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The sudden deaths of 15 Indigenous people in Thunder Bay require further investigation by police or the coroner’s office, including that of a two-month-old baby with cocaine in its system, investigators in Ontario say in a report that follows two investigations that found racism in the local force.

A secondary report that will not be made public recommends an external review of 25 unsolved cases of missing and murdered Indigenous women and girls at the Thunder Bay Police Service’s criminal investigation branch.

The main report was delivered last week to the Office of the Independent Police Review Director (OIPRD), the police board and Ontario’s Ministry of the Attorney-General. It has not yet been made public. It contains case summaries and comprehensive accounts of nine sudden deaths of Indigenous people that were reinvestigated, and cites shortcomings in police work, and a lack of documentation and coroner involvement.

The recommendation for a review of the cases of missing women and girls is part of a confidential report investigators produced that is not in the final report to the OIPRD.

Both reports were obtained by The Globe and Mail.

The local police force and police board had already been investigated twice, after an inquest into the deaths of seven First Nations high-school students ended in 2016. Gerry McNeilly of the OIPRD found in a report called Broken Trust that the force was guilty of systemic racism. It said Indigenous people were both over- and under-policed.

The second investigation, led by former senator Murray Sinclair, dissolved the board, also accusing it of racism and of failing to police the force.

Attorney-General spokesperson Brian Gray confirmed in an e-mail the ministry received the new, 42-page report, and a request from the committee that oversaw the work to refer 16 deaths for reinvestigation, including one of a non-Indigenous person.

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Mr. Gray said the ministry will determine the next steps, including notification of families “at the appropriate time and in consultation with the police service and victim services.”

The report – which will be released once all families receive copies – addresses four of the 2018 Broken Trust report’s recommendations.

The committee included retired justice Stephen Goudge, Ontario Chief Coroner Dirk Huyer, Thunder Bay Police Chief Sylvie Hauth, chief provincial forensic pathologist Michael Pollanen and First Nations elder Helen Cromarty. The group also included Irene Linklater, a representative of Nishnawbe Aski Nation, a political organization for about 49 mostly remote First Nations in the region.

A team of investigators led by retired Ontario Provincial Police superintendent Ken Leppert was tasked with reinvestigating the nine sudden deaths, identifying any additional cases that should be looked at again, and determining if the death in 2015 of Stacy DeBungee needed to be reinvestigated.

Mr. Huyer announced last June that the Ministry of the Attorney-General had asked the OPP to take on Mr. DeBungee’s case after initial work from the Broken Trust investigators.

Mr. DeBungee’s death spurred the Broken Trust probe, after his family and the community of Rainy River First Nation brought concerns to the OIPRD that police prematurely determined it was an accident because he was Indigenous and intoxicated. His body was found in a city river.

In the confidential report to the committee, the Broken Trust investigators said they reviewed 229 cases of concern from Thunder Bay Police Service and Ontario chief coroner’s records between 2003 and 2017, identifying 14 sudden deaths for further police investigation and two cases for a coroner’s review as a matter of public safety relating to missing persons and toxic drug deaths. All but one of the 16 people who died were Indigenous, 10 were women, and with the exception of the two-month-old baby, all were between the ages of 22 and 61.

Investigators reported that the baby’s cause and manner of death was undetermined, and if evidence had been collected properly, should have been investigated as possible criminal negligence causing death. The baby was found unresponsive in an apartment, pronounced dead at hospital, and police at the time were aware of previous abuse allegations against the parents, and another small child in the home, Broken Trust investigators said.

Investigators also recommended an external audit of the police service’s records management system, citing a “high volume of inconsistent classifications of sudden-death investigations, inconsistent records management, poor documentation of records and concerning cases that may require additional review.”

Comprehensive reports on each of the nine cases reinvestigated outlined the original Thunder Bay Police Service findings, and the process of the reinvestigations, including the independent review of records and evidence by members of the Broken Trust investigative resource committee that comprised Indigenous pathologists and coroners. Some witness names and other details were redacted from copies shared with families and their representatives.

Four of the nine reinvestigated cases were of youth whose deaths were examined in a 2015 coroner’s inquest into the cases of seven First Nations students attending high school in Thunder Bay when they died between 2000-2011. Their families and communities at the time voiced concerns that police had not investigated cases thoroughly because the people who died were Indigenous, such as the disappearance of 15-year-old Jethro Anderson, initially brushed off as a youth who was just out partying. Police found his body in the Kaministiquia River and concluded he drowned. The 2015 inquest jury also concluded he died by drowning, but could not determine how his death came about.

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Broken Trust investigators found fault with the way the cases were investigated, but concluded no changes were needed in the causes and manner of death for Mr. Anderson and the other three students from the inquest, Curran Strang, Kyle Morriseau and Jordan Wabasse.

Findings in only one of the nine cases resulted in a change of cause and manner of death.

Caitlyn Kasper, a lawyer for Mr. Anderson’s family and two others, said there’s been little transparency, follow-through or communication from the committee to the families about what will be made public in the final report. She said initially the final report was to include their feedback about the process, which they’ve outlined in 18 pages detailing what she called “repeated failures to provide adequate and effective communication and police services to the communities.”

Ms. Kasper is with Aboriginal Legal Services in Toronto.

She said the families received the investigative reports for Mr. Anderson, Mr. Morriseau and Mr. Wabasse from the committee in December, months after it met with them to discuss the findings. At that time, they were left with little information and nothing on paper. Ms. Kasper said when they finally received the reports, each about 30 pages, they were mostly redacted and “overwhelmingly, did not shed any new light on anything.”

She said if the committee knew that’s what the outcome would be, the families should have been told sooner.

Ms. Kasper said Broken Trust was supposed to restore confidence and build relationships between Thunder Bay police and Indigenous communities and families.

“That is certainly not what we have seen at all,” she said.

She added that the continued systemic injustices against Indigenous people are frustrating, given the number of interventions over the past five years.

Mr. Huyer has said the committee experienced significant delays, including travel to the families’ communities for interviews, because of the pandemic.

A separate report done independently from the committee will make recommendations based on the nine reinvestigations, lessons learned and input from families and Broken Trust team members.

“Evidence of systemic racism was recognized during the reinvestigation process as well as restriction of information and failure to equally share information with all investigative members, including the [committee],” Justice Goudge said in the report to the OIPRD.

He said the authors of the report faced “a challenging environment … to conduct their work in a meaningful, culturally safe manner.”

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