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Fraser Meekis stands by the grave site of his five year old son Brody Michael River who is buried in a cemetery in the Sandy Lake First Nation in Northern Ontario on May 5 2015. Last year Brody was taken to the nursing station in the community with what was thought to be a cold but he was sent home and to be given Tylenol. Fraser brought Brody back to the station several days later but his son eventually died from strep throat.Fred Lum/The Globe and Mail

First Nations leaders say coroners who are required to investigate unexpected deaths on remote Ontario reserves routinely ignore the law by failing to personally attend the scene – raising questions about whether the post-mortem analyses are adequate to recognize and address gaps in the northern health-care system.

As reported by The Globe and Mail on Wednesday, Brody Meekis died of strep throat in May, 2014, in Sandy Lake, 500 kilometres north of Thunder Bay. No coroner immediately arrived in the community to ask nurses at the local medical station how a curable illness could have taken the life of a healthy five-year-old boy.

Nor did an investigating coroner travel to Pikangikum, near the Manitoba border, five months before Brody's death to discern how an unnamed four-year-old girl could have succumbed to the same entirely treatable disease.

Julian Falconer, the lawyer for the Nishnawbe Aski Nation (NAN) which represents 49 First Nations communities including Sandy Lake, said the point of coroners' investigations is to protect the living by assessing what, if anything, went wrong.

If a coroner had travelled to Pikangikum after the death of the girl "at the time, on the scene, in that fashion …would Brody Meekis have died?" Mr. Falconer said. "Of course we will never know with any certainty what impact an investigating coroner might or might not have had in protecting Brody. We will never know. And that's not a satisfactory state of affairs."

Alvin Fiddler, the Grand Chief of NAN, has written to Dirk Huyer, the chief coroner for Ontario, to say investigating coroners must show up when children die on reserves.

Not only was there no medical authority to communicate in person with the families of Brody Meekis and the Pikangikum girl about the causes of their children's deaths, Mr. Fiddler wrote, "it remains a serious concern that the investigation that your office purportedly managed did not collect statements from the nurses involved."

In Brody's case, the boy was viewed after death by a member of the Sandy Lake police service who reported his observations to the coroner. Brody's body was then flown to Kenora for an autopsy.

Mr. Fiddler pointed to a 2008 report that followed a wide-ranging inquiry into pediatric forensic pathology in Ontario, in which Justice Stephen Goudge of the Ontario Court of Appeal said investigating coroners should not assume they can do their jobs from afar.

"Although it is recognized by everyone that investigating coroners may frequently be unable to attend the death scenes in a timely way because of weather, distances, and travelling logistics, it does not follow that their non-attendance should be presumed or effectively be treated as the norm," Justice Goudge wrote. "The death investigation is enhanced by their attendance in ways that are not always fully compensated for by surrogates, technological substitutes, or telephone conversations."

Michael Wilson, the regional supervising coroner for Northwestern Ontario, said the coroners in the region perform those duties on a part-time basis.

"Most of them are either emergency or family physicians, so it would be really unreasonable for me to expect them to take a day and neglect their living patients to go and investigate a death," Dr. Wilson said. "Where you have geographically a widely scattered population, it is just logistically and geographically not possible to get people to every scene at the time of the death."

Cheryl Mahyr, spokeswoman for Dr. Huyer, offered a similar explanation. "Our preference is to have coroners attend scenes but when that isn't possible, efforts are made to maintain close communication with investigative personnel at the scene," she said in an e-mail. The low volume of cases in the province's north does not justify hiring dedicated coroners, she said.

Still, "all Ontarians deserve high-quality death investigation services that are effective and sustainable, regardless where they live," Ms. Mahyr said. Dr. Huyer, she added, "is prepared to work with First Nations communities to explore ways to improve service delivery as this is a priority for him."

But Mr. Fiddler wants to know why a problem that has been recognized for many years has not yet been addressed.

"Our communities still experience regular failure by the investigating coroner to treat the deaths of their family members as matters worthy of the investigating coroner's personal attendance," Mr. Fiddler wrote in his letter to Dr. Huyer. "It is difficult for our communities not to perceive that the deaths of their children are somehow of less importance."