THUNDER BAY — The Office of the Chief Coroner of Ontario has completed an investigation into the circumstances surrounding the death of a First Nations man in Thunder Bay in September 2019.
A spokesperson for the office says it remains in contact with the family, however the findings are not being made public.
The 19-year-old man died by apparent suicide hours after he was discharged from the Thunder Bay Regional Health Sciences Centre.
Nishnawbe Aski Nation's leadership said a Lakehead University security guard found his body on university property adjacent to the hospital grounds.
When he heard about the incident, NAN Grand Chief Alvin Fiddler wrote the hospital to request an investigation.
Although he conceded "we do not have all of the information regarding [the] death," Fiddler asked "why the hospital would escort a young man who presented at the hospital in obvious distress to a secluded area of the LU campus".
Chief Coroner Dirk Huyer said at the time that his office was committed to getting a complete understanding of what happened.
TBRHSC said its own team had reviewed the incident and concluded "appropriate actions were taken and that the right decisions were made by clinical staff based on the information provided to them and the patient's presentation."
It added that the participants in the internal review maintained full confidence in the judgment and professionalism of those involved, but nonetheless the hospital was studying what it might do to prevent future such incidents.
Current procedures, it said, would be reviewed with the aim of addressing the needs of "a growing population of patients arriving with substance use and mental health issues."
Then-CEO Jean Bartkowiak also promised that the review would consider the unique needs and experiences of Indigenous patients.
In a statement on Wednesday, the spokesperson for the chief coroner said the investigation is finished, and that the office has communicated with both the family of the man who died and with the hospital.
The spokesperson said no further information can be provided as "communication is ongoing with the family."
Dr. Huyer said in November 2019 that his office may make recommendations to parties in this kind of case without necessarily calling an inquest.
Without commenting specifically on this incident, he said whenever an investigation brings systemic issues, policy or procedural issues to light, it's raised with the organization that can initiate required changes.
