Ministry of Public Safety and Solicitor General
BC Coroners Service
20062006 ANNUALANNUAL REPORTREPORT VISIONVISION our communities and homes are safesafe places. MISSIONMISSION providing exceptional public service through independent, factual death investigation to improveimprove community safety and quality of life. VVALUESALUES integrity, respect, inclusiveness, accountability, quality service, healthy work environment. MessageMessage frfromom thethe CHIEFCHIEF CORONERCORONER
I am pleased to present our Annual Report for 2006. You will note that the format of this report has changed significantly from previous annual reports. It is our hope that this new format will provide more thorough, transparent, and easily understood explanations of our activities, the deaths we investigate, and the results achieved through our efforts. We have included an extensive presentation of statistical data, analysis of that data, and representative examples of case investigations and their outcomes. Additionally, we have provided a historical overview of the British Columbia Coroners Service (BCCS), our current organizational structure, and an explanation of the functions of the various units.
The year 2006 was a particularly significant year for the BCCS. It was a year of change and building for the future. The BCCS undertook a major structural change; I created a five-person executive, which reports directly to me and assumes responsibility for five areas, Operations, Medical, Legal, Child Death Review, and Corporate Services. Also, specialized investigative units in Child Death, Identification and Disaster Response, and the Resource Industry were established to support front-line coroners. Work has been underway for several years to develop a new database for storing and managing all BCCS case information, which was implemented this year. Additional modules for this database, including an electronic reporting capability, followed in 2007. The completion of these steps in 2006 formed the foundation for even more advancements that will be detailed in our 2007 Annual Report.
A brief comment on the timing of the release of our annual reports is also in order. Historically, the BCCS has released its reports well over a year after the close of the year being reported upon, the rationale being that statistical data was not finalized until after the close of a calendar year as we awaited the final autopsy, toxicology and investigational results from often lengthy investigations. While preliminary indications provide an initial picture of the circumstances of the death, data was not finalized and presented until the completion of an investigation. However, upon reflection we believe that it is equally important for us to produce reports that provide clear information and transparency through the provision of timely information. Consequently, as of 2007 we will provide our annual reports as close as possible to March 31 of the following calendar year. As 2006 was a transitional year, this report has been released early in 2008. The statistical data contained within the reports will be provided along with a footnote indicating the preliminary nature of that data and noting the tendency for this information to change over time.
The staff of the BCCS continues to commit themselves to improving the work they do, including developing and sharing of prevention strategies, in order to meet the present and future demands and challenges of improving community safety and maintaining a high quality of life for all British Columbians.
Terry P. Smith Chief Coroner of British Columbia Note: In 2007 significant changes were made to BCCS policy and the Coroners Act. These changes will be reflected in the BC Coroners Service Annual Report (2007).
Copyright © 2007, Province of British Columbia. All rights reserved. This material is owned by the Government of British Columbia and protected by copyright law. It may not be reproduced or redistributed without the prior written permission of the Province of British Columbia. To request permission to reproduce all or part of this material, please complete the Copyright Permission Request Form at http://www.prov.gov.bc.ca/com/copy/req/ or call (250) 356-5055. Table of Contents
PART 1: Historical Background ...... 1
PART 2: The BC Coroner System ...... 5 A. Organizational Structure ...... 6 B. Function ...... 7 C. Budget ...... 11 D. Research & Prevention ...... 12 E. Child Death Review ...... 19
PART 3: STATISTICS ...... 21 A. General Statistics ...... 21 B. Accidental Deaths: An Overview ...... 23 C. Motor Vehicle Incident (MVI) Deaths ...... 24 D. Child Deaths Reported to the BCCS ...... 28 E. Suicide Deaths ...... 30 F. Illicit Drug Deaths ...... 31
PART 4: INQUESTS ...... 33 A. Inquest Process ...... 33 B. Inquest Statistics ...... 35 C. 2006 Inquest Summaries ...... 36
Glossary ...... 77 TABLES Table 1. Forestry-Related Deaths by Year (2002-2006) ...... 11 Table 2. Number of Recommendations by Type and Year (2004-2006) ...... 13 Table 3. Number of Recommendations by Classification of Death (2006) ...... 13 Table 4. Number of Recommendations by Source (2006) ...... 13 Table 5. Response Rate to Action Recommendations (2006) ...... 13 Table 6. Recipients Receiving Five or More Recommendations-Action or Information (2006) ...... 13 Table 7. Total number of deaths reported to the BCCS in 2006 ...... 21 Table 8. Total Number of Deaths Reported to the BCCS by Region of Death (2006) ...... 22 Table 9. Death Rate for BCCS Regions (2006) ...... 22 Table 10. Accidental Deaths by Recreational Activity (2006) ...... 23 Table 11. Accidental Deaths by Occupational ...... 23 Table 12. Accidental Deaths by Other Activity (2006) ...... 23 Table 13. Number of MVI Deaths ...... 24 Table 14. Motor Vehicle Incident Deaths by Region ...... 24 Table 15. Number of Motor Vehicle Incident Deaths by Gender (2006) ...... 24 Table 16. Number (% of all MVIs) of Alcohol/Drug-Related Motor Vehicle Incident Deaths (2006) . . . . .26 Table 17. Number of Motorcycle Fatalities by Region and Year (2000-2006) ...... 27 Table 18. Number of Licensed Motorcycle Riders and Fatality Rates by Year (2000-2004) ...... 27 Table 19. Number of Motorcycle Deaths in which Alcohol and/or Drugs were Involved ...... 27 Table 20. Number of Child Deaths by Classification of Death (2002-2006) ...... 28 Table 21. Number of Child Deaths by Gender (2006) ...... 29 Table 22. Number of Child Deaths by BCCS Region (2006) ...... 29 Table 23. Number of Child Deaths by Type of Accidental Death (2002-2006) ...... 29 Table 24. Number of Child Deaths by Motor Vehicle Incident Position (2006) ...... 29 Table 25. Number of Child Deaths by Ethnicity ...... 29 Table 26. Number and Rate (per 100,000 population) of Suicide Deaths by Year (1987-2006) ...... 30 Table 27. Number of Suicide Deaths by Type (2006) ...... 30 Table 28. Number of Suicide Deaths by Ethnicity (2006) ...... 30 Table 29. Number of Suicide Deaths by Gender (2006) ...... 30 Table 30. Number of Illicit Drug Deaths by Year ...... 31 Table 31. Number of Illicit Drug Deaths by Region (2006) ...... 31 Table 32. Number of Illicit Drug Deaths by Gender (2006) ...... 31 Table 33. Number of Inquest and Deaths at Inquest by Year (2002-2006) ...... 35 Table 34. Number of Deaths at Inquest by Classification of Death (2002-2006) ...... 35 Table 35. Number of Deaths at Inquest by Gender (2002-2006) ...... 35 Table 36. Cause of Death for Inquest Deaths ...... 35 Table 37. Type of Death and Totals for Inquest Deaths (2006) ...... 36
FIGURES Figure 1. BCCS Geographical Regional breakdown of the province...... 5 Figure 2. The structural organization of the BCCS, and relationship with the Ministry of Public Safety . .6 and Solicitor General. The Executive Directors of the BCCS are indicated in bold capital . . . .11 letters, beginning with the Chief Coroner. Figure 3. Forestry-related deaths by year (2002-2006) ...... 11 Figure 4. Budget expenditure for the BCCS for the 2006/2007 fiscal year ...... 11 Figure 5. Number of deaths reported to the BCCS by year (2002-2006) ...... 22 Figure 6. Motor Vehicle Incident Deaths by Age Group (2006) ...... 25 Figure 7. Number of Motor Vehicle Incident Deaths by Month (2006) ...... 25 Figure 8. Number of Child Deaths by Year (1996-2006) ...... 28 Figure 9. Suicide Rate (per 100,00 population) by Age Group ...... 30 Figure 10. Number of Illicit Drug Deaths by Year (1990-2006) ...... 31 Figure 11. Number (%) of Illicit Drug Deaths by Classification of Death (2006) ...... 32 Figure 12. Number of Illicit Drug Deaths by Age Group (2006) ...... 32 P P ART ART 1: 1: Historical Background PART 1: Historical Background Historical Background
The Office of the Coroner is one of the oldest common law institutions, with references dating as far back as the time of Saxon King Alfred in 925 A.D. The first detailed statute concerning coroners was the Statute of Westminster of 1275. Formerly, the coroner was a protector of Crown revenue, responsible for bringing suspects to trial. The coroner was known as a "Keeper of the pleas of the Crown" or "Crowner" from which the term "coroner" evolved.
Coroners have been investigating death in British Columbia for over 100 years. B.C. inherited the English Coroners Act (of 1848) when it became a province in 1871. Coroners conducted their work independently through their own municipalities, as there was no provincial organization.
In 1932, the City of Vancouver built the first "Coroner's Court" building. The building contained a court room, where coroner's inquests were held, a morgue and autopsy facilities. The building was also shared with the City Analyst's Laboratory. The analysts performed toxicological analysis for the Coroners Department (of Vancouver).
Coroners worked independently until the appointment of a Supervisory Coroner, Glen McDonald, who served in this capacity from 1969 to 1979.
The first BC Coroners Act was enacted into law in 1979. At this time, the Vancouver Coroners Department/Office came under the authority of the province and was declared a provincial service. The first Chief Coroner, Dr. William McArthur, was appointed in 1979.
In 1980, the Vancouver Coroners Department was moved from the Coroner's Court building into a provincial coroners service building. The morgue was moved to Vancouver General Hospital because the morgue at the Coroner's Court building was limited in First Coroner’s Court Building, Vancouver, B.C. size. The coroner's area of the building remained vacant for six years before being occupied by its current tenants, the Vancouver Police Museum.
BC Coroners Service Annual Report 2006 1 Chief Coroners of British Columbia
1969-1979 Glen McDonald First Supervisory Coroner • 1979- 1981 Dr. William McArthur First Chief Coroner • 1981-1986 Robert Galbraith Chief Coroner • 1986-1996 Vincent Cain Chief Coroner • 1996-2001 Larry Campbell Glen McDonald Chief Coroner • 2001-present Terry Smith Chief Coroner
Dr. McArthur
Robert Galbraith
Vince Cain
Larry Campbell Terry Smith
BC Coroners Service Annual Report 2006 2 P P ART ART 1: 1: Historical Background B.C.'s Longest Serving Coroner Historical Background - a historical profile
Dan Devlin has been a coroner with the BCCS since August 1978. He is also an owner and director of a funeral home in Gibsons. As a coroner, Mr. Devlin serves the communities of Gibsons, Sechelt, Pender Harbour and Jervis Inlet. He investigates approximately 35–40 fatalities per year.
His most memorable investigation was that of a double fatality Dan Devlin following a sailing incident in the waters off Gibsons in late 1978. This fatality was to become Devlin's first inquest, only a few months after he was appointed a coroner. The vessel belonged to a Vancouver sailing school. The Coroners Act at the time stated that "where a body is found drowned, the inquest shall be held only by the coroner having jurisdiction in the place where the body is first brought to land". Therefore, Devlin was required to hold the inquest, which was held at the Coroner's Court building in Vancouver. Unlike inquests today, no lawyers were present or involved.
For Devlin, the aspect of the job that he finds most rewarding is making cogent determinations regarding circumstances of a death. That is, being able to answer the question, "Why is this person dead?" However, dealing with the death of children and meeting with and trying to be of help to devastated parents and other family members, is the most difficult part of the job.
Devlin has seen numerous changes in the organization and structure of the BCCS since he was first appointed coroner. Before the 1979 Coroners Act was enacted, there was no Chief Coroner, and only a Supervisory Coroner, who could advise coroners if requested. Each coroner was independent and reported only to the Attorney General through a clerk in the Associate Attorney General Deputy's office. A local coroner is no longer an independent Judicial Officer of the Crown.
The Coroners Act prior to 1979 dealt heavily with inquests. In rural areas, but also in the City of Victoria, inquests were often held in funeral homes. Devlin conducted most of his inquests at the provincial courthouse in Sechelt. An inquest commenced within days after the death and required that the jury view the body. The investigation was completed when the coroner wrote the final report, which was then entitled "Inquisition." Today it is entitled "Verdict at Coroner's Inquest." Devlin currently works as a community coroner (i.e., part time) with the Vancouver Metro Region.
BC Coroners Service Annual Report 2006 3
P P ART ART 2: 2: The B.C. Coroner System PART 2: The BC Coroner System The B.C. Coroner System
A. Organizational Structure
The BCCS is an agency within the Ministry of Public Safety and Solicitor General (PSSG). PSSG works to maintain and enhance public safety across the province. Branches, divisions and programs within PSSG include the BC Lottery Corporation, the Crystal Meth Secretariat, Insurance Corporation of BC, Liquor Control and Licensing and the Office of the Superintendent of Motor Vehicles. Emergency Management British Columbia (EMBC) is an agency established within the ministry in 2006 that oversees the integrated planning, mitigation, response and recovery activities for the threat and occurrence of natural and other disasters. The BC Coroners Service, the Provincial Emergency Program and the Office of the Fire Commissioner are all overseen by EMBC.
The Chief Coroner, whose office is located in Burnaby, oversees the BCCS. There are a total of five regional offices, with one in each of the following cities: Victoria, Vancouver, Surrey, Kelowna, and Prince George. Each of these offices is led by a Regional Coroner.
Fraser Region: Burnaby to the Coquihalla Highway Toll Booth, east to Manning Park and north to Jackass Mountain bordering Merritt.
Interior Region: Includes the region north to 100 Mile House and Blue River, east to the Alberta border, south to the USA border and west to the Manning Park gate, including Ashcroft, Lytton and Lillooet.
Island Region: Includes all of Vancouver Island, the Gulf Islands and Powell River.
Northern Region: Includes the region north, east and west from 100 Mile House to all Provincial borders, and the Queen Charlotte Islands.
Figure 1. Vancouver Metro Region: Includes Sunshine BCCS Geographical Regional breakdown of the province. Coast, Sea to Sky Corridor, North Shore, Vancouver, UBC, Delta and Richmond.
These regions approximate the BC Health Authority Regions (Fraser Health Authority, Interior Health Authority, Vancouver Island Health Authority, Northern Health Authority, and Vancouver Coastal Health Authority). However, there are some differences in the regional delineations.
BC Coroners Service Annual Report 2006 5 Figure 2. The structural organization of the BCCS, and relationship with the Ministry of Public Safety and Solicitor General.
BC Coroners Service Annual Report 2006 6 P P ART ART 2: 2: The B.C. Coroner System B. Function The B.C. Coroner System
There are both Coroner and Medical Examiner systems in Canada. British Columbia, along with Ontario, Saskatchewan, Quebec, New Brunswick, Prince Edward Island, Nunavut, the Northwest Territories and the Yukon operate under a coroner system. Medical examiner systems operate in Alberta, Manitoba, Nova Scotia and Newfoundland. Coroners are not necessarily medical specialists, though many have some medical training. However, all medical examiners in Canada are physicians. Coroners in British Columbia have varied backgrounds including medical, legal, investigative and social scientific.
The responsibilities and functions of the BCCS include:
• ascertaining and clarifying the facts of all sudden and unexpected deaths in B.C. to determine the identity of the deceased, and how, when, where, and by what means the deceased died; • reviewing all deaths of children under the age of 19 in the province; • ensuring that no death is overlooked, concealed or ignored; • producing a judicial document1, either a Judgement of Inquiry or a Verdict at Coroner's Inquest, that reports on the findings of the coroner's investigation; • making recommendations, where appropriate and feasible, to both public and private agencies, so that a similar death is less likely to occur in the future; • conducting inquests (quasi-judicial court proceedings) when mandated by the Coroners Act or when there is a strong public interest in the circumstances of the death or potential for prevention of death in similar future circumstances; and • collecting death information and conducting statistical analyzes.
Furthermore, prevention of death forms a critical part of the overall mandate of the BCCS.
Coroner's Investigations Coroners conduct a careful examination of the circumstances surrounding a death to understand how, when, where, why and by what means an individual died. Pathologists, toxicologists and specialized investigators may be consulted to provide assistance in an investigation. Given the complexity of many death investigations, the BCCS has developed specialized investigation units including Medical, Child Death, Identification and Disaster Response and the Resource Industry Units. To illustrate the function of these units, brief descriptions of the units and highlights of their 2006 activities are included on the following pages.
1The Judgement of Inquiry or a Verdict at Coroner's Inquest form the official record of the identity of the deceased and how, when, by what means and where he or she died. The medical cause of death and classification are noted. See Glossary (page 77) for definitions of classifications of death.
BC Coroners Service Annual Report 2006 7 Pathology Services (Autopsy) An autopsy is a complete internal and external examination of the body after death. An autopsy is ordered when the cause of death cannot otherwise be determined. If a reasonable and probable cause can be deduced on the basis of the deceased's medical history, the circumstances surrounding a death and a careful examination of the body, an autopsy may not be necessary. An autopsy can be forensic or non-forensic.
Non-forensic autopsies are performed in cases where the death appears to be due to natural causes or the result of a non-criminal injury or accident.
A forensic autopsy may be required for several reasons: • to determine the cause of death when it cannot otherwise be determined, • to identify the deceased • to collect evidence from the body, • to document evidence useful for clarification of the time and circumstances of death, • to obtain evidence to aid in the identification of the body, and • to identify artifacts of violence and trauma that may be used to support a criminal investigation.
The BCCS retains the services of pathologists who conduct autopsies on a fee-for- service basis. In 2006, the BCCS ordered 2,250 autopsies.
Toxicology Toxicology is the study of the nature, effects and detection of poisons and the treatment of poisoning. The pathologist may collect specimens for toxicological analysis if the cause of death is not obvious at autopsy.
Toxicology testing is most often provided on a fee-for-service basis at the Provincial Toxicology Centre, an accredited laboratory. For deaths in which there is also a criminal investigation in progress, the RCMP Forensic Laboratory conducts toxicology testing. Toxicological testing can also be conducted at regional hospitals.
In 2006, the BC Coroners Service ordered 2,156 toxicological tests.
Medical Investigation Unit The Medical Investigation Unit provides coroners with guidance and assistance in investigation of medical issues and assistance in obtaining medical information. The unit also serves as a liaison with medical and nursing staff and health authorities and provides consistency in the management of investigation of deaths with complex medical issues through the development and use of medical investigation protocols. The latter function provides a provincial viewpoint for the identification of trends in health care factors that contribute to death and may be addressed through subject- specific review. Finally, the medical unit represents the BCCS on provincial committees such as the Perinatal Mortality Review Committee.
BC Coroners Service Annual Report 2006 8 P P ART ART 2: 2: The B.C. Coroner System Child Death Investigation Unit The B.C. Coroner System Death of children requires special consideration because of their vulnerable status in society. The BCCS developed a specialized Child Death Investigation Unit to assist and support coroners in the investigation of child deaths.
The Child Death Investigation Unit was developed as a result of proposed changes from several reviews on how child deaths were to be reported and investigated in B.C. In 2006, the review of over 900 child deaths identified the need for additional information specific to pediatric cases. The unit has developed to coincide with legislative changes reflecting the BCCS role and importantly, the distinction between child death review and child death investigation.
The BCCS also recognizes the unique and often complex challenges in investigation of child death and in dealing with the caregivers of these children. The distinct and differing physiology, anatomy and developmental stages of children compared to adults and the additional health risks children face affecting their life expectancy are all important considerations for an investigating coroner. The unit's intent is to ensure accurate, thorough and timely response and reporting of these sensitive investigations and to assist and support coroners conducting the investigation.
In addition, the unit provides training and identifies best practices for the BCCS. For example, a specific investigation protocol is completed for each child death in the province to ensure thorough and consistent investigation and data collection. This protocol was based on protocols used by other jurisdictions nationally and internationally and tailored by the Child Death Investigation Unit to meet the BCCS mandate. A Child Death Investigation Unit coroner is specially trained to understand the unique aspects of dealing with child death and to ensure that information gathered is considered from a pediatric perspective. This expertise is made available to all coroners conducting child death investigations.
Identification and Disaster Response Unit Consistent with the BCCS mandate to investigate all sudden and unexpected deaths, the Identification and Disaster Response Unit (IDRU) is responsible for facilitating the agency's recovery, identification and repatriation of all human remains in the event of a mass fatality incident. Also, consistent with the agency's responsibility to determine the identity of the deceased in cases of sudden and unexpected death, the IDRU either directly provides or co-ordinates the delivery of forensic services and has been innovative in analytical and investigative functions for the BC Coroners Service.
In 2006, the IDRU conducted a critical audit of the agency's 200 cold cases and sought opportunities for pursuing identification by implementing a systems-based approach to investigation of unidentified human remains cases. The unit also forged partnerships with outside agencies to strengthen identification capabilities. In a joint initiative with the Ontario Provincial Police and Office of the Chief Coroner for the Province of Ontario, the IDRU implemented the Missing Persons and Unidentified Bodies (MPUB) database. The first of its kind in Canada, the database stores unidentified human remains case information and enables searches, comparisons and cross-referencing with
BC Coroners Service Annual Report 2006 9 missing persons information. The public website component for this initiative is expected to be launched in 2008.
Resource Industry Unit In May 2006, the BC Coroners Service established the Resource Industry Unit. Dedicated to the investigation of deaths in the forestry industry and related sectors, the unit was created in response to an alarming number of deaths involving forestry workers. In 2005, 45 forestry-related fatal incidents were reported to the BC Coroners Service. In 2006, forestry workers continued to have one of the highest rates of fatal incidents, with 14 deaths reported. While the primary focus for the Resource Industry Unit was on incidents within the forestry and wood products manufacturing sectors, the unit also provided support to coroners conducting investigations into workplace incidents in other industries.
The unit assumed direct authority over 18 investigations in 2006. In addition to investigating the circumstances involved in the individual fatalities, the unit conducted an aggregate review of these deaths with consideration of conditions in the B.C. forestry sector.
In September 2006, the BCCS held an inquest into the death of a tree faller that occurred in 2005. The inquest publicly highlighted numerous areas of concern regarding safety of forestry operations and resulted in 23 recommendations from the jury. This inquest is summarized in a subsequent section of this report. A 2006 forestry-related fatality involving a log-hauling incident was also investigated through an inquest, and will be summarized in the 2007 annual report.
The Resource Industry coroner also made recommendations regarding the deaths of two forestry workers. One death involved a worker who was fatally injured when he was tree falling and was crushed by an uprooted tree, which had slid down from a rock bluff. A lack of effective supervision was noted at the worksite. The resource coroner directed two recommendations to the chair of the board of directors of WorkSafeBC. It was recommended that the board consider introducing a requirement that each forestry workplace, where manual falling of trees is taking place, have a safety supervisor whose primary responsibility is safety-focused supervision of fallers. It was further recommended that the supervisor conduct a daily inspection of each faller's work and that the supervisor conduct a walk-through of each faller's work area with the faller prior to work commencing. This latter requirement would serve the purpose of identifying and mitigating potential hazards.
The chair of the board of directors of WorkSafeBC responded to the recommendations made by the resource industry coroner. It was noted that the board was currently reviewing the Occupational Health and Safety Regulations pertaining to forestry activities (i.e., Part 26: Forestry Operations, of the Occupational Health and Safety Regulation). It was noted that the proposed amendments to Part 26 already under review were similar to the coroner's recommendations and that the recommendations would be carefully considered in the review process. The amendments were discussed at public hearings in June 2007 and stakeholder feedback obtained. The amendments were submitted to the board of directors in November 2007 for decision.
BC Coroners Service Annual Report 2006 10 P P ART ART 2: 2: The B.C. Coroner System Table 1. Forestry-Related Deaths by Year (2002-2006) and BCCS Region The B.C. Coroner System Region 2002 2003 2004 2005 2006 TOTAL Northern 11 7 4 15 9 46 Island 4 4 1 15 1 25 Interior 2 2 3 9 4 20 Fraser 0 2 3 5 0 10 Vancouver Metro 3 0 3 1 0 7 TOTAL 20 15 14 45 14 108
The Resource Industry Unit of the BCCS was created in response to a suddenly high number of deaths of forestry workers in 2005. In that year 45 forestry-related fatal incidents were reported to the BCCS. Over the last five years the number of forestry-related deaths have been especially high in the Northern region.
Figure 3. Forestry-related deaths by year (2002-2006)
C. Budget The BCCS annual budget in 2006/2007 was $13.9 million (April 1, 2006, to March 31, 2007). It was spent in three areas: salaries and benefits, direct costs and support costs. Salary and benefits comprised approximately half of the total budget. Direct costs comprised almost one-third of the budget and included expenses such as inquests (e.g., juries, court reporters and related inquest fees), forensic services (e.g., autopsies, toxicological analysis) and body handling (e.g., recovery, storage and transport costs). Support costs include expenses such as external contracts, computing, communications, and facilities.
2006/07 Annual Budget - $13.92 million
Support Costs Direct Costs Body Handling Communications Forensic Services Computing Inquests Contracts Facilities
Salary & Figure 4. Budget expenditure for the Benefits BCCS for the 2006/2007 fiscal year.
BC Coroners Service Annual Report 2006 11 D. Research & Prevention
Recommendation Process
Part of the mandate of the BCCS is prevention of deaths. In addition to the recommendations that a jury may make following inquest proceedings, a coroner may make recommendations, where appropriate and feasible, to both public and private agencies. These recommendations are made so that a similar death is less likely to occur in the future. During an investigation, a coroner may decide to make one of two types of recommendations:
1) “Action”: a change is recommended to the agency and a response to this recommendation is requested by the BCCS. Recommendations may be directed to one or more agencies/individuals.
2) “Information”: no changes are recommended but the findings of the investigation are being brought to the agency or individual's attention for informational purposes only. A response to the information is not requested, although a response may sometimes be received.
A response to action recommendations is requested within 90 days of distribution of the recommendation. Positive responses include those where agencies acknowledge the recommendation(s), have already taken action during the investigation, are going to be taking further action to implement the recommendation(s) or are taking the recommendation into consideration and evaluating further. A negative response includes those where agencies are unable to implement the recommendation. A negative response can sometimes be appropriate as the recommendation cannot be carried out by an agency due to legislative reasons, financial implications, or other circumstances.
Although the BCCS has no statutory authority to order change or to ensure that its recommendations are carried out, it is expected that the recommendations will be given serious consideration by those agencies to which they are directed. Furthermore, the BCCS has been successful in having recommendations considered and implemented.
As a direct result of coroner and jury recommendations, policies and procedures have been changed with the goal of preventing similar deaths in the future.
The Chief Coroner is responsible for bringing the findings and recommendations from coroner's investigations and inquest juries to the attention of appropriate individuals, agencies, the public, and ministries of government.
In 2006, the BC Coroners Service sent out to various agencies a total of 187 recommendations made by juries at inquests or through coroner's investigations. The majority of the recommendations resulted from accidental deaths.
BC Coroners Service Annual Report 2006 12 P P ART ART 2: 2: The B.C. Coroner System Table 2. Number of Recommendations Recommendation Statistics1 The B.C. Coroner System by TYPE and YEAR (2004-06) The BC Coroners Service had a 77 per cent Year Type Number TOTAL response rate to recommendations that were sent 2004 Action . . . .233 282 for action (i.e., requiring a response), with Information ...... 49 approximately 71 per cent of these responses 2005 Action . . . .228 274 being positive. Information ...... 46 2006 Action . . . .149 187 The agencies receiving five or more Information ...... 38 recommendations in 2006 are represented in Table 3. Number of Recommendations Table 6. by CLASSIFICATION of DEATH (2006) Death Class Number Accidental 106 Recommendations Made by Coroners Homicide 19 In 2006, a total of 119 recommendations were Natural 25 directed to agencies or individuals by Suicide 34 investigating coroners. Of these, 81 were action- Undetermined 3 focused, while 38 were informational in nature. TOTAL 187 Examples of several of the action Table 4. Number of Recommendations recommendations and responses from agencies by SOURCE (2006) receiving these recommendations are provided Recommendation Source Number on the following pages. Coroner 119 Jury 68 TOTAL 187
Table 5. Response Rate to ACTION Recommendations (2006) Percentage of recipients responding 76.5% Percentage of responses that were positive 71.0%
Table 6. Recipients Receiving Five or More Recommendations – ACTION or INFORMATION (2006) Recipient Number Ministry of Children and Family Development 15 Vancouver Police Department 14 Vancouver Island Health Authority 12 Ministry of Public Safety and Solicitor General 11 College of Physicians and Surgeons 10 B.C. Ambulance Services 7 St. Paul’s Hospital 7 Vancouver Coastal Health Authority 7 Chief Coroner of B.C. 5 Ministry of Health 5 Royal Canadian Mounted Police 5 Transport Canada 5 1 Recommendation statistics represent total number of WorkSafeBC 5 recommendations distributed to individuals and agencies. One recommendation may be distributed to multiple recipients.
BC Coroners Service Annual Report 2006 13 Motor Vehicle Incident Deaths In 2006 there were 431 motor In December 2003, a 28-year-old male was the driver of a vehicle incidents, representing stolen vehicle, being pursued by the Vancouver Police near the the leading cause of accidental 1 death in B.C. 800 block of East 8th Avenue. The driver committed a number of traffic violations and was driving at a dangerously high speed. There were 13 transport-related Moments before the crash, the police pursuit was called off. recommendations made in 2006 However, officers continued along the route believed to be taken by by coroners and juries regarding: the stolen vehicle, and came upon the vehicle, which had crashed • highway/roadway design into a tree. Witnesses reported that the police did not arrive or • licensing/driver training approach the scene with lights and sirens. The driver died later in • all terrain vehicles hospital. The coroner's investigation revealed that not all of the • air transport relevant information regarding vehicle speed, traffic violations or risk to public safety was being relayed to the police supervisor when the pursuit was in progress, as required by policy.
Recommendation to the Chief of the Vancouver Police Department: The coroner recommended that the operational policy related to patrol tactics for pursuit termination become departmental policy. It was also recommended that there be a review of all emergency vehicle driving regulations and Vancouver Police pursuit policy with a focus on timely reporting of information to the officer in charge. Response: All recommendations put forward by the coroner were implemented.
In August 2005, a 35-year-old female passenger died in a two-car collision at 58th 2 Avenue and 180th Street in Surrey. The coroner's investigation determined that visual obstructions at the intersection were exacerbated by the placement of the stop sign and stop line. The sign and line on 58th Avenue were too far back from the intersection and were significant contributory factors to this collision.
Recommendation to the City of Surrey: The coroner recommended that the placement of the stop sign and stop line be moved closer to 180th Street to increase visibility and response times for motorists approaching the intersection. Response: The City of Surrey Engineering Department conducted a number of on-site assessments and made the proposed adjustments at this intersection.
In June 2005, a 25-year-old male was a passenger on a four wheel all-terrain-vehicle 3 (ATV) on a logging road northwest of Port Alberni. The ATV was travelling at approximately 50-60 km/hour when it was hit in the side by another ATV coming from a side road. The male passenger was thrown from the ATV and died later in hospital from head injuries. He was not wearing a helmet at the time of incident. The coroner's investigation determined that there are no regulations requiring helmets for recreational ATV operators or passengers or training standards for recreational users.
BC Coroners Service Annual Report 2006 14 P P ART ART 2: 2: The B.C. Coroner System Recommendation to the Minister of Tourism, Sports and the Arts: The B.C. Coroner System The coroner recommended to the Minister that consideration be given to establishing regulations regarding mandatory helmet use for all recreational drivers and passengers of ATVs and that minimum age and training standards be established. Response to recommendations: The ministry responded that they will be partnering with the Coalition for Licensing and Registration of Off Road Vehicles in B.C. on the development and distribution of Best Management Practices for Motorized Recreation in B.C.'s Grasslands, as well as new safety guidelines. The ministry replied that they are working with clubs and community groups to prevent similar deaths. The ministry also indicated that the Province of B.C. is also presently discussing options which would specifically address the coroner's recommendation of mandatory helmet use for drivers and passengers, the minimum age for riders, and training standards.
Medical-related deaths can include deaths in which there may have Medical-Related Deaths been a missed diagnosis, complications from a diagnostic In September 2004, a 37-year-old female inmate had been procedure, or a treatment error. 1 discovered unresponsive in her cell at the Surrey Pretrial The BCCS makes numerous Centre. The inmate had a history of heroin use and had recommendations regarding these recently been started on a methadone program managed by types of deaths each year. For health care staff at the facility. Her death was subsequently example, in 2006, there were 23 determined to be due to a toxic accumulation of methadone. recommendations made regarding medical education and 17 made regarding medical procedures. The Recommendation to BC Corrections Staff: Medical Investigations Unit of the The coroner recommended to BC Corrections that all BCCS reviews these deaths and recommendations from an internal review conducted by the provides assistance and advice to Inspections and Standards Office and the Ministry of Attorney the investigating coroner. General be implemented. The review examined the existing policy regarding methadone induction and maintenance programs. Ongoing training for Corrections staff on procedures related to the methadone program and policy regarding documentation and access to historical medical records on inmates were also reviewed. Response: The Surrey Pretrial Centre implemented all of the recommendations resulting from the review.
In May 2005, a 52-year-old patient in Royal Jubilee Hospital suffered an 2 unwitnessed fall in a washroom during which she struck her head. Her neurological status was assessed by nursing staff as normal. She was treated for severe headache. However, her condition deteriorated over the next three hours. Revealed by a CT scan was an unsurvivable, massive acute subdural hematoma.
Recommendation directed to The Chief Medical Officer and the Chief of Professional Practice and Nursing (Vancouver Island Health Authority):
BC Coroners Service Annual Report 2006 15 The coroner recommended that the Health Authority adopt a Head Trauma Protocol that includes clear assessment guidelines for signs and symptoms of increasing intracranial pressure. Response: The Vancouver Island Health Authority has undertaken a revision of their existing medical and nursing guidelines for management of patients with head trauma. The revisions have been implemented in all of the emergency departments within the health authority's jurisdiction.
In February 2005, a male twin born prematurely at Matsqui-Sumas-Abbotsford 3 General Hospital was initially healthy. He quickly developed an infection and despite hospital efforts he died four days later from septic shock due to gram negative septicemia.
Recommendation to Quality Improvement and Patient Safety (Fraser Health Authority): The coroner recommended that two educational programs be adopted at the hospital: 1) Acute Care of the At-Risk Newborn (ACORN) and 2) Managing Obstetrical Risks Effectively (MORE). A review of the shift routine to ensure minimal delays in complete assessments of infants was also recommended. Response to recommendations: Yearly ACORN training sessions attended by medical and nursing staff, respiratory therapists and midwives have been held since this death. A target goal has been set to implement the MORE program in the 2007/2008 fiscal year.
In November 2004, a 45-year-old man with a history of previous suicide attempts 4 was brought to St. Paul's Hospital from his residence. He had been in cardiac arrest but was successfully resuscitated by emergency personnel prior to transport to the hospital. However, he had signs of serious neurological dysfunction that did not improve and his condition continued to deteriorate. When further aggressive medical management was deemed to be futile, he was placed on comfort care measures. He was given intravenous medication to maintain his blood pressure. He developed septic shock and multi-system organ failure. Analgesic and sedative medication were administered, which may have contributed to his death shortly thereafter.
Recommendation to St. Paul's Hospital: The coroner recommended that the documentation from health care professionals supporting decision making for medication administration related to comfort care and end of life be reviewed or developed. It was also recommended that the hospital consider developing guidelines for end-of-life analgesia and sedation. Response: The hospital responded that the Division of Critical Care Medicine and the Intensive Care Unit staff have worked together and developed a set of principles for withholding and withdrawing life sustaining treatment. They have also developed a new set of palliation (comfort care) orders for the Intensive Care Unit.
BC Coroners Service Annual Report 2006 16 P P ART ART 2: 2: The B.C. Coroner System Occupational Deaths The B.C. Coroner System
In March 2004, volunteer firefighters responded to a structure fire in There were 63 1 Clearwater. A 23-year-old male and his partner entered the building accidental occupational- which was engulfed in flames. The firefighter collapsed and his partner could related fatalities in not move him so he left to find assistance. The partner subsequently needed 2006. Coroners directed assistance to leave the building. The firefighter was later found deceased in five recommendations the building. to WorkSafeBC regarding these deaths. Recommendation to the Office of the Fire Commissioner and the Justice Institute of British Columbia: The coroner recommended initiation and maintenance of regular inspections and an audit process to ensure volunteer fire departments meet provincially recognized standards for equipment, training and operational procedures. Response: The Justice Institute of BC has met with the Office of the Fire Commissioner to establish a framework for more effective training of and improved education systems for B.C.'s firefighters.
In April 2005, a 41-year-old grapple log loader was crushed against a wall of a vat in 2 a plywood plant in Williams Lake. The coroner's investigation determined that the employer had not reviewed the job duties and hazards with the employee.
Recommendation to WorkSafeBC: The coroner recommended that WorkSafeBC issue a hazard alert to all forest-sector worksites advising of hazards and applicable regulations relating to the interface between pedestrian workers and mobile equipment at those worksites. Response: WorkSafeBC produced a hazard alert in accordance with the recommendation. In addition, an article discussing these types of hazards was published in the July/August 2007 issue of WorkSafe Magazine.
Other Prevention Activities
Agency Collaboration There are numerous deaths for which preventative changes are made by an agency or individual, during an investigation, pre-empting the need for a formal recommendation to be issued. Coroners may work actively with agencies in development of recommendations to prevent deaths, without the need to issue formal recommendations. During the course of an investigation, a coroner may meet with various agencies to discuss the death. Agencies are often eager to make changes that will prevent similar deaths in the future. In these cases, the coroner may aid the agency by making suggestions for change. If implemented during the course of an investigation, no formal recommendations are issued to the organization. However, this informal recommendation
BC Coroners Service Annual Report 2006 17 process is an important one through which the BCCS effects change in the community to prevent future deaths.
The following illustrates a case in which the investigating coroner collaborated with other agencies toward their common goal of prevention:
In July 2006, a 33-year-old male motorcyclist travelling eastbound on Highway #3 near Hope crossed the centre line and left the roadway. In this location, the road is straight with an uphill grade and a curve to the right as one approaches the Snass Creek Bridge. At the time, the road and weather conditions were good. This driver was witnessed to cross the centre line at an extremely high rate of speed, sideswiping a series of concrete barriers before impacting the bridge abutment.
This incident was one of three fatal motor vehicle incidents in the same location over a fourteen month period. The Ministry of Transportation and the Insurance Corporation of B.C. replaced the existing curve warning and speed advisory signs with high visibility signs. The BCCS joined a multi-agency safety committee with the specific objective of reducing incidents along this busy highway corridor.
Public Safety Bulletins To further its prevention efforts, the BCCS also issues public safety bulletins as part of its mandate to prevent deaths in B.C. These bulletins are released to the media provincewide and are also published on the BCCS website.
In July 2006 there were 12 drowning deaths reported to the BCCS. Three (25%) of these incidents involved travellers from outside of B.C. Recognizing this alarming number, the BCCS released a public safety bulletin in August 2006 regarding the risk of B.C.'s lakes and rivers, especially for tourists.
Identified risks included the cold water temperature, the swiftness of B.C. lakes and rivers, slippery shorelines and steep drop-offs near shorelines.
Research To further its data-monitoring and research/prevention efforts, the BC Coroners Service implemented a new database system in March 2006. Along with providing valuable research data, the new system is also a case- management application that enables the BCCS to:
• record information related to a death; • track progress of a death investigation; • create letters, reports and other forms through templates; • store documents related to a death that were received from external sources; • gather statistical information about deaths;
BC Coroners Service Annual Report 2006 18 P P ART ART 2: 2: The B.C. Coroner System • manage inquests; The B.C. Coroner System • manage and track recommendations and responses to recommendations; • generate statistical reports; and • allow for timely monitoring of difficult investigations, and facilitate the development and maintenance of the BCCS database and research capabilities.
The database was also designed to facilitate the participation of the BCCS in the National Coroner and Medical Examiner's Database being sponsored by Health Canada and Statistics Canada. The objective of the database is to collect information on deaths reported to and investigated by coroners and medical examiners, who work under independent provincial/territorial jurisdiction. The national database will enhance health surveillance and facilitate the identification and characterization of emerging health and safety issues facing Canadians.
The BCCS is also active in research, within the organization and also in collaboration with other organizations. For example, in 2006, the British Columbia Injury Research and Prevention Unit (BCIRPU) and the BCCS collaborated on a study of motor vehicle incident fatalities in B.C. (occurring from 2003-2005) using BCCS investigative data. Data from this study will be reviewed by the Insurance Corporation of B.C. to determine how motor vehicle incidents may be prevented. The research project examined numerous variables including demographic data, autopsy and toxicology data, and variables related to the specific incident such as road conditions, type of vehicle, location, and use of safety equipment. Several important findings emerged from this research project and will be released in a report in 2008.
E. Child Death Review
The Child Death Review Unit (CDRU) has a legislative mandate to review all deaths of children under the age of 19 in the province. The mission of the CDRU is to complete comprehensive reviews of all child deaths to better understand how and why children die, and to use those findings to take action to prevent other deaths and improve the health, safety and well-being of all children in British Columbia.
The responsibility for child death review in B.C. has been that of the BC Coroners Service since January 2003. Early on, the focus of the unit was on developing the foundation for a child death review program. The unit experienced many of the same challenges other jurisdictions reported, namely related to budgets and limited legislation. The CDRU, was however, significantly successful in strengthening the child death investigation process, including the development of a child death investigation protocol and the reporting of child deaths reviewed between 2003 and 2005.
The CDRU underwent significant change during 2006. In April 2006, the Honourable Ted Hughes, OC, QC, LL.D. (Hon.), issued a special report on B.C.'s Child Protection System. Part of his task was to examine and make recommendations to improve how
BC Coroners Service Annual Report 2006 19 child deaths were reviewed, including the issue of public reporting. With the recommendations accepted by government, the BC Child Death Review Unit (CDRU) remained a unit within the BCCS.
The CDRU review process is based on best practices for child death review from across North America. The purpose of the review process is to identify common risk factors that were present in the lives and deaths of the children, with a view to developing evidence-based recommendations that will reduce risk and prevent similar deaths of children and youth in the future. As the CDRU is notified of all child deaths as they occur, the unit is also involved in ongoing monitoring of all sudden and unexpected child deaths. Working within the BCCS allows unit members to:
• Identify trends in child deaths immediately; • Provide feedback to the Deputy Chief Coroner to improve the quality and consistency of information gathered for future individual and aggregate review; • Provide information collected from other child death investigations and review jurisdictions intended to strengthen the BCCS response to child death; and • Make informed decisions on topics for special reports based on contemporary themes and areas of risk.
Further information on the Child Death Review Unit, including the CDRU Annual Report 2006, is accessible at: www.pssg.gov.bc.ca/coroners
BC Coroners Service Annual Report 2006 20 P P ART ART 3: 3: S S t t atistics PART 3: Statistics atistics
2006 in Review
On a typical DAY in 2006 in B.C.
• Out of 84 deaths that occurred, over 20 deaths were reported to the BCCS • 4.3 deaths occurred in the Vancouver Metro region • 3.5 accidental deaths occurred • 1.2 deaths resulted from motor vehicle incidents • 1.2 deaths were due to suicide
In a typical WEEK in 2006 in B.C.
• Four deaths occurred due to illicit drug overdoses • There were 1.2 deaths of pedestrians • Every other week, a British Columbian of Aboriginal descent died due to suicide
In a typical MONTH in 2006 in B.C.
• 3.25 motorcycle fatalities occurred • At least one forestry-related death occurred • Five deaths resulted from accidental water-related activities • 6.8 recreational deaths occurred, including 1.2 due to snow-related activities • There were 18 deaths of children, including 1.3 deaths due to homicide
A. General Statistics2
Table 7. Total Number of Deaths There were a total of 30,522 deaths reported to the BC Coroners Service (2006) in the Province of British Columbia Classification of Death Number in 2006, of which 7,780 were Accidental 1,290 reportable to the BCCS as required Homicide 121 in the Coroners Act. Therefore, Natural 5,629 the BCCS investigated Suicide 452 approximately 25% of all deaths in Undetermined 288 the province in 2006. TOTAL 7,780
2 The BC Coroners Service works in a real-time database environment. Therefore, statistics are subject to change until all coroners' investigations are completed.
BC Coroners Service Annual Report 2006 21 Figure 5. Number of deaths reported to the BCCS by year (2002-2006)
Table 8. Total Number of Deaths Reported to BCCS by Region of Death (2006) Region Accidental Homicide Natural Suicide Undetermined TOTAL Fraser 331 38 1,526 118 51 2,064 Interior 322 21 1,316 82 72 1,813 Island 230 19 1,255 88 86 1,678 Vancouver Metro 261 29 1,140 128 33 1,591 Northern 146 14 392 36 46 634 TOTAL 1,290 121 5,629 452 288 7,780
While the greatest number of deaths occurred in the Fraser region in 2006, the Table 9. Death Rate by BCCS Regions (2006) highest mortality rates were observed in the more rural Region Number of Population3 Rate Per regions of B.C. (i.e., Interior, Deaths 10,000 pop. Island and Northern regions). Fraser 2,064 1,498,103 13.8 Similarly, a national report Interior 1,813 709,377 25.6 released last year found that Canadians living in rural and Island 1,678 738,785 22.7 remote areas had higher death Vancouver Metro 1,591 1,075,143 14.8 rates than their urban Northern 634 289,044 21.9 counterparts. (How Healthy Are Rural Canadians? An Assessment of TOTAL 7,780 4,310,452 their Health Status and Health Determinants. Sep 2006. Canadian Institute for Health Information, Public Health Agency of Canada, Centre for Rural and Northern Health Research at Laurentian University).
3 Population estimates for 2006 by Health Authority area (BC Statistics Agency). Health Authority areas approximate the BCCS regions.
BC Coroners Service Annual Report 2006 22 P P ART ART 3: 3: S S t B. Accidental Deaths: An Overview t atistics atistics
Table 10. Accidental Deaths by Table 11. Accidental Deaths by RECREATIONAL Activity (2006) OCCUPATIONAL Activity (2006)
Recreational Activity Number Occupational Activity Number Hang glider 1 Other place of work 28 Other aircraft 9 Construction sites: other 6 Total AIR 10 Forestry sites 5 Motorbike, ATV, off-road 14 Construction site: residential 4 Hiking, climbing 10 Mine, quarry, oil and gas 3 Street bike 3 Railway sites 3 Scooter 2 Yard work 3 Skateboarding 1 Commercial hunting, fishing, trapping, other vessel 2 Total LAND 30 Farm worksite 2 Snow skiing 6 Industrial 2 Snowmobiling 5 Excavating, paving, grading 2 Snowboarding 3 Construction site: commercial 1 Total SNOW 14 Electrical, powerlines 1 Swimming 7 Industrial: material handling 1 Canoe 3 TOTAL 63 Diving 3 Dinghy (boating) 2 Kayak 2 Scuba diving 2 Table 12. Accidental Deaths by Inner tube 1 OTHER Activity (2006) Power boating 1 Other Activity Number Rowboat 1 Motor vehicle traffic incidents 408 Fishing 1 (23 recreational & occupational deaths not included) Total WATER 23 Alcohol and/or drug poisoning 316 All other 5 Fall 206 Total other 5 Other 59 TOTAL 82 Airway obstruction 38 Drowning4 37 Not yet determined 32 Fire 19 Exposure 10 Carbon monoxide exposure 8 Air crash 7 Skytrain or railway 3 Firearms 2 TOTAL 1,145
4Does not include drownings in recreational activity category (i.e., swimming).
BC Coroners Service Annual Report 2006 23 C. Motor Vehicle Incident (MVI) Deaths
Of the 1,290 accidental deaths in 2006, 33 per cent were the result of motor vehicle incidents. There was an 8 per cent decrease in the number of MVI fatalities from 2005 to 2006. Table 13. Number of Motor Vehicle Incidents Deaths (2006) The highest number of motor vehicle deaths occurred in Year Number the Interior region. Farther distances traveled and 2002 472 remoteness from medical facilities have been suggested to contribute to increased motor vehicle fatalities in rural 2003 474 2004 460 areas (Urban-Rural Differences in Motor Vehicle Crash Fatality and Hospitalization Rates Among Children and Youth, Accident, Analysis 2005 468 and Prevention 38:122, 2007). 2006 431
Table 14. Motor Vehicle Incident deaths by BCCS Region (2006) MVI Type Fraser Interior Island Metro North TOTAL Driver 39 70 23 18 32 182 Passenger 18 27 14 12 13 84 Pedestrian 19 9 7 22 7 64 Motorcycle – Moped 814 67 439 Commercial Truck Driver 5600718 Pedal Cyclist 5243115 Commercial Truck 000011 MVI / Train 100001 Other 7642827 102 134 58 64 73 431
Table 15. Number of Motor Vehicle Incident Our statistics indicate that 72 per cent of MVI fatalities Deaths by GENDER (2006) were males, while 28 per cent were females. However, Gender Number when injuries are considered in addition to fatalities, the Male 311 gender difference is greatly reduced. While, more males Female 120 than females were licensed drivers in 2005, the mortality TOTAL 431 rate per 100,000 drivers was 20.7 for males and 8.5 for females (Traffic Collision Statistics: Police attended injury and fatal collisions, ICBC, 2005).
BC Coroners Service Annual Report 2006 24 P P ART ART 3: 3: S The greatest number of motor vehicle incident deaths was observed for those aged 19 to S t t atistics 29 years old. There were 101 fatalities in this age group, followed by 65 fatalities in those atistics aged 40-49 years.
Figure 6. Motor Vehicle Incident Deaths by Age Group (2006)
Figure 7. Number of Motor Vehicle Incident Deaths by Month (2006)
There were a total of 30,522 deaths in the Province of British Columbia in 2006, of which 7,780 were reportable to the BCCS as required in the Coroners Act. Therefore, the BCCS investigated approximately 25% of all deaths in the province in 2006.
BC Coroners Service Annual Report 2006 25 Alcohol use is a leading contributory factor to MVIs (see Special Focus Section on motorcycle fatalities). In 2005, ICBC reported alcohol use to be the fifth leading contributory factor to all collisions, but the second leading contributory factor to fatal collisions (Traffic Collision Statistics: Police attended injury and fatal collisions, ICBC).
Table 16. Number (% of all MVIs) of ALCOHOL-DRUG RELATED Motor Vehicle Incident Deaths (2006)
Alcohol or drug 2002 2003 2004 2005 2006 Alcohol - a contributory factor 114 119 125 143 97 (24%) (25%) (27%) (31%) (22%) Alcohol, drugs or both - a contributory factor 126 129 145 164 115 (27%) (27%) (31%) (35%) (27%)
BC Coroners Service Annual Report 2006 26 P P ART ART 3: 3: S Special Report: Motorcycle Deaths S t t atistics atistics There has been a 42 per cent increase in the total number of motorcycle deaths from 2000 to 2006. In 2006, motorcycle deaths accounted for almost 10 per cent of all accidental motor vehicle deaths. Almost two thirds of all motorcycle deaths occurred in the Fraser or Interior regions. The following statistics highlight further findings in this area. Table 17. Motor Vehicle Incident deaths by BCCS Region (2006) Year Fraser Interior Island Metro Northern TOTAL 2000 9 7 5 4 3 28 2001 10 5 4 3 0 22 2002 8 9 4 3 7 31 2003 14 6 7 5 1 33 2004 16 11 11 4 3 45 2005 14 18 9 4 3 48 2006 8 14 6 7 4 39 TOTAL 79 70 46 30 21 246
While the total number of motorcycle fatalities show a general increasing trend since 2000, there has also been an increase of over 20,000 more licensed motorcycle riders since the same year (Traffic Collision Statistics: Police attended injury and fatal collisions, ICBC). Therefore, the rate of fatalities (deaths per 10,000 licensed riders) of motorcyclists shows only a very small increase since 2000. Table 18. Number of Licensed Motorcycle Riders Table 19. Number of Motorcycle Deaths and Fatality Rates by Year (2000-2004) in which ALCOHOL and/or DRUGS Year # of Licensed Fatality Rate were Involved Motorcycles Per 10,000 Drug or alcohol use Number Licensed Riders Neither drugs nor alcohol 153 2000 60,934 4.6 Alcohol 56 2001 66,071 3.3 Drugs 11 2002 69,136 4.5 Alcohol and Drugs 10 2003 73,258 4.5 Data not available 16 2004 77,670 5.8 TOTAL 246 2005 83,218 5.8 Additional Motorcycle Death Statistics: • Alcohol and/or drug use were cited as contributory to the accident in approximately 77 (31%) of incidents. • A total of 99 (40%) out of 246 fatalities occurred on provincial highways, while 134 (54%) fatalities occurred on roadways other than provincial highways. • 103 (42%) fatalities were the result of single vehicle incidents (SVI) while multiple vehicle incidents accounted for 141 (57%) fatalities. • 232 (94%) fatalities were of a driver, while 14 (6%) were of a passenger. • Speed was also a contributory factor in a high percentage of fatalities-68 (28%).
BC Coroners Service Annual Report 2006 27 D. Child Deaths Reported to the BCCS
A child is defined by the BCCS as anyone under the age of 19. In 2006, there were more Homicide child deaths than in any of the previous 4 years. The Homicide deaths in 2006 included: • eight teenaged children, • a multiple Homicide in which 4 children died, • three Homicide deaths committed by parent(s), and • three gunshot and three stabbings.
Preliminary statistics from the BCCS indicate a significantly lower number of child Homicide deaths for 2007, suggesting that the elevated number of deaths in 2006 is not a continuing trend.
Table 20. Number of Child Deaths by Classification of Death (2002-2006) Classification of death 2002 2003 2004 2005 2006 TOTAL Accident 88 100 70 62 66 386 Natural 59 76 54 69 81 339 Undetermined 27 23 20 36 40 146 Suicide 24 19 25 14 15 97 Homicide 13 10 5 5 16 49 TOTAL 211 228 174 186 218 1,017
There has been a gradual trend toward a decrease in the number of child deaths reported per year to the BCCS since 1996.
Figure 8. Number of Child Deaths by Year (1996-2006)
BC Coroners Service Annual Report 2006 28 P P ART ART 3: 3: S Table 21. Number of CHILD Deaths by Table 22. Number of CHILD Deaths S t t atistics GENDER (2006) by BCCS Region (2006) atistics Gender Number Region Number Female 89 Fraser 51 Male 129 Interior 45 TOTAL 218 Vancouver Metro 42 Northern 41 Island 39 TOTAL 218
Deaths due to motor vehicle incidents are the leading cause of death among children. The BCCS has previously made recommendations regarding child restraint regulations to help mitigate this risk. New infant and child seat regulations will become effective in B.C. on July 1, 2008.
Table 23. Number of CHILD Deaths by Type of Accidental Death (2002-2006) Table 24. Number of CHILD Deaths Type 2002 2003 2004 2005 2006 TOTAL by Motor Vehicle Incident Motor Vehicle Incident 47 62 36 35 47 227 Position (2006) Drowning 9 11 6 9 4 39 Position Number Alcohol, Drug Poisoning 4 3 5 5 4 21 Passenger 17 Airway Obstruction 3 5 4 0 2 14 Driver 10 Fall 3 1 2 2 0 8 Pedestrian 7 Fire 2 1 2 1 3 9 Pedal cyclist 5 Air Crash 0 0 0 0 1 1 Motorcycle/Moped 1 Exposure 1 0 2 1 0 4 Other 7 Dirt Bike, ATV, Snowmobile 1 2 3 1 1 8 TOTAL 47 Other 18 15 10 8 4 55 TOTAL 88 100 70 62 66 386
Out of 218 child deaths in 2006, 29 (13%) were of Aboriginal children. This is significant because Aboriginal children only constitute approximately 7% of the population under 19 in B.C. There were 97 Suicide child deaths over a period of five years, of which 17 were Aboriginal children. For further information on Suicide and Aboriginal youth, see the Child Death Review Unit's previous reports posted on the BCCS website (www.pssg.gov.bc.ca/coroners).
Table 25. Number of CHILD Deaths by ETHNICITY (2002-2006) Ethnicity 2002 2003 2004 2005 2006 TOTAL Non-Aboriginal 194 185 140 160 189 868 Aboriginal 17 43 34 26 29 149 TOTAL 211 228 174 186 218 1017
BC Coroners Service Annual Report 2006 29 E. Suicide Deaths Table 26. Number and Rate (per 100,000 pop.) Although the number of deaths that occur each year varies, the Suicide rate of SUICIDE Deaths shows a gradual decline from 1987 to 2006. A recent study of Suicide in 32 by Year (1987-2006) countries indicated relatively stable rates between 1960 and 2000 (International Suicide Rates: Recent trends and implications for Australia, 2003). Year # Rate 1987 459 15.0 The Suicide rate in 2006 and the average rate (1999-2006) indicate the highest rates are among early to middle-aged adults. An elevated rate is also 1988 456 14.6 observed in seniors aged 90 years or older. 1989 489 15.3 1990 426 12.9 1991 489 14.5 1992 514 14.8 1993 492 13.8 1994 513 13.9 1995 534 14.1 1996 557 14.4 1997 583 14.8 1998 509 12.8 1999 498 12.4 2000 484 12.0 2001 470 11.5 2002 537 13.0 2003 478 11.5 2004 526 12.5 2005 488 11.4 2006 452 10.5
Figure 9. Suicide Rate (per 100,00 population) by Age Group Table 27. Number of SUICIDE Deaths by Type (2006) Type Number Hanging 152 Table 28. Number of SUICIDE Deaths Firearms 78 by ETHNICITY (2006) Alcohol/drug poisoning 77 There were 29 Ethnicity Number Fall 39 Suicide deaths of Non-Aboriginal 423 Aboriginal British Carbon monoxide poisoning 35 Columbians in 2006. Aboriginal 29 Stabbing/incised injuries 12 Seventeen (59%) of TOTAL 452 Drowning 11 these were children, Suffocation/smothering 11 while 12 (41%) were Table 29. Number of SUICIDE Deaths Other poisoning 10 adults. by GENDER (2006) Motor vehicle accident 9 Gender Number Skytrain or railway 3 Female 104 Fire 1 Male 348 Other 14 TOTAL 452 TOTAL 452
BC Coroners Service Annual Report 2006 30 P P ART ART 3: 3: S S t F. Illicit Drug Deaths t atistics atistics
A peak of illicit drug deaths was observed in 1998 (417 deaths), as well as in Table 30. Number of 1993. The peak in 1993 was the result of an increased potency of heroin as ILLICIT DRUG Deaths measured in prosecution samples by the Drug Analysis Service, Health Canada by Year (1990-2006) (Vancouver Drug Use Epidemiology, Canadian Community Epidemiology Network on Drug Use, 2007). The factors resulting in the high number of deaths in 1998 are unknown. Year Number 1990 82 1991 124 1992 164 1993 361 1994 317 1995 224 1996 312 1997 310 1998 417 1999 278 2000 248 2001 246 2002 170 2003 190 2004 194 2005 213 2006 213
Figure 10. Number of Illicit Drug Deaths by Year (1990-2006)
Table 31. Number of ILLICIT DRUG Deaths by Table 32. Number of ILLICIT DRUG REGION (2006) Deaths by GENDER (2006) Region Number Gender Number Female 41 Fraser 75 Male 172 Vancouver Metro 67 TOTAL 213 Interior 33 Island 31 Northern 7 TOTAL 213
BC Coroners Service Annual Report 2006 31 Figure 11. Number (%) of Illicit Drug Deaths by Classification of Death (2006)
Figure 12. Number of Illicit Drug Deaths by Age Group (2006)
BC Coroners Service Annual Report 2006 32 P P ART ART 4: 4: Inquest PART V: Inquests Inquest s A. Inquest Process s
The Legal Services Unit of the BCCS was established in the fall of 2006 with the hiring of a full-time, in-house lawyer as the Director of Inquests and Legal Services. In addition to providing general legal advice to the coroners in B.C., the main responsibility of this unit is to oversee the assignment of inquests to presiding coroners and to provide direction to and supervision of the presiding coroners and coroners counsel.
When is an Inquest Held? An inquest is a quasi-judicial hearing held in an open forum where witnesses are subpoenaed to testify under oath before a five-person jury.
There are several reasons to hold an inquest, which are outlined in the Coroners Act: • An inquest is held into a death that occurred while an individual was in police custody. • The Chief Coroner can order an inquest when it is determined to be necessary. • A coroner conducting an inquiry may, upon direction from the Chief Coroner, change the inquiry to an inquest and summon a jury for that purpose.
Over time, the circumstances for holding an inquest as outlined in the Coroners Act have been generally interpreted to call for an inquest for the following reasons: • if the death resulted from a dangerous practice or circumstances and similar deaths could be prevented if recommendations were made to the public or an authority, or • if the public has an interest in being informed of the circumstances surrounding the death.
In addition, under special circumstances, the Attorney General may also direct that an inquest is held.
Before the Inquest After it has been determined that an inquest will be held, the coroner begins preparation for the inquest. An inquest is scheduled well in advance to ensure that witnesses, the venue and counsel are available. Other investigating agencies (i.e., WorkSafeBC, police) and interested persons are advised that an inquest is planned. Once dates are confirmed, next of kin, counsel and other involved agencies are officially notified of the inquest.
The Coroners Act authorizes the coroner to issue a summons to any person who, in the opinion of the coroner, might be able to give material evidence on the matters to be inquired into at the inquest.
The Coroners Act also allows those whose interests may be affected by evidence presented at inquest to participate at the inquest. These individuals may be granted participant status and may appear personally or by counsel, tender evidence, call witnesses, examine, cross- examine and re-examine witnesses and obtain summons for
BC Coroners Service Annual Report 2006 33 witnesses. Anyone wishing to participate in an inquest should notify the investigating coroner in writing of their wish to appear or be represented by counsel.
Prior to the inquest, copies of all relevant material are made available to participants or their counsel. This material remains the property of the BC Coroners Service and must be returned at the conclusion of the inquest.
At the Inquest The Coroners Act states that the inquest must inquire into and determine who the deceased was, in addition to how, when, where and by what means he or she died.
Five people are required to be summoned to serve as jurors for an inquest. If fewer than five of those summoned as jurors appear at the commencement of the inquest, the coroner may direct the sheriff to summon additional jurors. If a juror must be excused or discharged during the inquest, the coroner may proceed with the remaining jurors. If the inquest is held for the death of a worker to whom Part I of the Workers Compensation Act applies, reasonable effort must be made to ensure all or part of the jury is composed of persons familiar with the type of work the deceased was doing.
Sheriffs, court reporters, witnesses, and family of the deceased are also present at the inquest and the inquest is open to the general public. Inquest proceedings begin with the presiding coroner explaining the purpose of the inquest to the jury and the jury's responsibilities under the Coroners Act. The coroner reviews applicable sections of the Coroners Act for the information of the jury and gives a short summary of facts relating to the death. Jurors must be sworn in prior to the presentation of evidence. Witnesses are then called and examined by Coroners counsel, participants and/or their counsel, the coroner and members of the jury. Once all the evidence has been given, a summary is given to the jury by the coroner. The jury prepares a verdict, which may be unanimous or by majority. The verdict and findings must not make any finding of legal responsibility or express any conclusion of law.
A jury may also make recommendations. The Coroners Act provides no power to order implementation of recommendations. However, the coroner submits the jury's recommendations to the Chief Coroner for dissemination to appropriate persons, agencies, and government ministries. The jury's recommendations must be lawful, relevant and reasonable with, no finding of fault.
After the Inquest The jury's findings and any recommendations are included in a public document entitled “Verdict at Coroner's Inquest.” The presiding coroner will prepare this document once the inquest is closed. It will include the presiding coroner's comments-a brief overview of the circumstances of the death and the evidence presented that supports the jury's recommendations. A copy of the Verdict at Inquest is available to the public upon request. Jury members are not permitted, at any time after the closing of the inquest, to discuss or reveal to anyone their deliberations, or the manner in which they reached their verdict.
BC Coroners Service Annual Report 2006 34 P P ART ART 4: 4: Inquest B. Inquest Statistics Inquest
Table 33. # of Inquest and Deaths at Inquest by YEAR (2002 - 2006) s 2002 2003 2004 2005 2006 s Number of Inquests 11 11 13 15 23 Number of Deaths 11 11 19 15 24
Note: In 2004 and 2006 there were inquests held for multiple-fatalities. In these cases, the jury is required to arrive at a verdict for each of the decedents. Therefore, in these years there are a greater number of deaths investigated by inquest than the number of inquests held.
Table 34. Number of Deaths at Inquest by CLASSIFICATION of Death (2002-2006) Classification 2002 2003 2004 2005 2006 Accident 5 6 11 7 11 Homicide 00637 Suicide 15026 Natural 50130 Undetermined 00100 TOTAL 1111191524
Table 35. Number of Deaths at Inquest by GENDER (2002-2006) Gender 2002 2003 2004 2005 2006 Male 11 10 14 14 19 Female 01515 TOTAL 1111191524
Table 36. Cause of Death for Inquest Deaths as DETERMINED BY JURY’S VERDICT (2004-2006) Cause of Death 2004 2005 2006 TOTAL Gunshot wounds 6 5 4 15 Restraint associated death and/or excited delirium 3 1 5 9 Alcohol or drug related 0 3 3 6 Blunt force injury 0 1 4 5 Drowning 5 0 0 5 Head injury due to fall 2 2 0 4 Cocaine intoxication 1 1 2 4 Hanging 0 0 3 3 Intracerebral hemorrhage due to hypertension 0 2 0 2 Other 2 0 3 5 TOTAL 19 15 24 58
BC Coroners Service Annual Report 2006 35 C. 2006 Inquest Summaries Table 37. Type of Death and Totals for Inquest Deaths (2006) Type of Death Number of Deaths Arrest No Lock-up 8 Police Shooting 1 Police Pursuit 2 Child Death 3 Industrial 1 Provincial Correctional Facility 2 Federal Correctional Facility 1 Suicide 3 Other 2 Total Number of Deaths 24 Total Number of Inquests 23 Total Number of Recommendations 128
In 2006, there was one inquest in which two related deaths were investigated. Therefore, there were 23 inquests held in 2006 for the deaths of 24 individuals. The 23 inquests held in 2006 resulted in a total of 128 recommendations that were distributed to agencies/individuals, addressing a variety of issues. Included here is a summary of these inquests, the recommendations made by the jury and the responses provided by the relevant agencies to these recommendations. There were five inquests in which no recommendations were made by the jury.
BC Coroners Service Annual Report 2006 36 P P ART ART 4: 4: Inquest Arrest – No Lock-up Inquest
Case 1 of 8 s s On January 9, 2006, an inquest was held in Burnaby, B.C., into the death of a 51-year-old male who died on April 20, 2003, due to acute cocaine intoxication.
On April 19, 2003, police responded to a 911 call in which it was reported that the male had entered a bar with a knife and a hammer. Four officers arrived at the scene and observed the male swaying back and forth through the windows of the swinging doors. The officers drew their sidearms and placed chairs between the male and themselves in case the male attempted to run towards them. At inquest it was heard that the male yelled repeatedly that someone was after him. Witnesses testified that he appeared disoriented and agitated.
One officer engaged the male in conversation in an effort to get him to drop the knife and hammer. However, the male ran toward the officer with a hammer and both he and the officer fell to the ground after colliding. Officers assisted in securing the hammer and handcuffing the male to check for further weapons.
At inquest it was heard that the male resisted handcuffing and was kicking his legs. He was noted to be agitated and was sweating. He also demonstrated considerable strength and it took the efforts of all the officers to restrain his arms and legs. The male also spat at the officers. During brief episodes when he was calm, he stated his name when asked and stated that he had taken a large amount of cocaine and had Hepatitis C. Eventually a Taser was used to aid efforts to restrain him. Although his demeanour changed little, the officers were able to handcuff him. Once he was restrained, an ambulance was called.
An ambulance attendant testified at inquest that the male was sweating and was extremely agitated and that these are common symptoms of cocaine psychosis. While being transferred to a stretcher, the male became unresponsive. CPR was initiated and an Advanced Life Support team was called. However, resuscitation attempts were unsuccessful.
A post-mortem examination was conducted and the pathologist stated at inquest that there was no evidence of any natural disease process or trauma. The pathologist also indicated that the male's underlying cardiac disease, his enlarged heart and the fact that he was being physically restrained were significant contributory factors in his death. However, the length of time between the Taser discharge and him becoming unresponsive precluded a contributory role of this weapon. A toxicologist testified to a blood concentration of cocaine within the lethal range.
An expert in the RCMP Use of Force Policy stated at inquest that given the male's conduct, location of the incident, the risk of harm to others and himself, that the officers applied the appropriate use of force consistent with their training, experience and police policy.
BC Coroners Service Annual Report 2006 37 The jury found that the death was due to acute cocaine intoxication and classified the death as Accidental.
Recommendation: The jury directed one recommendation to the Deputy Commissioner of Pacific Region and Commanding Officer “E” Division and the Commissioner of the RCMP. The jury recommended that the RCMP adopt a policy of dispatching an ambulance or paramedics to an incident immediately if there is an assessment that a threat of death or grievous bodily harm exists.
Response to recommendation: The RCMP responded that in January 2005 policy amendments to their Operations Manual addressed requests of BC Ambulance Service to attend scenes. The policy states that in urgent situations where their services might be required, immediate contact of the BC Ambulance Service and/or Emergency Fire/Rescue Department is appropriate. This policy was reported to meet the recommendations of the jury.
Case 2 of 8
On January 16, 2006, an inquest was held in Burnaby, B.C., into the death of a 32-year-old female who died on February 18, 2004, due to restraint-associated cardiac arrest.
On February 12, an officer spotted a group of individuals believed to be involved in an illegal drug transaction. As the officer approached the individuals, a female and a male left the group. The officers instructed the two to return to the group and although the male did, the female continued to walk away. The officer followed her and took her arm to move her to another location. A struggle between the officer and the female ensued. The officer placed the female on the ground to gain control. However, she bit the officer and was able to escape. At inquest the officer described her as extremely strong. A citizen on a bike followed the female to a hostel and then informed officers of her location.
Three officers approached the female in the lobby of the hostel and tried to handcuff her. They described her as having superhuman strength. The officers stated at inquest that they were conscious of applying any pressure on her back or abdomen that would restrict her breathing.
An ambulance was called and paramedics carried the female to a stretcher and then to the ambulance. At the ambulance it was noticed that she was not moving and was in cardiac arrest. Her hands were uncuffed and resuscitation was initiated. Resuscitation continued at St. Paul's Hospital and a pulse was established. She remained unconscious, was intubated and required intravenous medication to maintain her blood pressure. An assessment indicated severe neurological dysfunction. She was then transferred to Richmond General Hospital Intensive Care Unit. Her condition did not improve and she succumbed to the effects of the initial cardiac arrest six days later.
BC Coroners Service Annual Report 2006 38 P P ART ART 4: 4: Inquest At inquest, an intensive care specialist presented evidence on the effects of cocaine on Inquest the body. Major complications from cocaine use were said to be cerebrovascular accident, stroke, heart attack and irregular heart rhythm. He described the symptoms of a condition called excited delirium, which results from stimulant use, and includes s superhuman strength, increased heart rate and body temperature, muscle excitability, loss s of rational thought and decreased pain perception.
A post-mortem examination revealed that there were trivial external injuries and no evidence of a recent head injury or internal injuries, although there was evidence of a lack of oxygen to the brain. A toxicologist testified that blood samples taken from the female while in hospital indicated a concentration of cocaine and its metabolite that was eight times higher than the minimum lethal level. He advised that at the time of her death, the concentration of cocaine would have been even greater and significant to cause death regardless of the struggle with the police officers.
The jury heard the testimony of an RCMP expert on the use of force. Appropriate use of force and the National Use of Force Model was described. The officer testified that there is ongoing recognition that persons exhibiting excited delirium are now considered to be medical emergencies rather than police incidents. However, it was stated that paramedics are unable to treat an individual that is not controlled. It was further stated that the Vancouver Police have ongoing training in the use of firearms and intermediate force that exceeds the minimum provincial standard.
A Vancouver Police detective from the Major Crimes Section investigated the circumstances of the female's death. He testified that there was no evidence that excessive force was used to control the decedent and criminal charges were not supported.
The jury found that death was caused by restraint-associated cardiac arrest due to cocaine intoxication. The death was classified as Accidental and no recommendations were made.
Case 3 of 8
On January 25, 2006, an inquest was held in Burnaby, B.C., into the death of a 49-year-old male who died on September 29, 2004, due to a gunshot wound.
The police were responding to a 911 call and encountered the male at a location designated during the call. At inquest it was revealed that the male approached the police cruiser in a confrontational manner. When one of the two responding officers exited the vehicle he was stabbed by the male and called out to the second officer that he was being stabbed. The second officer drew his duty pistol and instructed the male to drop his knife. After the first officer broke free of the altercation, the second officer discharged his pistol once. He testified that his commands to the male were ignored and that he feared for his and his partner's lives.
BC Coroners Service Annual Report 2006 39 It was also revealed at inquest that the male had a history of interactions with police, schizophrenia and previous admissions to hospital for psychiatric care.
Advanced Life Support attendants arrived at the scene and attended to the injured officer and the male. Despite aggressive medical intervention, the male died as a result of the gunshot wound.
The jury found that the death was due to a gunshot wound to the abdomen and classified the death as a Homicide. Paranoid schizophrenia was cited as contributory to the death. No recommendations were made by the jury.
Case 4 of 8
On June 12, 2006, an inquest was held in Powell River, B.C., into the death of a 34-year-old male who died on September 2, 2005, due to excited delirium.
The male was witnessed driving his car across oncoming traffic and into a ditch. He then exited the vehicle and ran toward another vehicle, and jumped on the vehicle while screaming. The male was then witnessed to run into a nearby backyard and emerge with a pole-like object before running down the highway near the centreline. A witness to the events called 911.
The male attacked several cars, hitting them with the object and then entered one car. He appeared distressed and frantic and ran in and out of traffic.
Three police officers arrived and attempted to restrain the male. He was difficult to restrain because his right hand was amputated and he exhibited extreme strength. The male was eventually restrained with a Ripp Hobble restraint and a pair of handcuffs. Almost immediately after restraint, the decedent went rigid. Restraints were released and compressions were started, followed by ventilation. An ambulance arrived two minutes later but paramedics found no signs of life. Forty minutes of resuscitative efforts were unsuccessful. A core body temperature measurement taken five hours after death indicated an elevated temperature of 40.5 degrees Celsius.
No anatomical cause of death was identified following post-mortem examination. Toxicological analysis revealed the presence of cocaine and its metabolite in the blood and urine of the male. The toxicological data indicated more than one use of cocaine in the 12 hours preceding death. This data in combination with the observed erratic behaviour and the elevated body temperature is consistent with death due to excited delirium due to cocaine toxicity.
At inquest it was heard that an internal investigation of the incident by police found no rationale to forward a report to Crown counsel and no changes were recommended to policy.
The jury found that the death was due to excited delirium due to acute cocaine toxicity and classified the death as Accidental. No recommendations were made by the jury.
BC Coroners Service Annual Report 2006 40 P P ART ART 4: 4: Inquest Case 5 of 8 Inquest
On August 21, 2006, an inquest was held in Nanaimo, B.C., into the death of a
51-year old male who died on June 12, 2005, due to exposure and massive s s blood loss.
On the evening of June 11, 2005, an officer was conducting an ICBC road check when he saw an approaching vehicle make a U-turn and return to the parkway. The officer followed the car, activating lights and sirens, and pulled the vehicle over. The officer checked the identification of the occupants and determined that the male occupant was in breach of a bail curfew condition. The officer told him that he was under arrest. The male proceeded to exit the vehicle, and ran to the other side of the road and was lost to sight due to darkness. The officer did not pursue the male.
It was heard at inquest that the next morning, the male's wife reported him missing to police. On June 14, 2005, a search using dogs found the male below a cliff in a field, close to where he had last been seen. The male appeared to have fallen down a vertical cliff. The Forensic Identification Team did not find any evidence of foul play. Post- mortem examination indicated the cause of death to be due to a combination of exposure and blood loss resulting from blunt force trauma.
At inquest, police testified that only in the most critical conditions is a night search undertaken. The fact that the male was evading arrest and most likely did not wish to be found was a major factor in not initiating a search earlier.
The jury found that the death was due to exposure and massive blood loss resulting from extensive acute blunt force skeletal trauma. The jury classified the death as Accidental.
Recommendations: The jury made a total of two recommendations directed to the City of Nanaimo: • That a chain link fence is constructed along the entire length of the subject cliff area adjacent to the highway; • That appropriate signage is placed in a clearly visible manner indicating danger rom the presence of a sharp drop.
Response to recommendations: The City of Nanaimo has not yet provided a response to these recommendations.
Case 6 of 8
On August 30, 2006, an inquest was held in Burnaby, B.C., into the death of a 49-year-old male who died on February 6, 2005, due to excited delirium resulting from cocaine intoxication.
The male was yelling incoherently and running across a street in a state of undress during a cold February morning. Police were called and observed him behaving
BC Coroners Service Annual Report 2006 41 irrationally. The police asked the male to move onto the sidewalk. However, he would not co-operate and officers placed him on his stomach on the ground. The officers testified that the male continued to struggle against them. After he was handcuffed he was placed on his side. One officer testified that his skin felt hot and that he was very strong. An ambulance was called and shortly after it was noticed that he did not have a pulse and was not breathing. The request for an ambulance was upgraded to urgent as the male was in cardiac arrest.
The ambulance arrived and the paramedics initiated resuscitation. The male was transferred to St. Paul's hospital; however, resuscitation attempts were unsuccessful.
At inquest, a toxicologist presented evidence that indicated that the male's blood concentration of cocaine and its metabolite exceeded the minimum lethal level. He also gave evidence on the primary cause of excited delirium from cocaine use and described the behaviours an individual might exhibit when in this state. A forensic pathologist who conducted the post-mortem examination stated at inquest that the injuries to the male were minor and did not contribute to his death. The pathologist also stated that the concentration of cocaine and elevated body temperature was consistent with a condition known as excited delirium.
The jury heard the testimony of an RCMP expert on the use of force. Appropriate use of force and the National Use of Force Model was reviewed. The RCMP expert testified that a person in the state of excited delirium does not respond to verbal commands and that once the individual is controlled, the paramedics should be called.
A Vancouver Police detective from the Major Crimes Section investigated the circumstances of the male's death. He testified that there was no evidence that excessive force was used to control him and criminal charges were not supported.
The jury found that the male died from excited delirium resulting from cocaine intoxication and classified the death as Accidental.
Recommendations: The jury made a total of three recommendations. Recommendations were directed to the Minister of Public Safety and Solicitor General, Deputy Commissioner of Pacific Region and Commanding Officer “E” Division and the Chief Constable of the Vancouver City Police.
The Minister of Public Safety and Solicitor General and the Deputy Commissioner of Pacific Region and Commanding Officer “E” Division were issued the following two recommendations: • Mandatory training should be required of all peace officers on the medical symptoms and complication of excited delirium. Special attention should be given to the medical risks the victim could experience. • Due to changing events, medical advancements and research, training should be updated to reflect continuing research of this issue.
BC Coroners Service Annual Report 2006 42 P P ART ART 4: 4: Inquest The Chief Constable of the Vancouver Police Department received the following Inquest recommendation: • That continuing education and refresher courses are necessary to keep officers current, as testimony from the attending constables indicated that they were not s aware of the condition of excited delirium and its symptoms. s
Response to recommendations: The Minister of Public Safety and Solicitor General responded that training is currently not required by the Provincial Standards for Municipal Police in B.C. However, it was noted that the Police Services Division is currently reviewing and updating these standards and that the recommendations will be taken into consideration during this review.
Case 7 of 8
On September 5, 2006, an inquest was held in Burnaby, B.C., into the death of a 44-year-old male who died on June 23, 2004, whose death was consistent with restraint-associated cardiac arrest due to acute cocaine intoxication and psychosis.
The male was living in a hotel in downtown Vancouver and was known to have numerous medical issues. He had a congenital heart defect that had been surgically repaired several years ago. On June 23, other hotel tenants found the male in a shared washroom, yelling incoherently and heard the sound of porcelain smashing. Both officers and paramedics attended the scene. Based on sounds coming from the closed washroom, officers suspected the male may be under the influence of drugs. A decision was made to apprehend him under the Mental Health Act. Due to concern for their safety, officers requested additional officers with suitable training and equipment (i.e., the Emergency Response Team (ERT)). Paramedics informed the officers of the presence of syringes and a white powder, indicative of illicit drug use, in the male's room.
Suspecting the male was experiencing drug-induced psychosis, the ERT attempted to establish communication with him, though unsuccessfully. Elsewhere in the hotel, a fire alarm had been sounded and the presence of a fire in the hotel was confirmed. The ERT members decided to remove the male from the washroom for evacuation. The male was found supine on the bathroom and officers attempted to pull him out of the washroom. At inquest, an officer testified that he deployed his Taser in the stun mode. A second deployment of a Taser in stun mode was used by a different officer and the male was successfully removed to the hallway. Officers testified that the man exhibited considerable strength and resisted restraint and removal from the washroom.
An officer estimated that the male struggled for approximately 2½ minutes before being fully restrained. Soon thereafter, the male became unresponsive. A paramedic on scene was summoned, restraints removed and CPR initiated, although attempts at resuscitation were unsuccessful.
BC Coroners Service Annual Report 2006 43 After a thorough investigation by the Victoria Police Department, several recommendations were forwarded to the Chief Constable of the Vancouver Police Department. Several policy, procedural and operational changes were implemented.
A bioelectricity expert testified at inquest that stun mode is a safer option than discharging the probes. The expert did not present any evidence to indicate that Taser application had fatal effects. However, it was noted that further study would be useful to understand Taser effects on those with pre-existing cardiac disease or drug-affected individuals.
Autopsy revealed scrapes and bruises and markings for which origin could not be definitively established. Cardiac disease was also present. The male's heart was enlarged and mild atherosclerosis was observed.
Toxicological analysis found a lethal concentration of cocaine. Methamphetamine and digoxin were also detected. At inquest, the toxicologist provided an overview of the effects of stimulant drugs on an individual physically and mentally. He also explained the symptoms of excited delirium or cocaine psychosis which included erratic behaviour, increased body temperature, removal of clothing, paranoia, incoherent speech and increased strength.
The jury found that the death was consistent with restraint-associated cardiac arrest due to acute cocaine intoxication and psychosis. Recent methamphetamine administration and cardiomegaly with biventricular hypertrophy were listed as factors contributing to the death. The death was classified as Accidental and no recommendations were made.
Case 8 of 8
On November 14, 2006, an inquest was held in Burnaby, B.C, into the death of a 41-year-old male who died on June 30, 2005, due to acute cocaine intoxication.
On June 30, police were dispatched to a home in response to a call reporting that a male was yelling and exhibiting paranoid behaviour. At the home, a tenant indicated to the first officer to arrive that a couple upstairs were arguing. The officer made his way to the master bedroom where he observed the male and his wife involved in an argument that escalated to physical altercation. At this time, the officer requested additional officers. The officer then intervened in the altercation using verbal commands, without compliance from the male. The male continued to yell incoherently and his behaviour became combative. The officer employed a Taser to gain control. However, the effect of the Taser was only momentary and the male responded by throwing furniture at the officer.
Three other officers then arrived at the scene and assisted in restraining the male. Pepper spray was also used on the male to help gain control.
BC Coroners Service Annual Report 2006 44 P P ART ART 4: 4: Inquest The male's wife witnessed the initial events involving the first responding officer. She Inquest testified that at approximately 0200 hrs her husband awoke in a panic, hyperventilating and hallucinating rats and snakes. She attempted to calm him down and eventually asked a tenant to call for an ambulance. She testified that he may have grabbed her, but s did not strike her and that he became more upset when the first officer entered the s room.
At inquest, the officers testified that the male exhibited considerable strength and that it took the efforts of all four officers to restrain him. The first responding officer testified he kicked the male in the hand and may have used the Taser in stun mode, but could not recall how many times, nor if any stuns actually made contact. Shortly after handcuffing him, the male became unresponsive. CPR was subsequently initiated and emergency services summoned. He was taken to hospital but medical intervention was unsuccessful.
Toxicological analysis of blood samples taken from the male at hospital revealed a concentration of cocaine three times the minimum lethal amount. A toxicologist indicated that the amount of cocaine was high enough to cause death regardless of the struggle with police. The forensic pathologist that conducted the autopsy indicated that injuries identified at autopsy were not contributory to the death. She testified that that there was no evidence at autopsy that the use of a Taser contributed to his death, although she did not have a clear understanding at the time of the temporal relationship between the use of the Taser and the male's death. However, examination of the heart revealed severe atherosclerotic coronary artery disease and cardiac hypertrophy.
A police sergeant explained the development and use of the National Use of Force Model. He advised the jury that the officers involved applied the appropriate risk assessment and use of force for their training, experience and within policy guidelines. The sergeant also testified that data obtained from one of the officer's Taser indicated that it has been activated eight times during the attempt to subdue the male.
At inquest, BC Ambulance Service indicated that paramedics can not treat an individual who is not controlled, and that it is their policy to wait until control is achieved by the police before they attend to an agitated or violent person. An emergency room physician who had treated a number of individuals with symptoms of excited delirium, which are common with cocaine psychosis, indicated the importance of quick medical assistance. He indicated that sedatives (e.g., Valium) are normally used to treat these individuals. He stated that there is scientific evidence from the field of veterinary medicine regarding Rapid Chemical Restraint and that applicability of this restraint method should be further studied and considered as a restraint option for humans.
The jury found that the death was due to acute cocaine intoxication, with atherosclerotic coronary artery disease and cardiac hypertrophy as contributing factors. The death was classified as Accidental.
BC Coroners Service Annual Report 2006 45 Recommendations: A total of three recommendations were made by the jury and directed to the BC Association of Municipal Chiefs of Police and the Ministry of Public Safety and Solicitor General. Two recommendations were made to the BC Association of Municipal Chiefs of Police. It was recommended that all B.C. police forces implement a method of distribution and tracking of conductive energy weapons (e.g., Tasers). It was also recommended that a reporting system (of Taser use) similar to the one used by the RCMP be implemented, with the data submitted to an appropriate agency.
It was recommended to the Ministry of Public Safety and Solicitor General that research is conducted into the possibility of Rapid Chemical Restraint.
Response to recommendations: Responses to these recommendations are pending.
Police Shooting
Case 1 of 1
On February 28, 2006, an inquest was held in Nanaimo, B.C., into the death of a 29-year-old male who died on December 26, 2004, due to gunshot wounds.
The male had been released on parole from a national correctional facility. Pre-release assessments indicated that he was considered at high risk to re-offend. He was released to a community residential facility (CRF) in New Westminster on December 23 as there were no facilities near his family or support network in Prince Rupert. The male met with a community parole officer on the day of his release and was reminded of the conditions of his release. After he failed to return to the residential facility by curfew, a Canada-wide warrant was issued for the male.
Two officers were patrolling the streets in East Vancouver in their police cruiser when they encountered the male. The cruiser was operating with an overhead passenger side light beam. When asked what he was doing, the male indicated that he was engaged in drug-related activity. He provided his name and date of birth to the officers. The Canadian Police Information Centre (CPIC) data system indicated that there was a Canada-wide warrant, but it required confirmation. One officer exited the vehicle to detain the male while the warrant request was investigated. When asked, the male indicated that he had a weapon and removed a knife from his jacket prompting the officer to un-holster his pistol. The other officer called for additional assistance. An additional officer did arrive at the scene and witnessed some of the incident but remained at a distance due to the presence of drawn firearms.
The male advanced toward the officers with two knives drawn and the officers fired shots at him. However, the shots did not incapacitate the male who then tackled one
BC Coroners Service Annual Report 2006 46 P P ART ART 4: 4: Inquest officer to the ground. The other officer testified at inquest that he fired repeated shots at Inquest the male who appeared to be stabbing the officer and felt his partner's life was in imminent danger. The officer who had been tackled was able to break free of the altercation, while the male remained on the ground. s An ambulance was called. The officers testified that they did not hold a current s CPR/First Aid certificate. Other officers also arrived and found the male unresponsive and began chest compressions until an ambulance arrived. Resuscitative efforts were discontinued in the emergency room and the male was pronounced dead.
The pathologist who conducted the post-mortem examination testified that the male had sustained 13 gunshot wounds. However, only three of those wounds were considered serious and likely fatal. Toxicological analysis revealed low levels of the cocaine metabolite benzoylecgonine in the blood, although cocaine was not detected.
At inquest, a lead investigative detective with the Vancouver Police Department testified that at the scene two steak knives were found and an additional two were later found in the male's jacket.
At inquest it was heard that since this fatal incident, new VPD policy requires officers to provide a duty report within five days of an incident. The lead investigative detective also recommended that CPIC information regarding warrants is clarified.
A Use of Force expert with the RCMP testified at the inquest and provided the jury with information regarding appropriate use of force. Less-lethal force weapons such as bean bag projectiles and Tasers were discussed. The officers involved in this incident were not trained in the use of these weapons. This expert also testified that the service pistol was the most effective and appropriate weapon when confronted with an advancing, confrontational person with a knife.
The jury found that the death was due to gunshot wounds to the chest and abdomen and classified the death as a Homicide.
Recommendations: A total of 11 recommendations were made to the Commissioner of Correctional Services Canada and the Chief Constable of the Vancouver Police Department (VPD).
The following three recommendations were directed to the Commissioner of Correctional Services: • When statutory release dates coincide with a major holiday, there should be a stabilization period of the parolee in the community residential facility (CRF) for at least two weeks prior to that holiday; • Upon statutory release to a CRF, a minimum of 24-hour in-house supervision should occur and the parole officer should meet with the parolee within two hours of the parolee's arrival at the CRF; • The VPD engage in research and implementation of additional CRFs outside the Lower Mainland, with particular attention to aboriginal needs.
BC Coroners Service Annual Report 2006 47 Eight recommendations were directed toward the VPD. These recommendations were as follows: • Information regarding a death should be provided to the family before the public; Whenever possible, senior and junior officers should be partnered; • All weapons and ammunition from responding and witness officers should be seized; • Initial police training should include use of less-lethal weapons; • All major crime scenes should be videotaped; • All witness interviews should be audiotaped or, when possible videotaped; • During all street checks, all available lighting should be used; • First aid and CPR training should be a basic requirement for every VPD officer.
Response to recommendations: Correctional Services Canada responded that in the development of a release plan, each offender's needs and those relating to public safety are already addressed. It was further responded that plans are tailored to each offender and the circumstances surrounding their release, including the appropriate combination of controls, privileges and supervision. The response also indicated that community residential facilities can establish, on a case-by-case basis, rules that limit an offender's access to the community during the first few days after release. Finally, the response indicated that they have recently decided to pursue “group home” facilities in the Lower Mainland and in the North.
The VPD • Family informed first. However, in this instance, extraordinary circumstances required releasing certain details to the media. • Graduates are certified to work on their own, and do so in most other municipal departments and the RCMP. Nonetheless, it is VPD practice to attempt to pair junior and senior members whenever possible.
However, contrary to the recommendations the VPD responded that: • It is deemed unworkable and unnecessary to routinely seize firearms from all members who witnessed or responded to a shooting. • Initial police academy training includes Conductive Energy Weapon (CEW) training. • It is VPD practice to videotape/audio tape crime scenes only when it serves an investigative need and the benefits outweigh the risks.
Police Pursuit
Case 1 of 2
On August 14, 2006, an inquest was held in Nanaimo, B.C., into the death of a 46-year-old male who died on November 8, 2004, due to blunt force injury to the chest. The inquest also examined the death of a four-year-old male (child) who died on November 12, 2004, due to withdrawal of life support.
BC Coroners Service Annual Report 2006 48 P P ART ART 4: 4: Inquest Inquest At inquest, the male's wife testified that on the morning of the day of his death she was assaulted by him and forced to inform the school where her daughter attended that he would be picking the child up. By doing this, the male had violated conditions of his bail s resulting from charges of criminal harassment made by his wife. His wife called 911 and s requested that police attend the pre-school to stop her husband from taking their daughter. The police confronted the male at the school.
The male left the school with his daughter in a van and police pursued. At inquest, a witness testified that the male's van appeared to make a purposeful and controlled swerve into oncoming traffic where the vehicle then collided with a minivan. A four-year-old child was a passenger in the minivan that was hit. The male was thrown from the vehicle and died at the scene of the incident. The child died several days later in hospital following withdrawal of life support. Routine toxicological examination did not indicate that the male had used alcohol or common drugs.
At inquest it was stated that prior to the fatal incident the male's wife had been referred to police victim services, and had been given contact information for several community agencies, including a shelter for women and children. Police victim services had opened a file for the wife almost two weeks prior to her husband's death.
The jury found that the death of the 46-year-old male was due to blunt force injury of the chest and classified the death as a Suicide. The jury found that the death of the 4-year old male was due to withdrawal of life support resulting from brain stem and spinal cord injuries and classified the death as a Homicide.
Recommendations: There were five recommendations made by the jury regarding these fatalities.
A recommendation was directed to the Deputy Commissioner of Pacific Region and Commanding Officer “E” Division that the RCMP should ensure that their members follow the existing Violence in Relationships/Violence against Women in Relationships Policy. This policy states that when they exist, community- based victim services should be the primary service provider to those experiencing violence in relationships.
A second recommendation was again directed to the Deputy Commissioner of Pacific Region and Commanding Officer of RCMP “E” Division and the Minister of Public Safety and Solicitor General that police, government and community- based victim services work together to develop information-sharing protocols and co- ordinated risk-management strategies to deal with violence in relationships.
The last three recommendations were directed solely to the Minister of Public Safety and Solicitor General:
• That the ministry establish a joint community, police and government team to review best practices and provide recommendations to enhance responses to victims of violence in relationships;
BC Coroners Service Annual Report 2006 49 • That the Nanaimo Men's Resource Centre is provided with permanent funding and their current proposals for funding supported; • That the community-based victim services is provided with additional funding, which could assist in raising their profile in the community.
Response to recommendations: In response to the recommendations, the Minister of Public Safety and Solicitor General replied that the ministry supports the recommendations and took immediate action. A detailed action plan was enclosed with the response. The Minister indicated that a bulletin on Referral Policies for Victims of Power Based Crimes: Family Violence, Sexual Assault, and Criminal Harassment was released to the Commanding Officer of RCMP “E” Division and relevant agencies.
Case 2 of 2
On December 4, 2006, an inquest was held in Kamloops, B.C., into the death of a 45-year-old male who died on June 27, 2005, due to internal hemorrhage from a single gunshot wound to the left flank.
In the early morning of June 27, a 911 call was placed by someone reporting a break and enter in progress at a gas station by two males in a pick-up truck.
At inquest, the passenger of the vehicle identified himself to the jury as a long-time friend of the driver of the vehicle and the deceased male. He confirmed that crack cocaine was used by his friend a few hours prior to the fatal incident.
The pick-up truck left the gas station after unsuccessfully trying to access the property. A police vehicle approached them from behind, but despite the activation of emergency lights, the pick-up truck did not stop and a pursuit ensued. A second unmarked police vehicle, an SUV, joined the pursuit. As the pick-up continued on a rough road, the SUV became the lead chase vehicle. The pick-up ran out of fuel and came to a stop with the SUV stopped behind. The driver of the pick-up then put the truck in reverse and backed into the SUV. However, the officer had already exited the vehicle. At inquest, the passenger of the pick-up testified that he heard two to three gunshots and that his friend appeared to react as if he had been shot. The passenger was then taken into custody by a second officer who arrived on the scene.
At inquest the passenger testified that the truck he was in was stopped when the shots were fired and that he did not believe that the officer was in any physical danger.
The officer driving the SUV testified at inquest that when the pick-up stopped, he left his vehicle with his police dog suspecting that the occupants of the pick-up truck were going to flee on foot. He also stated that as the vehicle reversed toward him at a high rate of speed he drew his firearm and began yelling at the occupants. As the pick-up passed the officer and struck the police vehicle, he reactively discharged three rounds from his firearm into the driver's door. The officer indicated that he believed the vehicle
BC Coroners Service Annual Report 2006 50 P P ART ART 4: 4: Inquest was being used as a weapon and was concerned for his safety. Contrary to the passenger Inquest of the pick-up truck, the officer stated the truck was moving when he discharged his firearm. The driver was removed from the vehicle and chest compressions, but not artificial respiration, were performed due to lack of equipment. s s A BC Ambulance paramedic assessed the male driver but concluded that he was deceased. An autopsy concluded that the male died as a result of internal hemorrhage due to a single gunshot wound. Toxicological analysis detected cocaine and its metabolite in blood samples, although the drug was not said to be contributory to the death.
A Vancouver police sergeant presented the National Use of Force Model to the jury at inquest. He indicated that officers are required to assess a situation and use the least reasonable amount of force. However, in the application of tactical versus lethal force, it was noted that this is a context-dependent decision. The jury was shown the video entitled “A Dangerous Tactic-Shooting at Vehicles,” which is viewed by officers as part of their use-of-force training.
An RCMP Collision Reconstructionist conducted an investigation of the collision and determined that there was relative movement between the officer and the pick-up, with the officer stationary at the time the three shots were fired.
The jury found that the death was due to internal hemorrhage following a single gunshot wound to the left flank and classified the death as a Homicide.
Recommendations: The jury made two recommendations. It was recommended to the Deputy Commissioner of Pacific Region and Commanding Officer of RCMP “E” Division that it be mandatory that officers review the video entitled “A Dangerous Tactic-Shooting at Vehicles” as part of the “Use of Force” and refresher module. It was also recommended that every RCMP vehicle is equipped with a basic first aid kit, including an appropriate air mask/mouth piece.
Response to Recommendations: Responses to these recommendations have not yet been received.
BC Coroners Service Annual Report 2006 51 Custody – Provincial Correctional Facility
Case 1 of 2
On April 24, 2006, an inquest was held in Victoria, B.C., into the death of a 35- year-old male who died on June 26, 2005, due to anoxic brain injury.
The male was an inmate at Vancouver Island Region Correctional Centre (VIRCC) at the time of his death.
Approximately one month prior to his death, the male's girlfriend broke up with him and her children were apprehended by the Ministry of Children and Family Development (MCFD). The male was upset about the loss of the relationship and loss of access to the children. At this time, he admitted to a counsellor his thoughts of anger and suicide. This information was reported to a senior correctional officer (CO). A registered psychologist met with the male the day it was reported that the male might be suicidal. The psychologist's assessment was that the male was not suicidal. At a later date, another psychologist also met with the male and did not think that he required “close observation” (i.e., 15-minute checks).
Approximately 10 days prior to his death, the male had his phone privileges suspended due to repeated phone calls he had made to MCFD regarding his former girlfriend's children and the court hearing regarding their custody. MCFD had contacted the correctional facility and asked that the phone calls cease. The male later contacted a CO expressing his upset over the suspension.
The male was prescribed medication by the prison physician on June 17, as an antidepressant and a sleep aid. On June 20, the male sent letters, which are screened by the prison, in which he threatened to kill himself as part of a plan to kill his former girlfriend's new boyfriend.
On June 23, following a routine lockdown, the male's cell was checked visually through the view port prior to being unlocked. The CO performing the check noticed the male seated at his desk with a ligature around his neck which was tied to the bars on the window. The CO triggered an alarm indicating that he needed assistance. When the unit was identified as safe to enter, nursing staff were alerted and arrived with oxygen. However, the male was not able to breathe without assistance and was transferred to hospital where he was placed on life support.
At inquest, a physician testified that the male had suffered an anoxic brain injury. After three days, the male's family agreed to withdraw life support and the male succumbed to his injury.
Investigation of the male's cell found no evidence to suggest anyone else was involved with his death. A letter addressed to his mother was found on his desk, although it was ambiguous regarding suicidal intent.
BC Coroners Service Annual Report 2006 52 P P ART ART 4: 4: Inquest Following this death, it was heard at inquest that a recommendation was made that all Inquest health care and mental health staff are trained in and have ongoing access to CORNET, the corrections network. This recommendation was implemented and allows all mental and medical health care staff access to unit log entries and case notes made by these s staff members. A warden also gave evidence at inquest that two investigations are s conducted following a major incident in a B.C. correctional facility.
The jury found that the death was due to anoxic brain injury as a consequence of self- harm and classified the death as a Suicide.
Recommendations: A total of five recommendations were made by the jury. Recommendations were directed to the Deputy Provincial Director, Adult Custody Division, the Provincial Director, Adult Custody Division and the Warden at the VIRCC.
The Deputy Provincial Director received the recommendation that mental health and health care workers are directed to seek out and read all collateral information prior to meeting with a patient. Acknowledgment must be noted and signed upon completion of review of information.
The Provincial Director received the recommendation that enhanced training to front- line correction officers is provided to aid in recognition and reporting of signs of depression that may lead to self-harm. Two additional recommendations directed the Director to establish minimum training standards and a training schedule for both new and current employees.
A recommendation was made to the VIRCC Warden to eliminate the gap between the Plexiglas and window bars to prevent a reoccurrence of this method of self- harm.
Response to recommendations: The Provincial Director, Adult Custody Division responded to all of the recommendations. All recommendations were reported to have been implemented and completed, except for the recommendation concerning eliminating the gap in the window. An architect was consulted on the most effective means of caulking the gap between the Plexiglas and window bars in the living units at the VIRCC. Two solutions were attempted; however, neither guaranteed a secure alternative. Other alternatives were not feasible. It was noted that VIRCC policy directs staff to complete integrity checks of all windows on a weekly basis to identify potential problems.
BC Coroners Service Annual Report 2006 53 Case 2 of 2
On May 15, 2006, an inquest was held in Victoria, B.C., into the death of a 27- year-old male who died on March 24, 2004, due to acute heroin intoxication.
The male was an inmate at Vancouver Island Region Correctional Centre (VIRCC) at the time of his death. A correctional officer (CO) was conducting an early morning routine count of inmates while they were locked in their cells. The CO stated that he saw the male in his bunk with the blankets pulled over him. Less than half an hour later, the CO checked each cell again before unlocking the door for the day. Approximately half an hour after unlocking the doors, the CO heard another inmate say that something was wrong with the male. The CO went to his cell and found him lifeless on the bunk with the covers now pulled down. A Code Yellow (officer needing assistance) and a Code Blue (medical emergency) were called.
A nurse that responded to the Code Blue stated that her examination of the body indicated that the death had occurred four to eight hours previously. She determined that death was sufficiently established that medical intervention was not warranted.
The male had recently hurt his hand and was prescribed Tylenol #3 as an analgesic. The medication was dispensed at the health unit. While inmates sometimes hoard medication, this male was thought to be compliant. He was also experiencing anxiety and depression for which he was given a prescription for the antidepressant Effexor (venlafaxine).
A police officer was dispatched to the VIRCC to investigate the male's death. The police investigators found no evidence of trauma to the body or disturbance in the cell to suggest an altercation or drug use. The male's cell-mate was described as being shocked about the death and said that his cell-mate was alive late the previous evening.
At inquest, a toxicologist presented evidence that the male had a lethal concentration of morphine in his system at the time of his death. Acetaminophen and codeine, ingredients of Tylenol #3, and venlafaxine were also present. The toxicological finding of 6-monoacetyl morphine unambiguously indicated prior heroin intake shortly before death.
The control supervisor at VIRCC testified at inquest that review of telephone calls made by the male and two other inmates suggests that there was a delivery of heroin to the male in the days prior to his death. A CO stated at inquest that inmates have many opportunities to pass items including drugs to each other. However, a CO who conducted a search for contraband on the day following the death did not find evidence of drugs or drug paraphernalia.
At inquest, the warden of the VIRCC discussed the common methods of drug smuggling into the prison and the techniques used to deter and identify these methods. It was stated that a more thorough check of each inmate is not feasible and that each cell has a call button that an inmate can activate in the event of medical emergency. Programs are
BC Coroners Service Annual Report 2006 54 P P ART ART 4: 4: Inquest available to assist inmates with drug and alcohol issues and methadone is available to Inquest inmates who were on a methadone maintenance program when they were admitted only. However, methadone maintenance is currently not initiated in VIRCC. s The jury found that the death was due to acute heroin intoxication and classified the s death as Accidental.
Recommendations: The jury directed the following two recommendations to the Provincial Director, Adult Custody Division: • That there is an increase in the use of dogs in drug searches in correctional facilities; • The methadone maintenance is initiated for heroin-addicted inmates who are not on a methadone maintenance program upon intake.
Response to recommendations: The Provincial Director responded that a decision regarding this will be made after a review of all drug interdiction strategies that has been undertaken recently. It was also responded that a provincial policy that allows for the initiation of methadone maintenance in provincial correctional centres according to certain criteria and procedures has been introduced.
Custody-Federal Correctional Facility
Case 1 of 1
On April 19, 2006, an inquest was held in Chilliwack, B.C., into the death of a 30-year-old male who died on February 25, 2004, due to asphyxia.
The male was an inmate at a federal institution, serving a lengthy sentence. In December 2003, the male visited the institution physician and stated that he was feeling depressed. The physician prescribed an anti-depressant and received a weekly supply of this medication from the health care unit. At inquest, the physician testified that he did not feel that the male was at risk for suicide.
Shortly before his death the male had been having difficulty with his girlfriend as she had been hanging up on him, which he found frustrating. At inquest, it was noted that outgoing calls by inmates can become costly to the receiver of the call. The male spoke to the Social Program Officer at the institution regarding his frustration. The Social Program Officer had previously spoken with the male regarding his wish to get married and the steps involved in facilitating this wish. The Social Program Officer allowed the male to call his girlfriend from his office phone so that no charges would be associated with the call. However, the male's girlfriend continued to hang up on him and he became upset after several attempts and left the office. On February 25, the male declined another offer to use the Social Program Officer's phone to call his girlfriend.
BC Coroners Service Annual Report 2006 55 A cellmate testified at inquest that he found the male lying on his bed listening to a sad song and thought that he was upset about his relationship. Later that evening, the male got up and walked out of the cell without a word to his cellmate. The male had not returned to the cell prior to the scheduled count and his cellmate contacted a correctional officer. Correctional officers were dispatched to search the grounds. The body of the male was found in a storage shed. The door to the shed was tied from the inside with a strap. It was apparent the male had hanged himself. An ambulance was called. The correctional officers did not initiate CPR as they did not have a respirator mask and death was apparent. The paramedics arrived and initiated CPR but despite their efforts the male could not be resuscitated.
Post-mortem examination revealed that the male died as a result of asphyxia due to hanging. There was no evidence of any natural disease or significant trauma other than that due to hanging. Toxicological analysis indicated the presence of a sub-therapeutic concentration of the male's anti-depressant medication.
An RCMP investigation did not reveal any evidence of foul play. Correctional Service Canada also conducted an investigation and made four recommendations that were subsequently instituted. In addition, the storage shed was removed from the institution's grounds. All officers are trained and upgraded in current CPR protocol and each officer is equipped with a respirator mask to facilitate immediate resuscitation efforts.
The jury found that the death was due asphyxia resulting from self-hanging and classified the death as a Suicide and made no recommendations.
Suicide
Case 1 of 3
On May 2, 2006, an inquest was held in Prince George, B.C., into the death of a 34-year-old male who died on December 18, 2004, due to self-hanging.
The male was staying at a detox unit, but checked himself out against the advice of the staff. An RCMP officer later attended a grocery store where the male had been apprehended for shoplifting. The officer discovered three warrants for the male and brought him to the detachment. The male was described as cooperative and was searched prior to being taken to the detachment and once again at the detachment.
At inquest the officer asked the male to remove extra clothing prior to entering the cell block, but allowed him to retain what appeared to be long underwear as it was cold. The underwear was actually hospital pants that contained a drawstring. A second officer present at the detachment testified that he had been joking with the male as they knew each other from the male's hometown. This officer did not see any indications of depression or risk factors for suicide.
The male was checked into a cell at 1814 hours. At 1946 hours a jail guard checked on him as he could not be observed by the cell camera. The male was found unresponsive
BC Coroners Service Annual Report 2006 56 P P ART ART 4: 4: Inquest with a blue cord around his neck. Officers at the detachment started CPR and Inquest Emergency Health Services were contacted.
The jail guard testified that he was directed to remove the tape that was recording the s cell blocks. He stated he was then told to leave it in the machine, but had already s started rewinding the tape for removal. The tape recording was started again resulted in several previously recorded minutes being lost.
The male was transported to hospital and immediately placed on life support equipment. After discussion with family he was removed from life support and died as a result of injuries sustained from hanging.
At inquest, the manager of police services for the City of Prince George testified that following a review of the incident several improvements had been made to the recording systems at the detachment.
The pathologist who conducted the autopsy testified at inquest that the male had died as a result of asphyxial injuries caused by hanging.
The jury found that the death was due to hanging and classified the death as a Suicide.
Recommendations: Three recommendations were made by the jury. One recommendation was directed to the Superintendent, Officer in Charge of the Prince George RCMP Detachment. It was recommended that there be a review and revision of policy and procedures relating to prisoner searches at the time of booking.
The Manager of Police Services received the recommendations that 1) guards carry a two-way radio or alarm device while performing rounds and that 2) implementation of updated video camera and recording systems is expedited.
Response to recommendations: Responses to these recommendations are pending.
Case 2 of 3
On May 8, 2006, an inquest was held in Victoria, B.C., into the death of a 56- year-old female who died on July 29, 2005, due to an overdose of the drug venlafaxine.
On July 25, 2005, the female was admitted to hospital for depression. She was cared for in the psychiatric emergency department. At inquest it was stated that between July 26 and July 29, she received medication and was attended to by hospital staff. It was also stated that after receiving medication, she became calmer. On July 29, the female's psychiatrist granted a four-to-six hour pass for her to return home to run some errands, but she did not return to the hospital. The nurse on shift called her home and contacted
BC Coroners Service Annual Report 2006 57 the on-call psychiatrist. The female's bed was held for another 24 hours before she was given an administrative discharge.
The police were notified that the female was missing by her friends and a search was initiated by police but was unsuccessful. The female's body was discovered by a passer-by on August 17, in a park. She had left a note indicating she had gone into the woods intending to die.
Prior to her death, she had obtained the antidepressant Effexor (i.e., venlafaxine) from a pharmacy, through two similar prescriptions in two days, with one prescription for a slow- release formula. Toxicological analysis revealed that she had consumed a significant amount of Effexor.
The jury found that the death was due to an overdose of venlafaxine as a consequence of chronic and relapsing depression and classified the death as a Suicide.
Recommendations: A total of 10 recommendations were made by the jury regarding this fatality to the College of Pharmacists, the College of Physicians and Surgeons of BC, the College of Registered Nurses, the Vancouver Island Health Authority, the Director of Mental Health and Addictions of the Vancouver Island Health Authority and the Minister of Health.
One recommendation was directed to the College of Pharmacists that it review the dispensing practices at the pharmacy where the decedent had filled her prescriptions.
Two recommendations were directed to the College of Pharmacists and the College of Physicians and Surgeons of BC. It was recommended that the colleges educate physicians and pharmacists regarding PharmaNet and what it does and does not do with respect to the automatic cancellation of prescriptions. It was also recommended that advice is provided to physicians regarding the need to write a formal discontinuation order when replacing medications.
There were five recommendations directed to the Vancouver Island Health Authority (VIHA) as follows: • That the VIHA seek a legal opinion regarding obtaining informed consent from patients on admission to hospital for the purposes of gathering collateral information relevant to assessment and treatment and discharge planning; • That the admission process for all patients include a discussion regarding the possibility of obtaining informed consent from the patient about who can be contacted, including friends and family and for what purpose; • That these policy changes be discussed with appropriate health care professionals as to how it will affect their practice; • That upon admission to any hospital a current printout of the patient's PharmaNet record is included as part of the admission process.
One recommendation was directed more specifically to the Director of Mental Health and Addictions of the VIHA that case managers are notified of patient
BC Coroners Service Annual Report 2006 58 P P ART ART 4: 4: Inquest release from an acute care psychiatric facility on the first day pass following Inquest admission.
An additional recommendation regarding informed consent was directed to the s VIHA, in addition to the College of Registered Nurses of BC and the College of s Physicians and Surgeons of BC. It was recommended that all appropriate health care professionals are informed of the circumstances under which a patient's contacts, obtained through informed consent, can be consulted or informed without breaching confidentiality.
A final recommendation was directed to the Minister of Health to implement a suicidal behaviour reduction task force.
Response to recommendations: The College of Pharmacists responded that they would publish an article in the agency's bimonthly newsletter, ReadLinks, advising pharmacists about the limitations of the PharmaNet system as it applies to discontinued prescriptions. It was also noted that a quality outcomes specialist would visit the dispensing pharmacy to determine if any regulatory concerns exist. The College responded that the BC Coroners Service would be informed of the outcome of this review.
The College of Physicians and Surgeons of B.C. reviewed the recommendations that the jury made and responded that it would be publishing an article in the College Quarterly describing some of the deficiencies of PharmaNet. The College also responded that they believed physicians are aware of confidentiality and informed consent issues regarding patients.
The College of Registered Nurses of B.C. responded that they would write an article discussing the facts of the fatality, the Freedom of Information and Protection of Privacy Act and the Canadian Nurses Association Code of Ethics. This article was published in Nursing BC in the February 2007 issue. This periodical is sent to every College of Registered Nurses of B.C. registrant.
The VIHA responded they can not legally share information on a patient or contact friends or relatives of the patient, without the patient's consent, unless compelling circumstances exist that affect the patient's health or safety of another individual. The PharmaNet privacy policy precludes physicians who access information from passing it on to anyone else but the VIHA will request that admitting physicians access a patient's PharmaNet record and make any appropriate notes in the chart as may be required to ensure safe and effective care for the patient.
The Ministry of Health responded that it does not recommend the implementation of a provincial suicidal behaviour task force given the mandates of the individual health authorities. However, the ministry did respond that it will raise the issue with the health authorities. It was also stated that the ministry has recently developed a document entitled Working With the Client Who is Suicidal: A Tool for Adult Mental Health and Addiction Services in consultation with expert advisory committees, associations, advocates and each of the health authorities.
BC Coroners Service Annual Report 2006 59 Case 3 of 3
On November 7, 2006, an inquest was held in Burnaby, B.C., into the death of a 59-year-old male who died on August 11, 2005, due to a gunshot wound.
On August 10, 2005, two RCMP officers attended the home of the male to serve him with an arrest warrant. The male said he would go with the officers but that he first needed to get his shoes. However, he did not return to the door and did not respond to his name being called. The officers entered the home and found that the male had shut himself in his bathroom and informed the officers that he had a gun and was going to shoot himself. The officers immediately retreated from the home and called for additional members to assist.
The Emergency Response Team (ERT) and crisis negotiators were called to the scene. Contact was made with the male by telephone. Telephone conversations continued throughout the night. On the following morning, after repeated attempts at telephone contact were unsuccessful, police dispatched robots equipped with cameras into the residence. Police believed that the male had not left the bathroom. ERT members were sent into the residence and found the male with a rifle in the bathroom in a position to shoot himself. The police commanded him to put the gun down and sent a negotiator into the residence to talk him into surrendering. Shortly thereafter, the male fatally injured himself with the gun in the presence of the police.
At inquest, a friend of the male and his female companion gave evidence that the decedent made reference to taking his life with a firearm in the weeks preceding his death.
The jury found that the death was due to a gunshot wound to the head and classified the death as a Suicide.
Recommendation: The jury made one recommendation, which was directed to the Deputy Commissioner of Pacific Region and Commanding Officer “E” Division to ensure that prior to executing a warrant, peace officers should conduct a firearms registry search, in addition to Canadian Police Information Centre and Police Information Retrieval System searches.
Response to the recommendation: The RCMP responded that this fatality may serve as a yearly reminder to members, perhaps during the officer safety component of firearms training, to conduct a firearms registry check in these situations.
BC Coroners Service Annual Report 2006 60 P P ART ART 4: 4: Inquest Child Deaths Inquest s Case 1 of 3 s
On February 6, 2006, an inquest was held in Port Alberni, B.C., into the death of a 19-month-old female who died on September 4, 2002, due to a head injury.
On September 4, 2002, fire department personnel and the BC Ambulance Service were dispatched to a residence where a 19-month-old child was in cardiac arrest. The child was unresponsive and cardiopulmonary resuscitation was commenced. A relative of the child told first responders that another child in the home had pushed the decedent down the stairs. The child was taken to hospital, but despite continued efforts to resuscitate her, she did not survive.
At inquest a paramedic testified that he saw bruises on the child's abdomen. However, this was not documented on the crew report. The on-duty pediatrician who attended to the child testified that he did not see any external signs of abuse but was uncomfortable regarding the reported fall of the child down the stairs and didn't believe that it could have caused her death.
A police officer attended the residence after the paramedics had left with the child for the hospital. Police were told that the child's older 3½-year-old brother was aggressive and abusive towards her. The officer did not believe the scene was suspicious and attended the hospital to meet with the pediatrician. At inquest the officer testified that the doctor did not know the cause of death and did not express any suspicions regarding her death.
The investigating coroner testified at inquest that he viewed the child's body at the hospital with the police officer and pediatrician. He did not observe any external signs of injury. He stated that the doctor and police officer indicated to him that there did not appear to be any suspicious circumstance.
A post-mortem was conducted with police in attendance. The pathologist observed bruising to the child's back and abdomen. X-rays identified fractures of the ribs. The pathologist indicated to police that there were multiple injuries inflicted at multiple times. Some injuries were not recent. The pathologist stated that head injury was the likely cause of death.
A General Investigation Section officer and the investigating coroner met with Usma Family Services employees, one of whom was a family member of the child. Usma is an agency in the Nuu-chah-nulth Tribal Council that delivers child protection services. A police investigation officially began when the officer received the final post-mortem report. Police determined that the relative who spoke with first responders had an extensive criminal record. During a recorded conversation with his common law wife, he confessed to injuring the child. This relative was charged with second degree murder and was sentenced to 10 years in jail.
BC Coroners Service Annual Report 2006 61 The child had been placed in the home of this relative under Section 8 of the Child, Family and Community Service Act, referred to as the “Kith and Kin” agreement. A Section 8 agreement is made between the child's parents and someone known to the family, usually a relative, for care of the child. Legal custody remains with the parents. These agreements are usually short and temporary. Section 8 also refers to an agreement between the caregiver and the Ministry of Child and Family Development as the caregiver receives remuneration for caregiving.
The child's mother testified that she was not willing to let her daughter live with her aunt because she was concerned about her aunt's spouse. The child's mother was less concerned about her older son living with these relatives. She testified that she told Usma social workers of her concern about his short temper and anger. At inquest, the child's mother confirmed that her signature was on a Section 8 Kith and Kin agreement but she denied having any knowledge of signing it. The child's mother also reported that when she visited her children in their relative's home that they appeared fearful of their great aunt's husband. The relative charged with murder stated that he submitted a printout of his criminal record to Usma prior to the child and her brother being placed in his home. There was a discussion regarding the criminal record and his alcohol and drug use. It was also revealed at Inquest that the relatives with whom the child had been placed had children of their own and had required the services of Usma in the past.
An Usma social worker testified that the child's mother had breached conditions of a supervision order that resulted in her children being moved to a relative's home. Concerns regarding care were not expressed according to this social worker's testimony.
The inquest was held over 10 days and during this time several witnesses spoke of the role of MCFD, Usma and the Kith and Kin agreement. At times, there were conflicting witness statements regarding the agreement and the criminal record checks of the relatives receiving the child and her brother.
At inquest it was heard that since the child's death, the MCFD conducted a review in which recommendations were made that addressed training, communication and shared records. A list of these recommendations was provided to the jury. Furthermore, in 2003 new guidelines were introduced for the Kith and Kin agreement.
The jury found that the death was due to a head injury as a consequence of Battered Child Syndrome and classified the death as a Homicide.
Recommendations: The jury made a total of 19 recommendations to the Director of Child Welfare- Ministry of Children and Family Development (MCFD), Nuu-chah-nulth Tribal Council Usma Family and Child Services (Usma), Port Alberni Fire Department, the BC Ambulance Service (BCAS), Commanding Officer of RCMP “E” Division, Site Co-ordinator-West Coast Hospital, Chief Coroner-BC Coroners Service and the Premier-Province of British Columbia.
BC Coroners Service Annual Report 2006 62 P P ART ART 4: 4: Inquest The six recommendations directed to the MCFD were regarding training and the Inquest Kith and Kin program and are as follows: • That all delegated social workers should have access to the same training in the same time frame, regardless if they are an agency or ministry worker; s • That all conditions (i.e., criminal record checks, prior contact checks and s references) must be met pre-placement of children in a home; • That three references are required of potential caregivers, including one each from the paternal and maternal sides of the family and one from a neutral person who knows the caregivers; • That during a first intake call, parents are informed that Kith and Kin agreements can be made available; • That no discretionary power be given to social workers when any court order is in place; • That two audits are conducted within a three-year time frame.
The jury directed the recommendation to Usma that all employees of Usma must not compromise the integrity of the true meaning of “Usma.” Note: Usma is one agency in the Nuu-cha-nulth Tribal Council that delivers child protection services.
The Port Alberni Fire Department and the BCAS received the recommendation that members are reminded of their duty to report need for child protection services pursuant to Section 14 of the Child and Family Community Services Act. The BCAS also received the recommendation that all paramedics are required to document any external signs of injury, such as bruises, on their crew reports.
It was recommended to the Commanding Officer of RCMP “E” Division that: • The officer investigating any child death should attend the post-mortem examination so that there is direct discussion with the pathologist regarding findings and their significance; • That when a child known to the MCFD or MCFD designates has died, and other children remain in the home, post-mortem findings are shared with social workers so that safe decisions can be made.
Three recommendations were directed to the Site Co-ordinator-West Coast Hospital. It was recommended that the attending doctor receive the pathologist report for any sudden child death; that staff who attended to the injured child who died, and that medical intervention apparatus is only removed from a body by a pathologist. It was recommended that the attending doctor receive the pathologist report for any sudden child death; debriefing for staff who attended to the injured child who died; and that medical intervention apparatus is only removed from a body by a pathologist. The last recommendation was also made to the Chief Coroner- BCCS. The BCCS also received the recommendations that education of Section 14 of the CFCSA is included in coroner's training and that a method is implemented that allows for addition of new facts to the internal BCCS Kimble Report for ongoing investigations.
Finally, it was recommended to the Premier of B.C. to reinstate the Children's Commission.
BC Coroners Service Annual Report 2006 63 Response to recommendations: The MCFD responded that they supported four of the recommendations directed toward their agency and supported the intent of two of the recommendations. Policies and practices of the ministry were outlined in their response to reflect their support of the recommendations. Regarding training, the MCFD responded that ministry and agency social workers receive comparable core training and that the Provincial Director will ensure that equivalent training is developed and delivered to all social workers. Regarding the other recommendations, the ministry stated in their response that they will be meeting with police officials to examine opportunities to expedite criminal record checks to facilitate the timely use of a Kith and Kin agreement. It was also stated that in January 2006, an additional record check (known as Cornet) became a policy and practice of the MCFD.
The BCAS responded that all their employees would be reminded of their obligations under Section 14 of the CFCSA. In addition, it was noted that the BCAS had initiated an immediate review of its policies and procedures regarding patient abuse reporting. The Chief Executive Officer of the BCAS responded that all paramedics will be required to document all instances of suspected abuse and neglect. Furthermore, the BCAS drafted a new policy, Reporting Child Abuse or Neglect in response to the recommendations.
The Chief Coroner responded to the recommendations directed to the BCCS by stating that a training bulletin was provided to every BCCS employee outlining a coroner's obligation under Section 14 of the CFCSA. In addition, in June 2006, Section 14 training was incorporated into the BCCS annual Basic Coroners Training Course curriculum. Similarly, the issue of preserving in situ medical apparatus for post-mortem examination has also been incorporated into the annual training course for coroners. The Chief Coroner also responded that current BCCS policy requires that the internal Kimble report is updated with all relevant child death information. However, coroners are to refer to the entire case file during an investigation and not only a Kimble report in order to examine all available information.
The Premier of B.C. included in his response the public statement that was issued by the Minister of Children and Family Development. It was stated that given the scope and breadth of the review conducted by the Honourable Ted Hughes, that the recommendations of the jury are given serious consideration in the context of Mr. Hughes' review.
The Port Alberni Fire Department, Usma and West Coast Hospital have not yet responded to the recommendations.
Case 2 of 3
On April 24, 2006, an inquest was held in Kelowna, B.C., into the death of a three-year old female who died on April 29, 2000, due to abdominal blunt impact injury with additional signs of asphyxia.
BC Coroners Service Annual Report 2006 64 P P ART ART 4: 4: Inquest On the evening of April 28, the child's mother had left the child with her boyfriend Inquest while she went to babysit for a friend. She was awoken in the morning by a phone call from her boyfriend stating that her daughter had been taken to hospital. The mother proceeded to hospital where a physician informed her that her daughter had sustained s massive internal injuries and had died as a result. s
At inquest a number of medical and police experts, staff from the Ministry of Children and Family Development and a friend of the family testified regarding the injuries of the child and the relationship of the child's mother, her boyfriend and the child.
The boyfriend stated that he has never disputed that he was the direct cause of the child's death but that his actions were unintentional. He testified that on the evening of April 28, he had invited a friend over and they had consumed alcohol, although he was not intoxicated. He awoke in the early morning hours of April 29, to use the bathroom. In exiting the bathroom the out-swinging door struck an obstacle that he suspected to be either their cat or dog. He forced the door open and stepped onto something and fell onto what he realized was the child. He stated that he fell onto her abdomen with one knee. However, the child responded yes when asked if she was alright. She did not scream or cry at any time. The child then became unresponsive and did not respond to shaking in an attempt to wake her up. The boyfriend attempted to contact the child's mother and then called 911. The 911 operator instructed him to initiate CPR. The 10- minute 911 phone call recording was played for the jury. He also testified that he did not physically or sexually abuse the child.
A firefighter was one of the first responders to the 911 call and testified at inquest. The child was already cold with a distended abdomen and he believed that the child had been dead for awhile. Ambulance personnel initiated CPR. One paramedic stated at inquest that the child appeared to be already deceased for more than one hour when he arrived at the scene.
A nurse who attended to the child at the hospital testified that she observed bruises all over the child's body, which were recorded on a hospital Child Injury Survey form. There was an old, healing laceration on the child's hand that was noted to have required stitches at the time of injury. The bruises were observed to be in different stages of healing, with some older bruises. There was also injury to the vaginal-perineum area of the child. A physician in the emergency department testified that an x-ray indicated a mass of free air in the child's abdomen which could possibly result from a ruptured bowel. Given the type of injury that he observed, he believed that the child had died at least one hour prior to the child presenting at the emergency department.
An RCMP constable also attended the scene and obtained a witness statement from the boyfriend. The statement was inconsistent regarding the time delay between the child's injuries and when the child lost consciousness. The constable was contacted by another officer and instructed to arrest the boyfriend. The residence was cleared and secured as a homicide scene.
At inquest, the child's mother testified that she had been approached by a friend of the couple regarding her boyfriend's interactions with her child. The friend had concerns
BC Coroners Service Annual Report 2006 65 that he was engaged in inappropriate behaviour with the child, including showering with the child. She testified that her memory of the conversation was affected by the medication she had been chronically taking. She had moved herself and her child into her boyfriend's residence one month prior to her child's death. She testified that she had no knowledge of her daughter being physically or sexually abused.
The friend of the couple who had been at their residence the evening prior to the child's death also testified at the inquest. She stated that she had witnessed an interaction between the child and the boyfriend a couple of months previous to the child's death. The body language and facial expressions of the child indicated to the friend that she was fearful of the boyfriend. The friend also stated at inquest that she had previously commented to the child's mother on the number of bruises on the child and was told it was due to clumsiness.
A retired RCMP polygraph examiner explained to the jury the process of polygraph testing. He had initially conducted two different polygraph tests on the boyfriend and later a third due to inconsistent data with the second test. These tests indicated the boyfriend was truthful when he stated that he did not intentionally injure the child or sexually assault the child.
The pediatric pathologist that conducted the post-mortem examination testified that the most severe traumatic injury affected the abdominal region. There was also evidence to suggest an asphyxial contribution to the death of the child. Other experts were consulted regarding their review of the child's injuries. One forensic pathologist testified that the type of injuries suffered by the child could be due to the mechanism of injury described by the boyfriend.
The child and her mother had previous involvement with the Ministry of Children and Family Development. The child had previously been removed from her mother and later returned with a six-month supervision order. However, it was later determined that the child was no longer in need of protection and the file was closed.
Crown counsel reviewed the case twice and both times made the decision not to proceed with criminal charges. The last review was in January 2005.
The jury found that the death was due to abdominal blunt impact injury with additional signs of an asphyxial component and classified the death as a Homicide.
Recommendations: A total of three recommendations were made to the Chief Coroner of British Columbia and the Ministry of Children and Family Development.
The Chief Coroner of British Columbia received the recommendation that presentation of evidence at the coroner's inquest should include persons who attended and investigated the scene.
The Ministry of Children and Family Development received the following two recommendations:
BC Coroners Service Annual Report 2006 66 P P ART ART 4: 4: Inquest • A system be implemented to monitor persons of interest where childcare and/or Inquest parenting issues are identified when the child (children) are between birth and six years old (e.g., public nurses are directed by professionals to attend the family home and frequently visit and interview the child(ren) at their residence). s • A system where persons of interest are identified between social services s agencies in order that necessary assessments are done in a timely fashion (e.g., an interprovincial computer system providing particulars of the description of the person and issues of concern).
Response to Recommendations: The Ministry of Children and Family Development responded that the recommendations were forwarded to the Director of Child Welfare for review.
The Chief Coroner responded that he concurs with the jury's recommendation and that generally the recommendation is considered routine practice.
Case 3 of 3
On October 2, 2006, an inquest was held in Powell River, B.C., into the death of a three-year-old female who died on April 30, 2001, due to an incised wound to the front of the neck.
The child was under the care of the Ministry of Children and Family Development (MCFD) under a series of temporary custody orders during the years 1998 to 2000. The child's maternal aunt and her husband (i.e., the child's uncle) sought custody of her in 1999. Children can be placed with family under the Family Relation Act (FRA) with parental consent. However, the child's mother did not consent. Therefore, the child's aunt and uncle were advised by MCFD to apply as a foster home, with placement by court order, under a different act. References, a home study and a criminal record check were required before placement, none of which indicated any concern. During this process, the child's mother and aunt reconciled and the mother agreed to her daughter's placement in their home. Placement occurred under the FRA as ordered by a judge without additional information, such as a home study, being requested. MCFD involvement with the child ended when her custody was transferred to her aunt in April 2000.
In October 2000, the aunt took her children and her sister-in-law to the RCMP and reported that they were afraid of her husband. He was subsequently hospitalized under the Mental Health Act and discharged after approximately one week.
In late January 2001, the uncle contacted his counsellor to report his intrusive thoughts of harming his boss and children, wife and himself. However, the counsellor did not believe the plan was well developed. The next day the uncle contacted his physician and asked for a three-month supply of medication, suggesting to the physician suicidal intent. In consultation with the psychiatrist, the uncle was hospitalized and discharged after approximately one week. Two weeks later, he again reported to his physician a detailed plan to murder the child and was again hospitalized.
BC Coroners Service Annual Report 2006 67 His counsellor contacted an MCFD social worker to report concern for the children in the household. A risk assessment was completed. However, it was based on the fact that the uncle was in hospital and was not a threat to his children or niece. Mental Health contacted the RCMP and informed them of the situation but indicated that the child's uncle was receiving treatment and not at risk. MCFD met with the child's aunt to assess her ability to care for the family. Family support services were arranged.
At a discharge meeting for the uncle, his psychiatrist indicated to MCFD and the child's aunt that he posed no risk. The RCMP were informed of his discharge from hospital. The follow-up plan after discharge included medication reviews with his psychiatrist and mental health counsellor. MCFD also met with the couple. A family support worker also visited the couple at home a couple of times, with the last visit on April 30, 2001.
Later in the evening on April 30, 2001, the uncle went to his mother's and informed her that he had hurt one of his children. Police went to the home and awakened the child's family and the child was found deceased. Police charged the child's uncle with her death and he was eventually convicted of murder.
At inquest, the uncle's mother and sisters provided testimony regarding his history of anxiety, depression and violent incidents. Similarly, his employer indicated a series of absences from work due to mental health issues. The uncle's brother-in-law and co- worker testified that the uncle once threatened to run his truck into his shift boss and kill his family so they wouldn't have to deal with the consequences of this action. The brother-in-law and the uncle's sister later wrote a reference letter for the transfer of custody to the child, but felt at that time things had improved. The uncle had a mental health counsellor, was taking medication and had attended anger management courses. It was also assumed that the uncle's physician would be consulted.
At inquest the physician testified that he referred his patient to a psychiatrist due to his history and what his patient had disclosed to him. The physician also described his patient as having no definitive disorder, but rather cycles of paranoia and obsessive behaviour requiring medical and psychiatric help. The physician further stated that he completed the foster home application medical report based on what he knew at the time and did not include his chart. He was unaware of his legal duty to report child protection concerns to authorities. Similarly, the psychiatrist who treated the child's uncle also did not contact MCFD, assuming that they had also been contacted.
Numerous child protection issues were raised at inquest. Following the child's death, MCFD completed a review, which included recommendations for internal change.
The jury found that the death was due to an incised wound to the neck and classified the death as a Homicide.
Recommendations: The jury made a total of 24 recommendations to a variety of agencies.
The College of Physicians and Surgeons received two recommendations. First, it was recommended that the circumstances of this death be reviewed with specific
BC Coroners Service Annual Report 2006 68 P P ART ART 4: 4: Inquest focus on information-sharing and the duty to report under the Child, Family and Inquest Community Service Act. It was also recommended that the College of Physicians and Surgeons create a protocol that dictates what questions should be asked when dealing with someone with homicidal ideations. s s It was recommended that a copy of the verdict be forwarded for information and educational purposes to the medical schools in B.C., specifically to emphasize information sharing with the Ministry of Children Family Development and the duty to report under Section 14 of the Child, Family and Community Service Act.
It was recommended to the Minister of Health that the ministry create an advocate/liaison/case worker section, based provincially, with the sole purpose of assisting family members of a patient in a psychiatric unit.
The Provincial Health Authorities received nine recommendations. Two recommendations were regarding duty to report/information-sharing with MCFD and four regarding procedures when an individual is hospitalized under the Mental Health Act and expresses homicidal ideation. The other recommendations were regarding training of mental health workers in dealing with cases involving homicidal ideation,
Eight recommendations were directed to the Ministry of Children and Family Development. The recommendations targeted the home assessment process, the reference process, transfer of cases when a case worker isn't available, and dealing with families in which there have been repeated mental health hospitalizations of the parent or guardian.
Finally, three recommendations were directed to the Premier of B.C. It was recommended that a change be made to the Family Relations Act, that the Government of B.C. re-instate the child advocate position, and that the Government of B.C. create a funding program for psychiatric research.
Response to recommendations: The Ministry of Health responded that they do not recommend the creation of a new provincial section of the ministry with advocate/liaison/case workers.
The Interior Health Authority responded that they will contact the Ministry of Children and Family Development regarding provision of a workshop on child protection issues, information-sharing and duty to report. The authority also responded that the need for standardized assessment of homicidal ideation has placed this item on the agenda for the upcoming Provincial Planning Council.
Vancouver Coastal Health Authority responded that they have undertaken a review process and will respond to the recommendations when they have had the opportunity to consult across the organization.
The Vancouver Island Health Authority responded that staff and physicians will be reminded of information-sharing protocols with the MCFD as it relates to child protection issues by memo with follow-up through continuing education forums.
BC Coroners Service Annual Report 2006 69 VIHA Mental Health and Addiction Services inpatient and outpatient professional staff and physicians will be reminded via memo and continuing education forums of the duty to report and the penalties associated with a failure to report as per Section 14 of the CFCSA. VIHA will ensure that all Mental Health and Addiction Services staff and physicians are provided training on the assessment of the risk of violence by individuals in care, including cases in which homicidal ideation is expressed.
The MCFD responded that existing forms and policy comply with the recommendations, and accordingly, no changes to the form are being undertaken. It was also responded that current policy addresses the recommendation of directly contacting a physician or psychiatrist if a medical reference form indicates violence or mental health history. Regarding references, MCFD noted that requiring five references may be a barrier to recruiting foster parents particularly when, for example, a person does not work outside the home.
Industrial-Forestry/Logging
Case 1 of 1
On September 18, 2006, an inquest was held in Duncan, B.C., into the death of a 52-year-old male who died on November 19, 2005, due to blunt force trauma.
The male was working as a faller on a hand falling and bucking site. The male was the owner and sole employee of his company and was working as a subcontractor for a company under contract for TimberWest Forest Products. The male indicated on the contract that he had Level 3 first aid training, faller certification and was certified to fall dangerous trees.
The male's work had been previously inspected and he had been told that his work didn't meet WCB certification standards. Later inspection by WorkSafeBC also revealed issues with his falling cuts, about which his contractor had intended to follow-up with him at a later date.
The day of his death, the male and his falling partner were falling trees on separate cutting blocks, with a block vacant between them. The male's partner testified at inquest that it was not normal for fallers to be so far apart. The partners conducted radio checks every 30 minutes. The partner went to find the male when he didn't respond to a radio check and found him injured, conscious and exhibiting signs of shock. The partner radioed for immediate evacuation. However, the helicopters requested were grounded due to fog. A helicopter in an area where fog was not a factor was located and sent to evacuate the male. His partner had also arranged for a ground ambulance, with the knowledge that helicopters were grounded. He also started CPR. Another faller arrived and assisted the partner in moving the male onto a stretcher for transport by a logging helicopter to a helicopter landing spot.
When the MedEvac helicopter arrived it transported the male and his partner, who was still performing CPR, to meet the ground ambulance because fog prevented the
BC Coroners Service Annual Report 2006 70 P P ART ART 4: 4: Inquest helicopter from landing at the hospital. The ambulance paramedic testified that he Inquest believed that the male had been dead for some time prior to arrival. At the hospital a trauma team was waiting for the arrival of the ambulance. However, the male had already succumbed to his injuries. s s Toxicological analysis revealed the presence of the inactive metabolite of cannabis, 11- carboxytetrahydrocannabinol in blood samples taken from the male. However, the toxicologist indicated that cannabis was smoked approximately 11-24 hours prior to his death and that the male would not have been feeling the effects of the drug at the time of the fatal incident.
Later investigation by WorkSafeBC determined that the male had been trying to fall a Douglas Fir tree against its lean. It was identified that the undercut was too deep and not considered a safe falling practice. The male attempted to fall this tree using a second Douglas Fir. However, this pusher tree was the same size as the first tree and did not hit the tree squarely and was hung up. The male's chainsaw bar got stuck in the first Douglas tree which he tried to chop free with an axe. This caused the second tree to release from the first tree and fall onto him. A WorkSafeBC investigator testified that the initial cut to the first tree was the primary cause of the incident. The lack of an escape route, inadequate supervision by the hiring contractor and lack of indirect supervision by TimberWest were identified as secondary causes of the incident.
The Workers Compensation Act was also discussed at inquest. Specifically, the general duties or workers, employers and others were discussed. It was also stated that there are no regulations governing emergency response procedures, only guidelines.
At inquest, the general manager of operations for TimberWest reported that since this incident the company has reviewed its procedures and made changes to its existing program. TimberWest's goal for the fall of 2007 is to only do business with companies certified through the BC Forest Safety Council program – Safety Accord Forestry Enterprise Companies.
The jury found that the death was due to blunt force trauma and classified the death as Accidental.
Recommendations: A total of 23 recommendations were made by the jury to the BC Forest Safety Council, TimberWest Forest Corporation, the Minister of Labour and Citizen's Services, WorkSafe BC and the Chief Coroner of BC. There were eight recommendations directed to the BC Forest Safety Council. The majority of these recommendations were regarding standards for various programs. For example, site-specific safety program standards, supervision standards and prime contractor hiring standards for hand falling logging sites were recommended. A supervisors certification program was recommended in addition to a fast-tracking of the SAFE Companies program. It was also recommended that training standards are disseminated to the public as soon as possible after acceptance by the council. Five recommendations were directed to the TimberWest Forest Corporation. It was recommended that:
BC Coroners Service Annual Report 2006 71 • Quality control inspectors receive basic training on the recognition of acceptable falling practices and are required to report substandard practices in writing to the prime contractor and their contract manager; • Consideration is given to hiring safety inspectors; • The bid process for logging jobs include a budget that indicates amount for safety; • Contract managers make frequent and scheduled visits to check for compliance with safety standards; and • Contract managers perform a site inspection of new prime contractor worksites within one week of commencement of operations.
It was recommended to the Minister of Labour and Citizen's Services that the language and definitions of the Worker's Compensation Act be clarified to address the specified issues of the forest industry regarding timber tenure licensees, supervisors and prime contractors. It was also recommended that there is a review of the Worker's Compensation Act regulations regarding health and safety of workers as it relates to single-employee companies.
Seven recommendations were directly to both the Minister of Labour and Citizen's Services and WorkSafeBC. It was recommended that minimum first aid services and equipment are governed by regulation and that sufficient funding is provided to the BC Forest Safety Council to allow fast-tracking of the SAFE Company program. Increased inspection, enforcement and education were recommended of WorkSafeBC in addition to publication of identified trends in death investigations. In addition, there were five site-specific safety program components recommended as regulation, including the requirement that helicopter availability is verified at the start of each work day. The jury recommended a publicity campaign to educate the workforce on the responsibilities of the licensee/landowner, prime contractor, contractor, and subcontractor.
The recommendation that a post-mortem examination is performed following all workplace fatalities was directed to the Chief Coroner of B.C.
Response to Recommendations: WorkSafeBC responded that they had prepared an initial response to the recommendations and would be taking that to the board of directors for approval. The recommendations will also be addressed in a review of Part 26 of the Occupational Health and Safety Regulations. In addition, the vice president of the operational division was asked to closely monitor compliance and enforcement strategies in the forestry sector. It was noted in the initial response that WorkSafeBC's intention is to eventually post all investigations on its website. WorkSafeBC indicated that over the last year it has been working with industry and labour stakeholders to educate the workforce on the responsibilities of licensee/landowner, prime contractors, contractors and subcontractors. The chair of the board of directors has sent letters to all forest-industry CEOs and owners of companies outlining the legal responsibilities of all parties. The Minister of Labour and Citizen's Services responded that the recommendations fall within the scope of WorkSafeBC's review of Part 26 of the Occupational Health and Safety Regulations.
BC Coroners Service Annual Report 2006 72 P P ART ART 4: 4: Inquest TimberWest responded that in the fall of 2006 an independent, third-party safety Inquest evaluation would be undertaken, concluding with a report, which was included in the response to the inquest recommendations. TimberWest indicated that it was committed to implement all of the recommendations outlined in the report as s quickly as possible, as well as the jury's recommendations. It was stated that s TimberWest is working with WorkSafeBC and the BC Forest Safety Council to develop training programs and that the company's contract managers are using specialists to review safety performance in specific areas. It was also stated that a tool is being developed to track the safety content in bid prices.
The Chief Coroner of B.C. responded that the policy of the BCCS regarding industrial deaths states that a post-mortem examination will be ordered except when the individual is transported to hospital and there is documented medical treatment, evidence and information identifying the cause of death by a medical professional. It was indicated that the cause of death of the decedent was confirmed to be blunt force trauma through examination of his visible external injuries and the documented evidence of the attending medical professionals.
The BC Forest Safety Council has posted a response to all eight recommendations on its website: www.bcforestsafe.org
Other
Case 1 of 2
On March 13, 2006, an inquest was held in Kelowna, B.C., into the death of a 21-year-old male who died on February 11, 2004, due to a multi-organ failure.
The male entered an electronics retail store on February 10, 2005, and proceeded to the rear of the store. The male was approached by a store employee and asked about the whereabouts of a product that the employee identified as missing. The male removed the item from his backpack and returned it to the display area. Another store employee contacted the police. The male asked that the police not be called and a confrontation between the employee and the male escalated.
At inquest, the employee testified that he and the male fell to the floor during the altercation and that the male was restrained by the employee who lay across his back. The employee also said that he had only 50 pounds of his weight resting on the male and loosened his hold around his neck when the male stated he couldn't breathe. Speaker wire was used to bind his hands and feet. At this time the male was still breathing and had a detectable pulse. He stopped struggling prior to the arrival of the police.
Upon arrival, the police officer advised one employee that an ambulance should be called as he had checked the male and could not detect a pulse or respirations. The speaker wire was then removed from the decedent. No resuscitation was initiated prior to arrival of the BC Ambulance Service.
BC Coroners Service Annual Report 2006 73 BC Ambulance Basic Life Support and later, Advanced Life Support attended the store. The male was determined to be in cardiac arrest. An automatic external defibrillator could not detect a shockable heart rhythm.
Post-mortem examination indicated that the cause of death was multi-organ failure due to a combination of lethal levels of methadone and morphine and asphyxia as a result of a physical altercation. Toxicological analysis revealed that the blood concentration of morphine exceeded minimum lethal levels, while the concentration of methadone was elevated and approaching the lethal range.
A member of the RCMP clarified for the jury that despite the fact that the male returned the item while still in the store, his intent of committing a theft made it an offence. The officer further stated that individuals have a right to prevent a theft and make an arrest if they witness an indictable offence.
This incident prompted the installation of video surveillance equipment in the store as well as the store policy that shoplifters are not confronted. Expensive merchandise is now secured in place and signs request that backpacks and heavy jackets are not worn or carried in the store.
The jury found that the death was due to multi-organ failure as a consequence of respiratory depression as a result of levels of methadone and morphine exceeding minimum lethal levels in combination with a component of asphyxia and classified the death as Accidental.
Recommendations: The jury made two recommendations which were directed to the Ministry of Small Business and Revenue and Retail BC. It was recommended that all retail outlets have specific procedures and training for employers and employees with regard to shoplifting and for appropriate responses to physical confrontation.
Response to recommendations: The Ministry of Small Business and Revenue responded that it has partnered with Retail BC and WorkSafeBC to communicate the importance of avoiding violence in the workplace and what to do if such violence does occur to retail owners, managers and their employees.
BC Coroners Service Annual Report 2006 74 P P ART ART 4: 4: Inquest Inquest Case 2 of 2
On October 23, 2006, an inquest was held in Prince George, B.C., into the s
death of a 21-year-old male who died on January 25, 2005, due to s cardiorespiratory arrest associated with struggle and restraint.
A 21-year-old male was living at a group home for mentally challenged individuals. His functional ability was similar to that of a five-to-six-year-old child. While on an outing with two staff members, the male became agitated when a request of his was denied. For his own safety, the staff members attempted to restrain the male by holding him on his back on the floor of the vehicle. Following restraint, they noticed he was having medical difficulties and immediately placed him in a recovery position and transported him to a nearby hospital.
The incident was reviewed by Community Living Services, through which the male was receiving services. There were several other agencies that were providing services to the male at the time of his death.
At inquest, witness testimony indicated a general lack of understanding regarding guardianship of adults.
The jury found that the death was due to cardiorespiratory arrest associated with struggle and restraint and classified the death as Accidental.
Recommendations: The jury made nine recommendations, which were directed to Community Living BC (CLBC), the Ministry of Children and Family Development (MCFD), the Ministry of Health, and the Attorney General.
Four recommendations were directed to CLBC regarding education and training of staff, including coursework in developmental disabilities while employed with CLBC and additional occupational first aid training for those working with individuals who exhibit violent, aggressive or self-abusive behaviour. The jury also recommended implementation of a case management structure, in which a case manager is appointed from CLBC and is responsible for ensuring appropriate services are available to the client. The case manager should also conduct periodic reviews of behaviour management plans and other case information.
The Minister of Health received the recommendation that sections of the Health Care Consent and Care Facility Admission Act be immediately proclaimed.
Both CLBC and the MCFD received the recommendation that all staff working with mentally challenged children and/or adults should have training regarding Fetal Alcohol Spectrum Disorder. It was also recommended that an independent case review be conducted of youth with mental disabilities receiving services from MCFD and CLBC to determine the need for a substitute decision-maker for the individual upon them reaching the age of majority.
BC Coroners Service Annual Report 2006 75 The Attorney General, Minister of Health and CLBC all received the recommendation that individuals with developmental disabilities that are repeatedly violent or aggressive are placed in a facility that can ensure security for that individual, staff and the public. A treatment and behaviour management plan should be developed/modified for that person.
Response to recommendations: CLBC responded that their organization was already making changes that were congruent with a number of the jury's recommendations. The organization indicated that they would be working closely with the Ministry of Health, the Office of the Public Guardian and Trustee and community groups to assist with the implementation of proposed amendments to the Health Care Consent and Admission to Care Facilities Act. However, it was noted that the CLBC has no authority to place individuals in 'secure' environments or limit their mobility, as all services authorized under the Community Living Authority Act are voluntary. It was also noted that CLBC does not operate under a case management model to manage day-to-day activities of those receiving services. An extensive network of service providers is contracted to assume this function and their compliance with expectations is monitored.
The MCFD responded that there are several initiatives underway to strengthen staff training on Fetal Alcohol Spectrum Disorder. The MCFD also responded that there is an expectation that transition planning occur for all youth who are receiving services from the ministry as the youth approach 19 years of age.
BC Coroners Service Annual Report 2006 76 GLOSSAR GLOSSAR Y Glossary Y
Cause of Death The immediate medical cause of death (e.g., head injury resulting from a motor vehicle accident, asphyxiation due to hanging).
Classification of Death Classification of death as one of the following: Accidental: Death due to unintentional or unexpected injury. It includes death resulting from complications reasonably attributed to the accident. Homicide: Death due to injury intentionally inflicted by the action of another person. Homicide is a neutral term that does not imply fault or blame. Natural-Unexpected: Death primarily resulting from a disease of the body and not resulting secondarily from injuries or abnormal environmental factors. Suicide: Death resulting from self-inflicted injury, with intent to cause death. Undetermined: Death which, because of insufficient evidence or inability to otherwise determine, cannot reasonably be classified as Natural, Accidental, Suicide or Homicide.
Judgement of Inquiry The coroner's official record of the identity of the deceased and how, when, where and by what means the deceased died. It is a public document that forms the official provincial record of the death. It may include recommendations to agencies to aid in prevention of future deaths.
Natural – Expected Death A death reported to the BCCS from the BC Vital Statistics Agency of a child who died of natural and expected causes while under medical care. The family physician verifies the cause of death and completes the medical certificate of death.
Verdict at Inquest A summary of the jury's findings regarding how, when, where and by what means the deceased died. Recommendations made by the jury are also included in the Verdict at Inquest. The evidence presented at the inquest is summarized by the presiding coroner and is also included in the Verdict at Inquest. It is a public document that forms the official provincial record of the death.
BC Coroners Service Annual Report 2006 77
ACKNOWLEDGEMENTS
The BCCS would like to acknowledge Chris Mathieson of the Vancouver Police Centennial Museum and coroner Dan Devlin for providing valuable historical information.
The BCCS would also like to thank every coroner in British Columbia for their diligent efforts in death investigation and reporting. The important information they collect through their investigations contributed greatly to the data presented in this report and will also contribute to understanding and preventing mortality in the province.
For more information or additional copies of this report, please contact:
Office of the Chief Coroner Metrotower II Suite 800 - 4720 Kingsway Burnaby, B.C. V5H 4N2
Tel: (604) 660-7746 Fax: (604) 660-7766
www.pssg.gov.bc.ca/coroners/index.htm
03/2008 PSSG08004