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Pam Freeman pays tribute to her grandson, Devon Freeman, at Bayview Cemetery in Burlington, Ont., on Dec. 16, 2019.Tijana Martin/The Globe and Mail

A long-awaited coroner’s inquest into the death of a First Nations teenager began on Monday at the community centre of the Chippewas of Georgina Island on Lake Simcoe with the testimony of the boy’s grandmother, as well as child welfare experts Cindy Blackstock and Barbara Fallon.

Devon Freeman went missing from a Hamilton-area group home in the fall of 2017. His body was located nearly seven months later – about 35 metres away from the group home’s back door – by another resident.

His death was an apparent suicide.

On Monday, Devon’s grandmother, Pamela Freeman, shared about Devon’s curious and caring nature – whether studying world maps, learning about the solar system, recognizing cars’ makes and models, skateboarding and scootering, or shielding her eyes if a snake popped up on TV, as he knew that she was afraid of them.

“Your story does not end here. Love does not end here,” Ms. Freeman told those gathered for the inquest, her voice breaking. “Let’s talk about mental health and suicide, so our kids know we can help them navigate the tough years. I only had you for 16 years, but I am grateful for each one. You taught me a lot.”

The inquest has been years in the making – and was never guaranteed. While inquests are mandated in Ontario when a person dies in custody or on the job at certain sites, for instance, there is no such requirement when a child dies in care. The discretionary inquest for Devon was announced in 2020, after a request from Devon’s family and community. Nearly 30 witnesses will participate, some of whom were directly involved in Devon’s care, while others will address systemic issues that First Nations children face in the child welfare system – a system in which they are vastly overrepresented.

As of the 2021 census, Indigenous children made up nearly 54 per cent of all youth in foster care, according to Statistics Canada.

“This is an opportunity to create better outcomes for all children,” Shannon Crate, band representative for Georgina Island, said in a statement. “We want this inquest to be different – we want more than recommendations. We want meaningful change.”

When Devon went missing, he was a Crown ward and in the care of the Hamilton Children’s Aid Society. The Chippewas of Georgina Island never knew he was missing and was not advised when his body was found, according to a statement by lawyers for Ms. Freeman and the First Nation.

Devon entered foster care for the first time when he was two and a half, before Ms. Freeman assumed child care responsibilities when he was four. When Devon was six, his mother died, and in his teenage years, his mental health worsened, and he spoke to his grandmother about suicide, The Globe reported previously.

Ms. Freeman sought support for Devon, but eventually – believing she could no longer safely care for him – she arranged for him to be accepted at Jeb’s Place, a residential treatment service for teenage boys. After Devon reached the maximum time he could spend there, he was moved to a group home near Hamilton operated by the Lynwood Charlton Centre.

Devon attempted suicide in May, 2017, months before he died. While he disclosed this to a Lynwood staff member, the group home did not inform Ms. Freeman, nor his community, lawyers for Ms. Freeman and the Chippewas of Georgina Island said in a 2019 submission requesting the inquest.

A public hearing conducted before a jury of community members, an inquest is not meant to determine fault, but to examine the circumstances of a person’s death and make recommendations to prevent future deaths.

Prof. Blackstock, executive director of the First Nations Child and Family Caring Society who teaches at McGill University’s School of Social Work, told the inquest about the removal of children from their families and communities under colonialism – throughout generations.

“Child welfare is a symptom of the unattenuated, multigenerational trauma that continues – that was emboldened by residential schools, but continued on with the Sixties Scoop,” she said.

Prof. Blackstock focused on the importance of culture and cultural practices, saying, “Devon’s connection to his family – his loving family – but also to his nation was fundamental to his well-being. The absence of culture would get in the way of him being able to understand who he was, what the special gifts are that were handed down to him, and what his place would be in the world going forward.”

In the context of ongoing colonialism, she emphasized the need for what’s known as substantive equality.

“[Devon’s] loving mom getting the support she needed, when she needed it, and a loving grandmother being supported in her care of her family – had those things been in place, then I don’t think we would be unfolding this tragedy,” she said.

The inquest will continue until Oct. 21, with all the remainder of the proceedings taking place in Hamilton.

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