'That's not going to change anything': Why Sask. coroner's inquests leave people wanting more

Saskatchewan coroner's inquests are leaving participantsdissatisfied and sparking questions about whether the process brings about any change.

Meanwhile, thecost of inquests is rising.In 2013-14, the average cost of an inquest held by the Saskatchewan Coroners Service (SCS) was $16,800. In 2017-18 the average was$29,300.

"Inquests are becoming more complex and time consuming," wrote former Saskatoon police chief Clive Weighillin a review of the service, just months before he tookover as the province's newchief coroner.

Weighill cited several reasons for the increase, including "longer questioning and cross examination of witnesses" and lawyerstreating inquests like criminal trials.

Despite the increased cost and effort, inquests are leaving some participants feeling shortchanged.

"I was torn up. I wasn't happy at all walking out of there," said Charmaine Dreaverof her recent inquest experience.

• Jordan Lafond's mom says she will 'keep fighting' after inquest

Dreaver's son, 22-year-old Jordan Lafond, was involved in a police chase in Saskatoon. The stolen truck Lafondwasin crashed into a fence, ejecting him from the vehicle. He later died.

A forensic pathologist testified that the impact of the crash was a major factor in Lafond's death. The six-person inquest jury also heard a police officer admit he repeatedly kneed Lafond in the head after the crash because he thought Lafond was resisting arrest.

Exactly what killed Lafond remained unclear, but neither of the jury's two recommendations this past summer focused on police conduct. Instead, the jury stressedthe need to educate people about the safe storage of guns. Police had testified they were concerned about ahigh-powered gun inside the truck.

"That's not going to change anything with what happened to my son," said Dreaver of the recommendations from the week-long inquest.

Chris Murphy, the lawyer who represented Lafond's family, said they"didn't want to find out fault, but at the same time, we wanted to get to the bottom of what happened."

That was made difficult by the narrow scope of what inquest juries are allowed to rule on, said Murphy.

Coroner's inquests limit juries to ruling on "how, when, where and by what means" a person died, while their recommendations are strictly meant to prevent similar deaths.

Weighing in on Saskatoon police officers' conduct just wasn't on the table,Murphy said.

"From the perspective of the family, you go through this and you don't really get the answers that you want," he said.

'Role of an inquest isoften confused'

Coroner's inquests are not meant to assign legal responsibility for a death. No one is on trial.

Many people still think otherwise, said Brian Pfefferle, a Saskatoon defence attorney.

"It's still remarkable the number of people that will review whatever's online about these things but say 'Why can't this person be charged criminally?' " he said.

Weighill agreed that people sometimes don't understand the process.

"The role of an inquest is often confused by the family and the public who are looking for answers surrounding the death and are seeking to find a person or persons at fault," he wrote.

An upcoming inquest into the death of Brydon Whitstone faces similar expectations.

Beginning December 3, asix-person jury will hear details about how the22-year-old man was shot and killed by an RCMP officer inNorth Battleford last year.

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Up to now, authorities have offered few details about the altercation, though Saskatchewan prosecutors recently decided the officer's actions did not call for criminal charges.

Asked about the inquest,Whitstone's motherDorothyLaboucane said, "I just hope everything will work out, that we'll get justice."

'Gathering dust in a filing cabinet'

Weighill's report on the SCS didn't make any specific suggestion for how to combat the perception that inquests are criminal processes. He did recommend hiring a family advocate to answer families' questions about the inquest process.

Another change he proposed went into effect even before he started his new job last September. Inquest juries' recommendationsand how groups respond to themare now posted online, something most other coroners services do.

• Incoming Sask. coroner Clive Weighill flags potential changes to death inquests

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Ron Piche, the lawyer who originally represented Whitstone's family, said inquest participants have been candid with him about where they think jury recommendations end up.

"Gathering dust in a filing cabinet somewhere," he said. "If I were to wager a guess, I'd suggest that very few of them get implemented."

Delayed response tragic: lawyer

CBC News has reviewed all the recommendations made by Saskatchewan coroner's inquest juries from 2014 toNovember 2018, plus the responses filed by the agencies to whom the recommendations were made.

One high-profile case still hasn't received a response from a key party.

Nadine Machiskinic, 29, was an Indigenous mother of four who died in 2015 after she fell 10 storeys down a laundry chute at Regina's Delta Hotel.

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The inquest jury's sole but sweeping recommendation, directed to "all hotels," was that "any service chutes should be locked and only accessible by staff."

A combined four hotels in Saskatoon and Regina responded, somejust to say that their buildings don't have chutes.

More than 18 months later, the Ministry of Justice says the SCS has not received a response from the Regina Delta where Machiskinicwas injured.

"The SCS has posted all responses received to date," said a spokesperson, adding that the coroners service reminds groups that don'trespondwithin six months.

Beyond that,"If theSCSdoes not receive a response, the responsibility remains with the affected agency to explain why the recommendationshave not been responded to," the spokesperson said.

Just as inquest jury recommendations are not legally binding, groups aren't legally required to respond them.

"There's nothing saying there has to be a response," said lawyer Ammy Murray, adding, "Maybe there should be some kind of ongoing follow-through."

CBC News has reached out to Marriott Canada,the owner of the Delta. Machiskinic's family has filed a civil suit against the hotel company.

Post-inquiry gaps

The vast majority of recommendations from coroner's inquestsget a response. Many are quite detailed. Several point out that agencies are already doing what's being asked ofthem or something similar.

Some have broughtimmediate results, such as more workshops on Indigenous social history for staff at Saskatoon's Regional Psychiatric Centre (RPC). Others have sparked promises, such as a pledge from Correctional Service Canada, which runsRPC, to aim for 20 per cent Indigenous employment by 2022.

Some garner no responsefor months or years. Others get responses that do not satisfy people who went through the inquest process.

In 2015, Shauna Wolf, 27, was found unresponsive in a single-bunk cell at Pine Grove Correctional Centre in Prince Albert.

In May 2017, aninquest jury heard Wolf was transferred from a medical cell to a segregation cell before her death because she smuggled in heroin. A nurse testified she believed Wolf died from opioid withdrawal.

The jury made more than a dozen recommendations to Saskatchewan's Ministry of Corrections.

"There were some very basicrecommendations that came out of it, like 'Check on people who are sick,'"saidMurray, whorepresented Wolf's family.

• Coroner's inquest jury recommends improved health care to inmates

The ministry's response receivedon Oct. 23 of this year, more than 16 months after the inquest was not available from the coroners service website as of earlier this week. It was posted after CBC News asked about it.

Wolf was ultimately underwhelmed with its four briefparagraphsand their promise of a working group to "attend to the recommendations." She called the response tragic.

"There's no level of detail whatsoever about who's on this working group, which recommendations they are looking at, what's going to be implemented," said Murray."You'd think in a year and a halfsome progress could be made."

"The families come in having lost somebody they love very much and wantto see that people have learned from their tragedy, that things are going to change," she said.

• 'Recipe for miscommunication': Lawyer says Sask. gov't response not enough to prevent in-custody deaths

A 2014 report that responded to a jury's callfor more medical professionals at Prince Albert Youth Residence wasn't posted on the coroners service websiteuntil this week.

Another recommendation, stemming from an inquest into the death of Vincent Sewap, is still missing any response.Thejury in that case called onSaskatoon's Royal University Hospitalto installlow-impact flooring to reduce the risk of head injuries from falls.

A spokesperson for the Saskatchewan Health Authority told CBC News this week that "officials have shared this concept with the design team and Infection Prevention and Controlteam to see what options are available."

Sewapdied in August 2013.

Checking in on changes

Even when groups commit to carrying out juries' suggestions, the outcomescan remainunclear.

Adele Jennifer Morin was found unresponsive in her holding cell at the Sandy Bay, Sask.,RCMP detachment in 2014. The inquest jury suggested in September 2016 thatthe RCMP replace the plexiglass windows on the detachment's cell doors to ensure members couldsee clearly through them.

The RCMP agreed two months later, sayingit would replace the windows as soon as possible. But while the RCMPmonitors its inquest responses internally, no further update was on file with the coroners service.

An RCMPspokesperson told CBCthat the windows were replaced in June 2018.

Inquest as legal triage

Despite their shortcomings,coroner's inquests can be useful in paving the way for a potential civil lawsuit, Piche said.

"You have the same witnesses [at inquests] that likely would be present at the civil trial," he said. "They're subject to cross-examination. The disclosure that's provided by the coroner's office is often much the same as what would be at play in a civil trial."

Inquests can also have the opposite effect,said Murray.

"It can very clearly setout to a family, 'Hey look, there's no civil liability here on anybody. This was completely unpreventable.' Thatends up saving the families money."

'Hope for the best'

Jordan Lafond'smother was disappointed with thejury's recommendations. Charmaine Dreaversaid she wanted to see more,such as a recommendation that officers be barred from reviewing their dash-cam footage after an incident, as oneofficer admitted to doing during the Lafondinquest.

Despite her own experience, Dreaver is hopeful Dorothy Laboucane, Brydon Whitstone's mother,will get more out of the inquest process in Battleford next week.

"I'll be sending prayers and strength and everything," said Dreaver. "We've got to stand together and hope for the best."

A record of Saskatchewan coroner's inquest jury recommendations and responses can be found at this link.