Retired Saskatoon police chief Clive Weighill said the staff of Saskatchewan’s coroner’s office is doing the best they can with what they have in his full review of the office.
“The situation is not a reflection of the people that work in there. It’s a reflection of the system that they’re working in,” Weighill said.
“The office is challenged with insufficient capacity. It’s unable to keep pace with the day to day pace that they have, never mind some of the additional things that have been asked of them.”
As a result of 120 interviews that included staff, stakeholder agencies and families from cases involving the coroner’s office, Weighill prepared 44 recommendations to improve the Office of the Chief Coroner.
READ MORE: Former Saskatoon police chief to lead Office of the Chief Coroner review
Weighill was tasked with this job at the end of November 2017. This followed a $5 million verdict against the office and chief forensic pathologist earlier that month. The province is appealing the court decision.
The jury found Dr. Shaun Ladham did not act in good faith during a professional review. The case also included allegations of racism, which Ladham denied.
READ MORE: Jury awards $5 million against Coroner’s office in lawsuit
While not explicitly part of the review’s mandate, Weighill did look for signs of bias against marginalized communities. He said while perceptions of racism in investigations exist, he did not find evidence.
“The concerns I’ve heard have been based on the way the coroner system is running. The same concerns are happening, doesn’t matter what race you’re from, the same concerns,” Weighill said.
Concerns include lengthy waits for toxicology reports. All specimens from non-homicide autopsies are sent to the Saskatchewan Disease Control Laboratory (SDCL). There, a lone PhD lab scientist analyzes about 528 samples every year.
The backlog in toxicology creates a ripple effect throughout death investigations.
“Because the toxicology is taking so long, by the time the police investigation gets done and the pathologist gets done you’re looking at a year to 14 months. And families are wondering what’s going on? Why’s it taking so long? It’s capacity issues,” Weighill said.
Because Saskatchewan does not have a forensic toxicologist, the lab scientist can only provide an analysis, but not an opinion on cause of death.
This is why Weighill recommends the office pay for training to elevate the scientist to a forensic toxicologist, and a second laboratory scientist be hired.
Recommendations in the toxicology field are among the most pressing for Weighill. Others include hiring a regional supervisor for the Regina area, a position that has been vacant since 2004, and creating an advocacy position for those dealing with the coroner’s office.
“I think that’s what will help some of the concerns about the coroner’s system not being fair or maybe discriminatory because they have to go up against that bureaucracy,” Weighill said. “I think if it’s a softer approach with people that you can deal with you don’t feel that way.”
Discretionary inquests also formed a portion of the recommendations. Weighill said a criteria needs to be established on whether or not an inquest of this type is needed, in addition to a forming a committee that weighs in on the process.
Government Response
Justice Minister and Attorney General Don Morgan said the government agrees with all of the recommendations, but implementation is a more complicated step.
“We knew going into the process we would have to spend significant additional resources to maintain confidence in the coroner’s office,” Morgan said.
In order to implement recommendations in a timely fashion, Morgan has been having discussions with the finance ministry to see what resources are available. The province remains committed to balancing the budget next year, so money is tight.
The province will examine their options when deciding how to implement ideas. This includes following Nova Scotia’s lead, contracting toxicology services to the United States. That province usually gets results in around five days.
“It’s not merely a matter of recruitment, they were talking about labs in Philadelphia. So I think those are the discussions we need to have with the Ministry of Health,” Morgan said.
Justice critic Nicole Sarauer is calling on immediate action to begin on these recommendations.
“It’s important for families to families to have answers and closure. It’s important for society to as a whole to know what’s happened in these deaths,” Sarauer said. “It’s also a work environment. As work environment it needs to be stable and healthy.”
Over the summer, Morgan will be discussing options with cabinet to determine what the next steps are in working to improve the office.
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