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The Office of the Chief Coroner’s Death Review of the Youth Suicides at the Pikangikum First Nation 2006 – 2008 Table of Contents LETTER TO THE CHIEF CORONER....................................................................................... 5 PURPOSE OF THE REVIEW .................................................................................................... 7 PROCESS OF REVIEW ............................................................................................................. 9 ACKNOWLEDGEMENTS ........................................................................................................ 11 EXECUTIVE SUMMARY .......................................................................................................... 13 Pikangikum First Nation: The Social Challenges .............................................................. 13 Pikangikum First Nation: The Review of the Deaths of the Youth.................................. 15 Pikangikum First Nation: Health care.................................................................................. 15 Pikangikum First Nation: Education..................................................................................... 16 Pikangikum First Nation: Policing Services........................................................................ 17 Pikangikum First Nation: The Provision of Child Welfare Services................................ 17 Pikangikum: Social Determinants of Health....................................................................... 19 Advocate for Children and Youth’s Report: Summary...................................................... 20 The Key Recommendations of this Report......................................................................... 21 Summary.................................................................................................................................. 23 PART A: THE DEATHS OF THE YOUTHS BY SUICIDE.................................................. 25 A1. Introduction....................................................................................................................... 25 A2. Method of Review............................................................................................................ 25 A3. The Deaths ....................................................................................................................... 26 A4. Emerging Themes from Review of the Individual Cases .......................................... 32 A5. The Cumulative Report and Identified Trends............................................................ 33 A6. Discussion ........................................................................................................................ 35 A7. Concluding Remarks....................................................................................................... 40 PART B. SUICIDE ..................................................................................................................... 41 B1. Definition of Suicide ........................................................................................................ 41 B2. History of Suicides in Pikangikum................................................................................. 41 B3. Adolescent Suicide in Canada ...................................................................................... 41 B4. Canadian Suicide Rate Statistics.................................................................................. 43 B5. Suicide Among Aboriginal People ................................................................................ 43 B6. First Nations Youth Suicide Rates................................................................................ 44 B7. Suicides in Ontario and in Pikangikum, 2006 - 2008................................................. 44 B8. Concluding Remarks....................................................................................................... 45 PART C: HEALTH IN PIKANGIKUM..................................................................................... 47 C1. Introduction....................................................................................................................... 47 C2. The North West Local Health Integration Network (LHIN) ....................................... 47 C3. The Sioux Lookout First Nation Health Authority (SLFNHA) ................................... 48 C4. Sioux Lookout Regional Physicians’ Services Inc. .................................................... 49 C5. Sioux Lookout Meno-Ya-Win Health Centre (SLMHC)............................................. 50 C6. The Pikangikum Health Authority (PHA) ..................................................................... 51 C7. Challenges ....................................................................................................................... 53 C8. Recent Successes .......................................................................................................... 54 C9. Land-based Solvent Abuse Program ........................................................................... 54 C10. The Nursing Station...................................................................................................... 56 C11. Relationship with the Federal Government............................................................... 57 C12. Concluding Remarks .................................................................................................... 77 PART D: EDUCATION ............................................................................................................. 79 D1. Introduction....................................................................................................................... 79 D2. Education Governance: The Pikangikum Education Authority ................................ 79 D3. Truancy ............................................................................................................................. 82 D4. Overcrowding and the Inadequate Physical Plant ..................................................... 87 D5. Federal and Provincial Involvement in Education Delivery ...................................... 90 D6. Concluding Remarks ...................................................................................................... 94 PART E: POLICING SERVICES IN PIKANGIKUM............................................................. 97 E1. Introduction....................................................................................................................... 97 E2. Pikangikum First Nation ................................................................................................. 97 E3. Community Expectation of Policing.............................................................................. 99 E4. Governance Structures................................................................................................. 100 E5. Pikangikum Policing Statistics..................................................................................... 100 E6. Concluding Remarks..................................................................................................... 102 PART F: THE PROVISION OF CHILD WELFARE IN THE NORTH AND TO PIKANGIKUM........................................................................................................................... 103 F1. Tikinagan Child and Family Services ......................................................................... 103 F2. Pikangikum: A community in crisis.............................................................................. 109 F3. The Development of Child Welfare in Ontario .......................................................... 109 F4. Cultural Tension............................................................................................................. 110 F5. The Functions of a CAS ............................................................................................... 112 F6. Children in Care (CIC) .................................................................................................. 112 F7. Funding...........................................................................................................................