Here’s hoping review can breathe new life into coroner’s inquests

I’ve covered countless coroner’s inquests through the years.

My first one, nearly three decades ago, involved the shooting death of a troubled teenage boy, who took his own life in the midst of a confrontation with police officers. The last, in 2017, examined the death of Nadine Machiskinic, a 29-year-old woman who plunged 10 storeys down a laundry chute at a downtown Regina hotel.

In between have been numerous others: a man shot by

RCMP after a lengthy standoff, a distraught inmate who hanged himself at the Regina jail, an intoxicated teen who fell from a catwalk in a dark theatre, a chronic alcoholic who died of severe alcohol poisoning while sleeping in a police cell, an epileptic pepper-sprayed and handcuffed in the back of an ambulance, a drowning victim in a care home, a foster child who slowly succumbed to a treatable chest infection, a man with a head injury who walked away from hospital only to die in a drunk tank, a six-year-old boy beaten to death by a deeply disturbed 10-year-old, a young father who went into cardiac arrest in a tussle with several police officers — to name a few.

Over the course of several days, the inquest tries to unravel and make sense of events that often unfolded in mere minutes. At best, they lay bare the missteps, mistakes and missed opportunities that culminated in that tragic, final outcome.

I found myself reflecting on all those inquests Tuesday after learning that retired Saskatoon police chief Clive Weighill is scheduled Wednesday afternoon to release his eagerly anticipated review of the Saskatchewan Office of the Chief Coroner.

It’s a rocky path that leads us to this juncture — an announced plan in 2016, then quickly rescinded after public backlash, to do away with inquests for most in-custody deaths; criticism of conflicting coroner’s reports in the case of Machiskinic; controversy surrounding the investigation into the 2015 drowning death of 14-year-old Haven Dubois; lengthy delays in the inquests into the in-custody deaths of Breanna Kannick in 2015 and Kinew James in 2013; a civil trial last year that raised allegations of racism against the Coroner’s Office.

And most recently a mix-up in identifying victims in the Humboldt Broncos bus crash.

Each inquest has its own unique set of circumstances and tensions.

But there is also one, resounding similarity. Seated somewhere near the front of the room is a group of grieving loved ones, hanging on each word of testimony, seeking answers that seem so elusive.

And by the end of the inquest, more often than not, they leave drained and frustrated.

Understandably, many families crave a process that will hold someone to account for whatever went so horribly wrong. At the very least, they want to know that if there was some failing, it will be set to right — so it can’t happen again and this death will perhaps ensure life for someone else.

But as is repeatedly pointed out before and after every inquest, there are legal limits on what it can achieve by law.

The jurors are restricted to determining who died, when, where, and by what means; classifying the death as accident, suicide, homicide or undetermined; and, if they desire, making recommendations around unsafe practices and the like, although there’s no way to actually enforce such suggested changes.

Better than nothing ? Definitely. Just ask the families who seek a public inquest and don’t get one.

And in that same vein, I don’t mean to pre-judge Weighill’s review. It will no doubt be thorough and fair, approaches he often took while navigating thorny issues, whether as Saskatoon’s police chief or Regina’s deputy chief.

But I suspect for some of the families who pressed for this review, it will still leave them wanting because it, like an inquest itself, has limitations. Weighill said from the outset his task was not to examine any individual case.

His job is to examine “the mandate and performance of the coroner’s service and offer recommendations.”

In the wake of questions surrounding the handling of Machiskinic’s death, then-justice minister Gordon Wyant, in announcing a public inquest as well as a review of the coroner’s office at that time, said, “I’m concerned that the confidence in the coroner’s office and the confidence in the administration of justice has been put into question.”

Let’s hope Weighill’s review can at least restore that confidence.

There are a lot of lives — and deaths — counting on it.