Michael Kritz's family speaks about coroner's inquest, recommendations to improve 911

After two weeks of testimony from two separate cases inSudbury and Ottawa,the jury in a coroner's inquest is expected to deliver its recommendations this week.

It's looking into problems with the 911 system in Ontario.

The first part of the inquest focused on a tragic boat crash that resulted in the death of three people on Lake Wanapitei in June 2013. The second portion was in Ottawa and centred around the 2014 death of a woman in Casselman.

While in Sudbury earlier this month, the inquest heard about the circumstances that lead to the death of Michael Kritz, 34, Matthew Humeniuk, 33, and Stephanie Bertrand, 25.

Rob Dorzek is the lone survivor of the crash.

The four had been in a boat on Lake Wanapitei, after midnight on June 30, 2013 when the vessel struck a small island.

All four were badly injured, but only Dorzek was conscious and able to call 911 for help. He testified he was not familiar with the large lake and didn't know where they were.

While on one of his five calls to 911, the operator told Dorzek he needed to light a signal fire so emergency responders could find them in the dark. But that signal fire spread and engulfed the boat.

The five-member inquest jury heard that while both Humeniuk and Bertrand died from trauma injuries incurred from the crash, Kritz died from effects from the fire.

'Mike could have come home to us'

The inquest also heard about a lack of communication between the three emergency services in their response to the call for help.

Toni Kritz-Roque is one of Michael's four siblings. She was at the inquest all five days it was held the Sudbury. Several times she even represented the victims' families during questioning of witnesses.

She told CBCNews that many developments were revealed during the inquest that neither she nor her family knew about.

Along with the fire situation, the inquest heard about a long list of communication problems that surfaced that night:

• The first 911 call taker had been texted a Google map by Dorzek of the crash site, but the mapwasn't shared.
• The dispatcher for ambulance services didn't connect with police or fire about the call.
• Ambulances were sent to find the scene, but the paramedics weren't told it was on an island.
• Fire services was told it was a medical call and volunteer firefighters who were called to usetheir rescue boat were told to wait for EMS crews. They were also not told there was a fire.

Kritz-Roque says if not for the huge problems with communication, her brother Michael would still be here.

"Any of those things could have changed, then we know that Mike could have come home to us. So I don't think I could put into words to tell you how that makes me feel."

"It absolutely would have been easier to deal with losing him if he had of just died in the boat accident."

Remembering Mike

"I think the best way to remember him is not because of the way he died, but probably for the way he lived," said Candace Ricker, also a sister to Michael Kritz.

There are two other siblings, Blaine and Matthew. Matthew Kritzis Michael's twin. Their parents are Jim and Loretta Kritz.

Ricker described her late brother Michael as someone who lived for the moment, was full of joy, compassionate, loving and generous.

"I think the world would be a better place if we all lived like Mike. So I think that's a great way to remember him," Ricker said.

"It's important to remember, he should still be here."

To make sure this never happens again

Kritz-Roque says she and her family have many suggestions for improvements to the 911 communication, which they hope will be in the jury's official recommendations.Those are expected to be released this week.

The biggest requirement, according to Kritz-Roque, is that there should be firm timelines for implementation.

"I don't want this to turn into pages and pages of documents of policy that sit on a shelf somewhere and collect dust, and never really amount to anything."

The Kritz family and others in Sudbury lobbied hard to get this inquest.

Kritz-Roque says the goal was to hear the truth and make sure a tragedy like this never happens again.

"To look at what went wrong that night and stop that from happening again," she said.

"This happened to our family, but tomorrow night or the next night, this could be your family. You better hope that they do a better job getting to the person you love than they did for us."

Listen to the interview here.