14 sudden death cases of Indigenous people in Thunder Bay, Ont., recommended for police reinvestigation

An investigative team that has been looking into sudden death cases in Thunder Bay, Ont., for years is recommending thatpolice reinvestigate an additional 14, according to a confidential report leaked to CBC News.

Thecases involveIndigenous people and date back to between 2006 and 2019. The youngest person was two months old and the oldestwas 61.

Thereport is part of the final work ofthe Broken Trust committee, formed after the province's oversight agency, the Office of the Independent Police Review Director, found evidence of systemic racism in the city's police force in 2018.

The committeecalled for the reinvestigation of the sudden deaths of nine Indigenous people. Part of the process was to consider if other sudden deathinvestigations undertaken by the Thunder Bay Police Service should beconducted again.

The leaked report, most recently updated in February, begins with a disclaimer that"due to finite timelines and resources allocated to the process outlined in this report, cases provided here are not an exhaustive list," adding there may be other sudden death cases that "warrant further investigation."

Brian Gray, a spokesperson with Ontario's Ministry of the Attorney General, confirmed to CBC News that the ministry has received and is now considering the request to refer 16 sudden deaths for reinvestigation.

Those 16 includea coroner's review for a missing persondeath and for a drug death.

In addition, there are 25 unresolved missing and murdered Indigenous women and girls (MMIWG) cases from Thunder Bay some of which have remained open and have been unresolved for over two decades that the report recommends be reviewed.

Report examines years of investigations

This is the latest development in a series of complaints and external investigations into the city's police force over the past two months, and it comes as the original Broken Trust process begins to wind down.

In 2018, the Office of the Independent Police Review Directorissued its Broken Trust report, which found evidence of systemic racism within the force. At the time, the office reviewed 37 sudden death investigations by Thunder Bay police and found nine of them to be "so problematic" that they should be re-conducted by a multidisciplinary investigative team.

Those original nine reinvestigations have been criticized by families and their lawyers for lacking transparency, but they have since concluded and the results are now being shared with family members, according to Ontario's chief coroner.

The Broken Trust report also recommended the team establish a protocol to determine if other Thunder Bay police sudden death investigations should be redone.

CBC News has requested but has not yet received a copy of that protocol from Ontario's chief coroner, who acts as a spokesperson for the executive governance committee overseeing the reinvestigations.

But as part of itswork, the multidisciplinary investigative team conducted a non-exhaustive review of the police service's and the provincial coroner's records for sudden death and Indigenous death cases between 2000 and 2020. They included 229 cases.

The 16 cases recommended to be reinvestigated and reviewedrange from what were initially determined to beapparent suicides or deaths ruled "accidental" under suspicious circumstances including due to drownings, repeated falls or hypothermia drug overdoses, and twoshortly after theindividual left or was discharged from the Thunder Bay hospital.

A CBC News analysis of the case reviews included in the report has identified several similar trends, including:

• 15 of the people who died were Indigenous.
• In 13 of the cases, there was insufficient investigation of suspects at the death scenes, despite themhaving violent pasts, including prior involvement in murders and serious assaults.
• For at least seven of the deaths, the last person to see the deceased alive was an intimate partner.
• Seven of the cases had investigations explicitly described as "incomplete" in the leaked report.
• In at least six of the cases, Thunder Bay police investigators did not use major case management a system developed by Ontario in 1997 to establish minimum standards for police investigations of serious incidents.
• Investigations did not establish a timeline of the individual's whereabouts and actions before their death in at least five cases.

One of the key concerns that has emerged over the last decade of public scrutiny of Thunder Bay police and coroners is that they do not adequately communicate with families. That continues to be an issue, with a failure to update family members identified explicitly in three cases reviewed in the report.

In January 2017, Thunder Bay police created a sudden death review committee that was required to go over all sudden deaths to ensure all investigative steps were taken. But the leaked report says the police broke thatnew policy in three of the four sudden death cases reviewed since 2018.

CBC News has requested an interview with Thunder Bay police Chief Sylvie Hauth. Her spokesperson hadnot yet responded at time of this story's publication.

Coroner reviews requested to improve public safety

While 14 of the cases in the report are recommended for police reinvestigation, the investigative team suggested two sudden deaths be sent to Ontario's coroner for a review or an inquest, to create awareness and recommendations to improve public safety.

The first sudden death recommended for coroner re-review involvesa vulnerable Indigenous person who went missing from the Thunder Bay hospital and was found dead months later.

The report acknowledged Thunder Bay police have updated their missing person policies since 2016.

But it added"this case demonstrates the degree of vulnerability Indigenous peoples with mental health needs can face in Thunder Bay and the need for attention to be brought to missing persons cases of Indigenous peoples of all ages."

The investigative team found considerable issues with the initial police response, including the passing of 20 days before a media release was issuedand 30 days before a police ground search occurred.

The report presented a similar scenario to a staff sergeant with an Ontario Provincial Police emergency response team to review. That sergeant suggested OPPwould have been able to find the person more quickly, the report states.

The lack of resources and strategies to properly investigate and curb these occurrences have become a significant threat to public safety.- Investigative team report

The otheris a fatal drug overdose case in 2019. The report said that case is being raised,given the increasing number of drug-related sudden deaths in Thunder Bay and across the province, with Indigenous people at an increased risk in the city.

"The lack of resources and strategies to properly investigate and curb these occurrences have become a significant threat to public safety," the report added.

The case summary included in the report says that when the coroner attended the scene, they immediately indicated it would be a coroner's case and no foul play was suspected, and there "appeared to be no consideration by police or the coroner about seeking the source of the drugs and determining if Criminal Code charges, such as manslaughter or criminal negligence causing death, may be applicable after some investigation."

But the case review adds there was evidence a woman and two other "persons of interest" were present when the victim died.

A background check by the investigative team confirmed the suspect was associated with an earlier drug-related homicide and two other overdoses. Yetthe suspect wasn't interviewed until two months later, and a number of other leads were never followed up, according to the report.

Ontario's chief coroner, Dr. Dirk Huyer,told CBC News in an interview Tuesday thathis office was awaiting any direction or recommendationsby the provincial attorney general before taking action on the 16 sudden death cases.

Huyer previously confirmed to CBC News he would be ordering a new, independent systemic review of the Thunder Bay police death investigation process under the Coroner's Act. That review would take all the materials gathered during the last several years of the Broken Trust process to offer their observations of how the process was conducted, and identify recommendations to create a pathway forward.

The chief coroner would not say who was on the Indigenous-led advisory circle guiding that workor who was included on the writing team, but said theyincludepeople with a wide range of expertise, including policing, death investigations, human rightsand intergenerational trauma.

Their work began in February.