Sask.'s coroner has no plan to deal with mass fatalities like Humboldt crash: external review

Development of a plan to deal with mass casualties like the Humboldt bus crash is among the recommendations to Saskatchewan's Office of the Chief Coroner in a new report that concludes the office is not fulfilling its mandate.

The 104-page report, presented Wednesday, is the result of an external review of the officeled by former Saskatoon police chief Clive Weighill.The review cost approximately $102,000, according to a provincial government spokesperson.

It contains 44 recommendations in response to findings that included "inadequacies" around training, communication and workload, as well as concerns expressed by families about the office. Recommendations include development of guidelines for when to call an inquestand education on Indigenous culture.

Weighillsaid thecoroner's officeis lagging behind similar agencies in other provinces due to capacity issues, which are tied to funding.

"I don't think Saskatchewan should be lagging behind anybody. If somebody dies in the province of Saskatchewan and there has to be an investigation into that death it should be done in a very professional and very quick manner," he said.

"I don't think Saskatchewan should take a backseat to anybody on that."

Weighillrecommendednew training for community coroners and the addition of six positions including a third forensicpathologist, a regionalsupervisor in Regina and laboratory scientist to improve thingslike wait times fortoxicology results, which he said is the most common complaint from families.

No planfor mass fatalities

The reviewsays it's time the coroner's office worked with health officials in order to develop a plan to deal with mass casualties.

It states that no such plan exists, despite discussion aboutdeveloping one dating back more than a decade.

"It is not a question of 'if' it will happen it is a case of 'when' it will happen," the report reads.

The review mentions the collision between a bus carrying members of the Humboldt Broncos junior hockey team and a semi, which killed 16 people earlier this year although, butWeighill said the recommendation to create a policy was already in the works.

It also points to a plane crash in Fond-du-Lac as a "near mass-fatality event."

The report says a plan is needed in order to lay out the responsibilities of the on-scene coroner when responding to such incidents, and to address issues around evidence collection, body transfer and "temporary morgue infrastructure."

Ladham case sparked review

Saskatchewan Minister of Justice Don Morgan called for an external review last November after a case where a jury found the province's chief forensic pathologist, Dr. ShaunLadham, unfairly assessed another doctor who was trying to get a job with the coroner's office.

Once public, the case also revealed allegations that Ladhammadederogatoryremarks about the bodies of Indigenous people.

In astatementcirculated to media, Morgan said the ministry will consider the report and itsrecommendations.

"We know that the public has questions and I'm assuming that there will have to be some hires made and some of the positions filled before people are going to say that they've got some resorted confidence," he told reporters afterwards.

NDP Justice critic Nicole Sarauercalled for the recommendations to be implemented as soon as possible, saying the coroner's office plays a crucial role.

"There are many problems in the office that are a result of capacity issues and this iswhat happens when the coroners' office is chronically underfunded for several years."

The coroner'soffice is responsible for investigating deaths that are deemedunnatural, unexpected and unexplained.

No 'overt' concerns, but cultural training needed

The report also heard concerns from families with respect to the office.

It noted accusations made by some people that they were treated differently as a result of their "race, culture or social status" when it came to matters such as a coroner's ruling on cases of accidental deaths or a suicide, where a family disagreed.

Weighill said also he met with the family of NadineMachiskinic, a 29-year-old mother who fell down a hotel laundry chute.

"No overt systemic issues were observed; nevertheless there are some practices that need to be put into place to ensure families are being treated fairly," his report reads.

Weighillacknowledgedconcerns about discrimination and the distrust some Indigenous people feel towards government, however, he did he did not discover any "red flags" in his review.

He still recommends all staff that work with the coroner's office undergo cultural training around Indigenous culture and the practices of new Canadians

As well, be believesthe position of advocate be created in order to address concerns a family may have about a coroner'sinvestigation.

Lack of clarity on inquests

The review highlighted a lack of clarity around when to call inquests intodeaths of people who are not in the custody of police or corrections.Itcalled for a set of criteria to be created and an inquest review committee to be established in order to solve this.

Current legislation states deaths that occur while someone is in the care of police of corrections are subject to a mandatory inquests.

However for non-custody deaths, the report says there is a lack of criteria as to when to call an inquest, with the decisionarbitrarilylying with the chief coroner or, in some cases, the minister of justice.

"This has caused criticism from families who believe that, in previous similar circumstances, inquests have been called, yet, in their circumstances, they are denied an inquest."

The review also recommends increased training for community coroners, who are called on to investigate unexpected deaths outside of Regina and Saskatoon, saying an initiativeto transition this role to police officers is not working.