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Valerie Warmerdam, daughter of murder victim Nathalie Warmerdam, during the Borutski Inquest in Pembroke, Ont., on June 28.Sean Kilpatrick/The Canadian Press

The Ontario government should formally declare intimate partner violence an epidemic, says an inquest jury after three weeks of testimony into a rural triple femicide nearly seven years ago.

The call is the first of the jury’s 86 recommendations in response to the murders of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam by a mutual ex-partner on Sept. 22, 2015.

The bulk of the action items are directed at the provincial government, and include calls for bolstered and consistent funding for intimate partner violence, or IPV, resources; enhanced education in schools and continued training for law enforcement personnel; and the exploration of justice-system reforms.

They also include specific proposed changes to the criminal code and to the Coroner’s Act, to recognize femicide as a distinct crime and manner of death. They also call on stricter conditions for serial IPV offenders on bail or probation – but also expanded rehabilitative supports.

Pamela Cross, a lawyer who provided testimony at the inquest, said she was moved by their call to recognize this as an epidemic, and also highlighted the jury’s recommendation to explore adding “femicide” to the Criminal Code.

“When women are killed because they’re women, that’s different than first-degree murder, second-degree murder, manslaughter or general homicide,” Ms. Cross said.

Kirsten Mercer, counsel to advocacy group End Violence Against Women Renfrew County, agreed and stressed a similar recommendation to consider amending the Coroner’s Act to include femicide as a manner of death.

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“The jury has asked that we use the right words, that we adopt the language of femicide,” Ms. Mercer said. “Because in obscuring that … we hide the reality that is all around us.”

A woman is killed by a current or former intimate partner every six days in the country, according to Statistics Canada. Including attempted murders, that stat becomes one almost every other day.

The inquest jury had received a list of 72 proposed recommendations that had been jointly prepared by Prabhu Rajan, chief counsel to the Chief Coroner for Ontario; Ms. Mercer; and Ms. Warmerdam’s daughter, Valerie, who had legal standing in the inquest, allowing her to ask questions of witnesses.

The jury accepted all of them, and after deliberations added another 14 of its own.

The recommendations also include requiring an automatic review of firearm licenses when someone is charged with IPV; a 24/7 hotline for men who fear they might use violence; exploring changes to the Family Law Act to allow for court-ordered counselling; and exploring the use of electronic monitoring bracelets for offenders.

Attorney General Doug Downey’s office sent an e-mailed statement in which he thanked “the jury and all participants for taking part in this difficult inquest. The government will take the time to review and properly consider these important recommendations.”

During the testimony period, the jurors heard that intimate partner homicides are not only preventable but often predictable.

Ms. Warmerdam had been so afraid of Mr. Borutski that she slept with a panic button on her pillow and a shotgun under her bed. She had a safety plan with her kids for what to do if he showed up at their home.

He’d been convicted for domestic violence against her and other women, with a record going back four decades. Multiple assessments deemed him high risk and his police file was peppered with red flags. Yet he continued to manipulate people and systems, flouting court orders without consequence.

In addition to countless explicit threats by Mr. Borutski, the jury also heard of more subtle warning signs that went missed or ignored by those tasked with supervising him, including victim blaming, denial, alcohol abuse and access to weapons. A death review committee concluded that there had been at least 30 risk factors evident to friends, family, community members and criminal-justice professionals dealing with Mr. Borutski.

The inquest included testimony from case witnesses – including family of the victims, local police and probation officials – as well as experts in the anti-violence sphere, who contextualized the murders as part of a systemic crisis, and emphasized the increased dangers for women in rural communities.

As part of their recommendations, the jury also called for accountability measures, such as an implementation committee, to track whether their calls are accepted and applied. They also requested that the inquest panel return in a year’s time to assess progress.

“When we come back a year from now, we will be expecting real results, real delivery, and real change from the leadership in this province and this country,” Ms. Mercer said.

Valerie Warmerdam said after the inquest that she is prepared for further work ahead. She did not choose to participate in the inquest for any form of closure, she said, but rather to be part of the solution. She recalled the furor she felt when she discovered some of the very action items that might have been life-saving in her mother’s case, had been recommended at a previous inquest back in the 1990s – to no avail.

“I want change,” she said. “These recommendations are a good start, if they are actioned. That’s a big if.”

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