RELEASE DATE: July 22, 2004 Manitoba THE PROVINCIAL COURT OF MANITOBA IN THE MATTER OF: THE FATALITY INQUIRIES ACT AND IN THE MATTER OF: SUSAN CAPELIA REDHEAD APPEARANCES: Mr. T.J. Preston, for the Crown Mr. J.R. Norman Boudreau, for Sarah Wood and Shamattawa First Nation Mr. Issie D. Frost and Mr. Alan Ladyka, for Department of Family Services and Department of Justice Mr. Michael Thomson, for Winnipeg Child and Family Services Mr. Jeffrey F. Harris, for Awasis Agency of Northern Manitoba Mr. Randal T. Smith, Q.C., for First Nations and Inuit Health Branch Mr. Mark G. Mason, for the Royal Canadian Mounted Police Manitoba THE FATALITY INQUIRIES ACT SCHEDULE ATTACHED TO PROVINCIAL JUDGE’S REPORT RESPECTING THE DEATH OF: SUSAN CAPELIA REDHEAD TABLE OF CONTENTS Page No. HOLDING OF THE INQUEST.............................................................................. 1 LEGISLATIVE AUTHORITY ................................................................................ 2 FEBRUARY 20, 2000........................................................................................... 4 SUSAN REDHEAD: FAMILY HISTORY............................................................. 5 SUSAN REDHEAD: PERSONAL HISTORY ...................................................... 6 THOMPSON CHILD AND FAMILY SERVICES................................................. 18 Recommendations ...................................................................... 19 WINNIPEG CHILD AND FAMILY SERVICES ................................................... 19 Recommendations ...................................................................... 20 AWASIS AGENCY OF NORTHERN MANITOBA ............................................. 21 Recommendations ...................................................................... 24 MANITOBA JUSTICE Prosecutions .......................................................................................... 31 Recommendations ...................................................................... 34 Probation Services ................................................................................ 37 Recommendations ...................................................................... 40 LOCAL MEDICAL SERVICES/NURSING STATION......................................... 41 Recommendations ...................................................................... 43 NATIONAL NATIVE ALCOHOL AND DRUG ABUSE PROGRAM (NNADAP).......................................................................................................... 49 Recommendations ...................................................................... 51 - ii - MENTAL HEALTH SERVICES .......................................................................... 51 NON-INSURED HEALTH BENEFITS ................................................................ 60 Recommendations ...................................................................... 60 END NOTE......................................................................................................... 70 EXHIBIT LIST..................................................................................................... 72 WITNESS LIST .................................................................................................. 82 Inquest – Susan Redhead Page 1 HOLDING OF INQUEST [1] Susan Redhead was 15 years old when she committed suicide at the home of her mother and stepfather in Shamattawa on February 20th, 2000. She had been discharged from the care of the Awasis Agency of Northern Manitoba (Awasis) approximately six weeks prior to her death. At the time of her death her stepfather also resided in the home. He had recently been released from custody after being convicted on charges of sexually abusing both Susan and her sister. Susan was also known to be a high risk for suicide and had been receiving mental health services while in agency care. [2] On November 10th, 2000, an Inquest was called by the Chief Medical Examiner of the Province of Manitoba pursuant to section 19(2) of The Fatality Inquiries Act to address the following: (1) to determine the circumstances and events leading to the death of Susan Redhead; (2) to determine whether, given her difficulties and history, Susan received appropriate child protection and child welfare services, particularly after her discharge from care in January of 2000; (3) to determine the circumstances under which the individual convicted of sexually abusing Susan was released from incarceration without an order prohibiting contact with his victim; (4) to determine the availability of access and appropriate mental health services for youth in First Nations communities; (5) to increase awareness of the need to protect children from known sexual offenders; and (6) to determine what may be done to prevent similar deaths in the future. Inquest – Susan Redhead Page 2 LEGISLATIVE AUTHORITY [3] Sections 19(2), 25 and 26(1) of The Fatality Inquiries Act are the authority for a Provincial Court Judge to hold an inquest with respect to the death and are as follows: CME to direct holding of an inquest 19(2) Where the chief medical examiner determines under subsection (1) that an inquest ought to be held, the chief medical examiner shall direct a provincial judge to hold an inquest. Ministerial direction for inquest 25 The minister may direct a provincial judge to conduct an inquest with respect to a death to which this Act applies. Provincial judge to hold inquest 26(1) Where a direction is given by the chief medical examiner under section 19 or by the minister under section 25, a provincial judge shall conduct an inquest. [4] The duties of the provincial judge at an inquest are set out in section 33(1). After completion of an inquest, the presiding provincial judge: (1) shall make and send a written report of the inquest to the Minister setting forth when, where and by what means the deceased person died, the cause of death, the name of the deceased person, if known, and the material circumstances of the death; (2) shall, upon the request of the Minister, send to the Minister the notes or transcript of the evidence taken at the inquest; (3) shall send a copy of the report to the Medical Examiner who examined the body of the deceased person; and (4) may recommend changes in the programs, policies or practices of the Government and the relevant public agencies or institutions or in the laws of the province where the presiding provincial judge is of the opinion that such changes would serve to reduce the likelihood Inquest – Susan Redhead Page 3 of deaths in circumstances similar to those that resulted in the death that is the subject of the inquest. [5] The Inquest regarding the February 20th, 2000, death of Susan Redhead was held over a period of 37 days: ♦ on November 5th, 6th, 7th, 8th, 9th, 13th, 14th, 15th, 16th, 19th, 20th, 2001, at the City of Thompson, in Manitoba; ♦ on November 21st, 2001, at Shamattawa, in Manitoba; ♦ on November 22nd, 28th, 29th, 2001, at the City of Thompson, in Manitoba; ♦ on February 4th, 6th, 7th, 8th, 11th, 12th, 2002, at the City of Winnipeg, in Manitoba; ♦ on May 6th, 7th, 8th, 9th, 13th, 14th, 15th, 21st, 22nd, 23rd, 24th, 2002, at the City of Winnipeg, in Manitoba; ♦ on June 28th, 2002, at the City of Winnipeg, in Manitoba; ♦ on September 6th, 2002, at the City of Winnipeg, in Manitoba; and ♦ on September 9th, 10th, 11th, 2002, at the City of Thompson, in Manitoba. [6] When the Inquest commenced on November 5th, 2001, Mr. Boudreau withdrew as counsel for Sarah Wood and the Shamattawa First Nation. Chief Eli Miles was present and was invited to attend the proceedings on behalf of his community. Other than to give evidence on November 16th, 2001, he did not attend further. Sarah Wood was not present on the first day although she was aware Mr. Boudreau was withdrawing. Ms. Wood was invited to sit in on the proceedings. She gave evidence on November 13th, 2001. Other than that, she did not attend. Inquest – Susan Redhead Page 4 [7] A total of 59 witnesses were called. FEBRUARY 20, 2000 [8] In the early hours of February 20th, 2000, Susan Redhead hanged herself in a bedroom of her mother’s home with a coaxial cable meant to support a baby’s hammock. She had been in the company of three young men earlier in the evening and Susan had been sniffing. The four spent time at Susan’s mother’s home where they talked and played music. Susan’s mother, Sarah Wood, was in the home and told them to get out so that the music would be stopped because she was trying to sleep. During the time the young men were there, Susan was apparently upset and had been talking about an incident several days earlier when she had stabbed her stepfather, John Wood, with a knife. She had also been upset when she was speaking to her mother earlier that night about her stepfather not wanting to come home while Susan was in the home. She knew her mother wanted John in the home. Michael John Wood had been convicted in February of 1999 of sexually assaulting Susan and her sister and had been sentenced to a year in jail as a result of that. [9] After the three young men left, Susan did not leave. Shortly after, her sister C. stopped by the house, having just been released from the R.C.M.P. cells. Susan had at first wanted her to stay the night because she did not like to be alone in the house with just her mother. She changed her mind, however, and told C. to go on home where her own people would be waiting for her (C. did not live with her mother and stepfather). John Wood was not in the home