Coroner’s office being restructured
City woman’s fatal fall in hotel laundry chute prompts changes
There will be more coroners working in the province following a promised review into the workings of the Office of the Chief Coroner (OCC) over the case of Nadine Machiskinic — the Regina woman who died after falling 10 storeys down a laundry chute at the Delta Regina Hotel on Jan. 10, 2015.
Undertaken by the Ministry of Justice and the OCC, the review has led to the hiring of two additional coroners in the province, with one more to follow. An inquest is also to be held, but no date has been set.
Machiskinic, 29, was found unconscious at the foot of a chute in a basement area of the hotel, and died a short time afterward. She is thought to have entered the chute via an unlocked door on the 10th floor.
In his coroner’s report into the case, chief coroner Kent Stewart concluded blunt force trauma consistent with a fall was the cause of death, with drug toxicity a contributing factor. The manner of death was determined to be accidental.
However, after her family questioned how the investigation was handled, Minister of Justice and Attorney General Gordon Wyant announced June 29 that an independent inquest would take place, and that a full review of the coroner’s office would be held.
“I’m concerned that the confidence in the coroner’s office and the confidence in the administration of justice has been put into question,” he said at the time.
In two separate emailed statements sent to the Leader-Post, a government spokesperson said the review of the OCC has been completed and next steps are underway. Two extra full-time coroners have been hired in Regina, bringing the number of full-time coroners from one to three. The hiring process for another full-time coroner is underway in Saskatoon, which would bring that city’s full-time coroners up from two to three.
“This (review) has led to some immediate steps being taken to restructure the office in order to improve services to clients,” the first statement read.
“The OCC will continue to look for additional opportunities to ensure coroners’ services are delivered in an effective and efficient manner.”
Asked which deficiencies in particular were looked at in terms of the day-to-day running of the office, a followup government statement said, “The program review focused on the effectiveness, quality and efficiency of the investigative services provided by the Office of the Chief Coroner.”
No precise details on the review’s findings are expected to be made public. In particular, questions were raised about the case when on June 24 the Machiskinic family released two contrasting autopsy reports that they had received from the OCC.
In the final autopsy report — which formed part of the coroner’s overall report — the office consulted Alberta toxicologist Dr. Graham R. Jones, who said he did not think “that there is sufficient evidence to conclude that she would have been incapable of climbing into the laundry chute without assistance.”
However, the family was also given an earlier version of the autopsy report — accidentally, they have claimed — in which Saskatchewan forensic pathologist Shaun Ladham took the view that, “the levels of the drugs present would make it unlikely that she would have been able to climb into the laundry chute on her own.”
When the updated report was provided to the Machiskinic family, it contained no references to the fact that Ladham had once held a different opinion, and had initially recommended that the manner of death be listed as undetermined.