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Mamakwa, McKay inquest jury hands down 35 recommendations

Jury in coroner’s inquest examining the circumstances surrounding the deaths of Don Mamakwa and Roland McKay in police custody delivers 35 recommendations, while ruling manner of Mamakwa’s death was undetermined, not homicide

THUNDER BAY - For the last 17 days, family and friends of Don Mamakwa and Roland McKay sat and listened to testimony in the coroner’s inquest into how numerous systemic failures led to their deaths while in police custody.

With the inquest jury handing down 35 recommendations to various organizations and the provincial government, the families are hopeful meaningful change will take place so no family has to suffer the same pain they did.

“This inquest was very important to us and we are glad that this happened, even though we are tired. I like all the recommendations that were put in and I hope they are put forward by the parties,” said Don Mamakwa’s sister, Rachel Mamakwa.

“We were just so happy to be involved, to make changes for the people, for our people. We are happy.”

The coroner’s inquest examining the circumstances surrounding the deaths of Mamakwa and McKay, who both died while in the custody of the Thunder Bay Police Service, concluded on Friday following 16 days of testimony from more than 30 witnesses.

Mamakwa, 44, of Kasabonika First Nation died in cell 13 of the Thunder Bay Police Service headquarters on Aug. 3, 2014 after being arrested for public intoxication.

McKay, 50, of Kitchenuhmaykoosib Inninuwug First Nation, was also arrested for public intoxication and died on July 19, 2017 while in cell 12 of TBPS headquarters.

Family of Mamakwa was asking that the manner of his death be ruled a homicide, but the four-person jury ultimately ruled it as undetermined.

“I respect the jury and their hard work. They were at it a long time,” said Asha James, counsel on behalf of the Mamakwa and McKay families.

“I’m sure it wasn’t an easy decision for them. Regardless of what the verdict is, I think this inquest really shed a light on how much the systems failed Don and Roland and how much racism, bias, and stereotyping played a role in their inability to get the help that they needed and deserved.”

The jury included a statement of principle for its 35 recommendations, stating all institutions involved should provide services reflective of Indigenous cultural needs and that it is essential inclusion and consultation be done with Indigenous communities and agencies.

There must also be a trauma-informed approach to ensure individuals who have suffered traumas are not excluded from services that could provide assistance.

One of the key issues raised throughout the inquest was a lack of alternatives available in the city for people facing addictions, such as more detox beds or a safe sobering site.

The jury is recommending the Thunder Bay Regional Health Sciences Centre, Ministry of Children, Community, and Social Services, and Ministry of health create a task force with a mandate of establishing a sobering centre in the city of Thunder Bay.

The sobering centre should also have an alternate level of care designation in order to allow paramedics and police to transport individuals to the centre rather than the emergency room.

Other recommendations directed at provincial ministries are to increase the number of detox beds in the city, support community-based programs like the Street Outreach Service (SOS) at Thunder Bay Shelter House, the Care Bus, and WiiChiiHehWayWin Street Outreach, increase the scope and availability of managed alcohol programs, and create a consent-based medical alert bracelet program for high-risk individuals with substance abuse issues so first responders can contact case managers or care team members.

It is also recommended Superior North EMS and the Thunder Bay Police Service establish joint training on an ongoing basis, stop using ‘wave offs’ at scenes, that officers be trained that paramedics cannot medically clear a patient, and that training on systemic and cultural racism, the history of residential schools and colonialism, and trauma-informed approaches be available.

Recommendations directed specifically at the Thunder Bay Police Service include a review of the role of jailers and the level of supervision given to individuals in custody, that arresting officers and jailers clearly indicate verbally and through the use of signage at the police headquarters the procedure and rights of people taken into custody, and institute a policy of mandating debriefs following serious incidents such as a death in custody.

The process for booking an individual should also be changed, with the jury recommending the force switch to digital arrest sheets, use ‘medically fragile’ flags in its record management, and that reconciliation training be continuous over the course of an officer’s career.

Recommendations for the Thunder Bay Police Services Board include the creation of a deputy chief, Indigenous relations position within the TBPS and retention of an expert consultant to provide assessments of the level of staffing required.

The jury is also recommending the board consider yearly public reports detailing the initiatives it has set out and progress made, as well as create terms of reference for its governance committee open to the public and consider creating an implementation for timelines of all recommendations, how consultation and follow-up will occur with Indigenous communities, and that the implementation plan be made public.

The Ministry of Health is advised to address patient flow at the Thunder Bay Regional Health Sciences Centre to address offload delays for police and paramedics, and that funding should reflect Thunder Bay as a hub city serving communities across the region.

Other health care-related recommendations include paramedics across Ontario having access to electronic health records and that police officers and jailers receive training on medical conditions that may mimic intoxication.

It is also recommended the Ministry of Colleges and Universities include training relating to Indigenous history and issues at the Ontario Police College.

Kate Forget, counsel for the coroner, said the jury did an amazing job in developing its recommendations.

“The recommendations speak for themselves,” she said. “They clearly put in a lot of work and thought and dedication over the course of the last four weeks and that is evidenced in the recommendations that they delivered.”

The next step will be the implementation of the recommendations. Forget said the Office of the Chief Coroner will communicate with all parties involved within in the next six months to determine if any plans on implementation are in place.

“Recommendations are not mandatory, but given the number of recommendations that were proposed by all parties, I think [that] demonstrates their commitment to implementing the recommendations as well,” Forget said.

James is less confident all parties will fully implement the recommendations, pointing to past reports and inquests that have also handed down recommendations that are yet to be implemented.

“What we are hopeful of and what we were looking for from those recommendations is that they have to make their work public and that is the way the community can hold them to account,” she said.

“That is the goal of inquests and those reports and recommendations, is that you can’t just say you are doing something, we need to be able to see it. We need to understand that if there is a delay, why is there a delay. That’s the only way we will be able to try and rebuild any trust.”  

Denise Tait, niece to both Mamakwa and McKay, said she's glad the inquest is complete and thanked James for her work.

“Our families are relieved it is over so we can finally start our healing journey and let them rest,” she said. “All my family has ever wanted was to find out what happened to my uncle. We are happy that we now have those answers. We want to thank the jury for their work during this four-week inquest."

Forget added an inquest is an opportunity to shine a light on issues the public often doesn’t hear about, and while it's important to know what happened, it's also important to know that Mamakwa and McKay were people, with family and friends.

“Learning about who Don and Roland were and what they meant to their families and what they meant to their communities is also an essential part of the process, so that we can truly understand the gravity of their loss and what we need to do to prevent it from happening to another family or community,” she said.

“The family’s presence here demonstrated their love and commitment for Don and Roland. It just demonstrates they needed to be here for both Don and Roland, and that was conveyed to us every day walking into that space.”

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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