Alberta's fatality inquiry system dysfunctional, says internal document

Alberta's antiquated fatality inquiry system fails to prevent future deaths, wastes public resources and should be replaced, a confidential internal Alberta Justice document says.

The document, obtained exclusively by CBC News, says the province's system is unique in Canada, both for its dysfunctional structure and its lack of focus on death prevention.

Alberta is the only province where the chief medical examiner does not have a death-prevention mandate, nor the authority to recommend a public fatality inquiry. And although fatality inquiries have been held for decades, the recommendations from those inquiries are neither tracked nor enforced.

Critics say the system, established in 1977, has limited value.

"It is like a lot of (fatality inquiry reports) just go into a black hole or (it is) the proverbial, 'Put it on the shelf and gather dust,' " said Edmonton lawyer Tom Engel, who has acted as legal counsel in at least 10 fatality inquiries into the deaths of people in police or prison custody since 1994.

"Alberta just has utterly failed to be accountable in that area in terms of enforcing recommendations (to prevent similar deaths) where they make sense," he said.

• READ:Prisoners continue to die in custody as fatality inquiry recommendations ignored

Alberta Justice created the document in early 2014 to seek feedback for changes it proposed to the Fatality Inquiries Act. There has been stakeholder support for the recommendations. But the government never implemented them.

A fatality inquiry is a legal proceeding which examines a preventable death, or one which requires greater public scrutiny or investigation. A provincial court judge oversees the process.

The judge does not find fault but can issue recommendations to governments and institutions to prevent similar deaths in the future. Grieving families also often hope to receive some closure from inquiries.

• READ:Family says Alberta fatality inquiry system failed them and their mother

Fundamentally flawed

But the document details a system that is fundamentally flawed, starting with which deaths are chosen for a fatality inquiry.

Alberta is the only jurisdiction in Canada which does not utilize the expertise of its chief medical examiner in determining which deaths are subject to an inquiry. Instead, a fatality review board, comprised of a doctor, a lawyer, and a layperson, makes recommendations to the justice minister.

But board members are not required to have "experience, qualifications, or training in sudden-death investigations.

"From the perspective of the sudden-death investigation experts at the office of the chief medical examiner (OCME), recommendations to hold public inquiries have often been made due to a lack of understanding of the preventability of the incident."

Prisoners continue dying in custody

9 years ago

Duration 0:39

Lawyer Tom Engel says prisoners continue to die in custody because recommendations from fatality inquiries in similar deaths are not implemented.

The document says the board not only recommends too many inquiries, "it often does not recommend inquiries in cases where a public fatality inquiry should have been conducted.

"This is troublesome considering how costly it is to conduct a public fatality inquiry and the importance of these inquiries in avoiding preventable deaths in Alberta."

Alberta holds more inquiries than any other jurisdiction in Canada: an average of 35 a year. Between 2009 and 2012, Alberta averaged more fatality inquiries than Ontario and British Columbia, both of which have larger populations.

"This high volume of cases is a strain on court resources and may not serve the public interest as well as was anticipated when the current system was designed" in 1977, the document states.

On average, a three-day fatality inquiry costs the province more than $65,000. That figure factors in the time and resources of a provincial court judge, the justice ministry lawyer who acts as counsel for the inquiry, and a court clerk.

It does not include any costs associated with expert witnesses or travel. Many fatality inquiries also last longer than three days, with some stretching into weeks.

These resources are spent with the expectation that a fatality inquiry may shed light on a death and identify problems which must be fixed to prevent similar ones.

Some recommendations from inquiries are implemented but many are not, and sometimes judges don't make recommendations. Even when recommendations are made, the province does not track them and under the current legislation, it can't force institutions to comply with them.

"Clearly, in the end, if you don't have any teeth to the recommendations, (a fatality inquiry) is helpful to some extent but the utility is greatly reduced," Engel said.

No prevention mandate

Despite this lack of enforcement, fatality inquiries are the province's only formal avenue for addressing death prevention, the document states.

But Alberta is the only province where the office of the chief medical examiner does not have a death-prevention mandate. The office also has no mandate to issue annual reports, which critics say makes it nearly impossible to identify trends and patterns in preventable deaths. The document recommends the provincial government expand the medical examiner's role to include prevention, and also mandate annual reports from the office.

It also recommends the provincial government eliminate the fatality review board and create three death-review committees - one each for children, adults, and seniors - comprised of experts who would - only when necessary - recommend fatality inquiries to the justice minister.

"It is important to note that a public inquiry is not always the most effective way to provide recommendations to prevent similar deaths," the document states. "There are alternative methods to investigate preventable deaths that provide better outcomes."

Preventing child deaths

9 years ago

Duration 0:53

Dr. Lionel Dibden says a proposed new system of death investigation for Alberta would generate data critical to child death prevention.

The chief medical examiner would chair the committees and select the experts.

The committees would make recommendations, track them, and perhaps most importantly, gather long-term data on preventable deaths.

Edmonton pediatrician Dr. Lionel Dibden said data is critical to death prevention.

"A fatality inquiry addresses one event. It doesn't allow for the comparison from one event to another," he said.

Dibden is the director of the Child Adolescent Protection Centre at the Stollery Children's Hospital in Edmonton. He participated in the government's 2014 roundtable discussions into the deaths of children in provincial care.

Alberta Justice consulted Dibden about the proposed changes to fatality inquiries, specifically the proposal for a specialized committee to review, under the purview of the medical examiner's office, all deaths of children.

Dibden said he wholeheartedly supported the changes and has urged the government to adopt the review-committee system. He is disappointed nothing has been done.

"This is a critical process for the health and well-being of children in the province," Dibden said. "It is something that we need to do and need to get right as soon as possible."