forget said.

Forget acknowledged that police and EMS faced many challenges at the time including a lack of resources and high call volume, which impacts their own well-being and can lead to burnout, compassion fatigue, unconscious bias, and post-traumatic stress disorder.

“But we must focus on Don and Roland,” she said. “This is a we and us issue. We are all responsible. Their deaths demonstrate what we are doing as a society when it comes to individuals suffering from alcohol use disorder is not humane, it is not dignified.”

Family wants Mamakwa’s death classified as homicide

Asha James, counsel on behalf of the Mamakwa and McKay families, began her closing submission by recognizing the profound impact their deaths have had on family and friends and the importance of having a public hearing of the facts and circumstances involved.

“We heard the families say they don’t trust the police,” James said, referencing the broken relationship between the Thunder Bay Police Service and the Indigenous community. “This is not a recipe for a successful police service. The change has to be felt by the Indigenous community and quite frankly we are not there.”

The family of Mamakwa is asking the jury to determine the manner of death as a homicide.

James advised the jury that a finding of homicide in an inquest is not a finding of liability but rather a finding based on facts.

According to James, the evidence in the inquest has shown that the actions and omissions on the part of Superior North EMS paramedics, Thunder Bay Police Service officers, the jailer, and watch commander involved with Mamakwa ultimately resulted in his death.

“Their failure to take Don to the hospital contributed to his death and homicide would be an appropriate verdict,” she said.

Counsel on behalf Aboriginal Legal Services also supported the jury finding Mamakwa’s death a homicide.

Counsel representing involved police officers, the Police Services Board, the police chief, Solicitor General, and Superior North EMS disagree that Mamakwa’s manner of death should be characterized as a homicide, arguing instead it should labelled as an accident or due to natural causes.

Kevin Matthews, who represented several Thunder Bay police officers, argued the officers involved in the arrest of Mamakwa were acting within their legal right and believed he had been cleared by paramedics to be transported to the police headquarters.

Matthews went on to argue that Mamakwa’s death was the result of ongoing health issues that resulted in hospitalization in the past.

“Opportunities to get Don to the hospital didn’t start on Aug. 2, 2014. The system let Don down,” he said. “He didn’t die because he was in a police cell, he didn’t die because he didn’t get an assessment from EMS, he died because he did not get medical intervention, which started weeks ago.”

Holly Walbourne, counsel on behalf of the Thunder Bay Police Service chief, added in her closing submission that there is no evidence that any decision made by officers had any foresight that it could or would result in Mamakwa’s death.

Expert evidence presented during the inquest indicated that Mamakwa had a 97 per cent chance of surviving if he had been transported to the hospital the night he was taken into custody.

“It does not mean, however, that any individual actor can be blamed for Mr. Mamakwa not having made it to the hospital,” Walbourne said. “What you have here is an extremely tragic, unfortunate accident, not a homicide.”

Walbourne also pointed out that since 2017, there have been no other deaths of individuals while in police custody, and while the cases involving Mamakwa and McKay are significant, they are rare.

“I would submit we have grown as a society in that amount of time,” she said. “There is more willingness to be open to unconscious bias and stereotyping and more willingness to change.”

The jury received draft recommendations from counsel. Throughout the inquest, several recommendations were raised by witnesses, including a sobering centre in the city, more detox beds, more cultural sensitivity and medical training for frontline officers, and better communication between police and EMS.

James said the implementation of recommendations is important to the family and all those involved and there needs to be meaningful follow-up and accountability.

“The only way the Indigenous community in Thunder Bay can have real trust in what’s being done is to see it and to feel it. They don’t just want to hear it,” she said, adding that addressing systemic racism in the Thunder Bay Police Service and Police Services Board is within the scope of the inquest.

“It is the family’s position that those unconscious bias, stereotyping played a part in the way both Roland and Don were treated. If we don’t address those root causes to repair that relationship, we will continue to be back here raising the same issues over and over again."

The jury will receive instructions from Cameron on Friday morning and then begin its deliberations.



Doug Diaczuk

About the Author: Doug Diaczuk

Doug Diaczuk is a reporter and award-winning author from Thunder Bay. He has a master’s degree in English from Lakehead University
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