Who, where and when would seem to be straightforward questions in most cases. The distinction between how and by what means can be illustrated by looking at the jury’s verdict from Muskoka Heights, in which cause of death (how) is determined as smoke inhalation (or complications thereof) and by what means as accidental.

Coroners’ offices will invariably have a motto such as Ontario’s "We speak for the dead to protect the living". Answering who, how, where, when and by what means does little to protect the living, which brings us to potentially the most important societal function of a coroner’s inquest: A jury may make recommendations that attempt to prevent deaths in similar circumstances in the future. I say potentially the most important function because there is no legal obligation for these recommendations to be implemented, nor does there appear to be any precedent set in common law to hold up a coroner’s jury’s recommendation as a standard of care. If anyone with a stronger legal background wants to comment on that, I welcome such a discussion.  Let’s find out if we can fix a system that seems to be dysfunctional.

Ours is not the only industry (speaking here of the broader fire-protection community) that trumpets the adoption of worldwide best practice, nor is it the only one that regularly fails to live up to that lofty standard. Neither is the dubious efficacy of a coroner’s jury recommendation solely an Ontario thing.

Two weeks ago, a coroner’s jury in British Columbia returned six recommendations after investigating the 2010 death of a man in an RCMP use-of-force incident. Among them was a recommendation that junior officers be paired with more senior officers. Previous juries have returned similar recommendations. David Eby, executive director with the B.C. Civil Liberties Association, was quoted in the Kamloops Daily News saying that “Most of the use-of-force incidents that we see, especially the very serious ones, involve junior officers but unfortunately (that recommendation) is one that’s often ignored.”

I first became aware of the inherent flaw in the coroner’s inquest system when reading about the 1994 drowning death of a young girl at the Variety Village swimming pool in Scarborough, Ont., after her hair became caught in the pool filter. I remember reading that the coroner’s jury recommendations were apparently almost identical to those from a previous coroner’s jury investigating a similar drowning from Manitoba. Unfortunately, time and technology being what it was, I can’t immediately retrieve all of this online. If this were a legal brief instead of a blog, certainly all of that information would be researched and presented, but for now you will have to rely on my memory. The key point is that the knowledge existed within Canada that pool filters as designed constituted a potential danger to children, and nothing was effectively done to prevent the death of 10-year-old Cristin Fitzpatrick.

A quick online search produced information on pool-filter entrapment drowning cases from Australia, Japan and the United States, many of which were investigated by coroners’ juries.  One hard statistic stands out: between 1985 and 2004, at least 33 American children under the age of 15 died as a result of pool and spa entrapment, and almost 100 others were seriously injured. So, ineffective coroners’ inquest systems are not just a fire or police thing, and not just a Canada thing either.

I accessed the most recent report on inquests on the Ontario coroner’s website. The summaries and categorizations of inquest recommendations for the years 2003 through 2009 yielded these statistics; of the 2,897 total recommendations made by juries over that eight-year period, 1,001 (or 35 per cent) have been implemented. A further 688 (24 per cent) either will be implemented, have had alternate solutions implemented, or will have alternate solutions implemented. So a total of 58 per cent of jury recommendations have been or are in the process of being effectively addressed. Another 108 (four per cent) are listed as having been rejected, leaving 1,100 (38 per cent) in one form of holding pattern or another. The report does not address individual recommendations, but it seems obvious that sprinkler retrofit is somewhere in one of those states of limbo. How low can you go?

Fingers have been pointed at fire marshals and fire commissioners on this and similar issues when systemic inaction is evident, but they are policy watchdogs, not policy makers. They receive their marching orders from elected officials. As Christie Blatchford rightly points out in the National Post (see the link on the FFIC news page), now it’s up to Ontario Premier Dalton McGuinty to stop seniors from burning to death. I would suggest that McGuinty, along with former premiers Davis, Miller, Peterson, Rae, Harris and Eves, along with their respective ministers responsible for public health and community safety since the 1980 Extendicare Nursing Home fire in Mississauga, be asked to frankly explain why seniors are still dying in inadequately protected residences. I’m not even going to give Frank Miller a pass on this issue for being dead already. If civil servants are responsible to politicians, then so are politicians responsible to the electorate. There is an indelible trail of death and sorrow from Extendicare and Meadowcroft Place in Mississauga, through the veterans’ wing of Sunnybrook Hospital in Toronto, on to Muskoka Heights and now Place Mont Roc. Only legislators have the power to ensure that the trail will end here and now. We must all hold our employees (that’s what they are, after all) accountable.

In British Columbia, family members of the man killed in the RCMP use-of-force incident have said they will follow up on the six suggestions intended to avoid similar incidents in the future. “I will fight until my last breath,” said his mother, as would your mother or mine.

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