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The six-person jury involved in a coroner’s inquest into the deaths of four Indigenous women at the Whitehorse Emergency Shelter has classified all four deaths as “accidental.” Jurors also made numerous recommendations to prevent similar deaths.
The inquest, which began on April 8 at a hotel in downtown Whitehorse, is examining the circumstances of the deaths of Cassandra Warville, Myranda Aleisha Dawn Tizya-Charlie, Josephine Elizabeth Hager and Darla Skookum.
Jurors were given their instructions for deliberation by the presiding coroner, Michael Eglison, just after 9 a.m. on April 25. The jury deliberated the details of the inquest for roughly seven hours before returning with their verdict.
The jury found that Warville died on Jan. 18 or 19, 2022, between the hours of 11:30 p.m. and 3:25 a.m. The cause of her death was found to be complications of alcohol and fentanyl intoxication, with cocaine use as a contributing factor.
Tizya-Charlie was found to have died between 3:15 a.m. and 3:25 a.m. on Jan. 19, 2022, as a result of complications of combined drug and alcohol intoxication. Cocaine use was also listed as a contributing factor.
Hager’s death was deemed to have been because of combined morphine and alcohol toxicity, with fatty liver disease listed among the contributing factors. The jury listed her time of death as Feb. 1, 2023, at approximately 4:35 a.m. to 5 a.m.
Skookum was found to have died on April 16 or 17, 2023, between 9:45 p.m. and 6 a.m. as a result of acute alcohol toxicity. Several health issues, including cirrhosis of the liver, fatty liver disease and hepatitis C, were listed as contributing factors.
Surveillance footage captured inside the emergency shelter on the night of Skookum’s death was aired earlier in the inquest and showed her being put to bed on her stomach by shelter staff. In their decision, jurors also found that “being positioned on her stomach” was another contributing factor in her death.
Jurors in a coroner’s inquest can make recommendations on how to prevent similar deaths in the future. In this case, the jury made eight recommendations.
The first recommendation calls for a policy review of the Whitehorse Emergency Shelter by Connective, the shelter operator (along with the Council of Yukon First Nations), within six months. The review should include “interested Yukon First Nations shelter guests, shelter staff and people with lived experience in the review, development and implementation of policy procedures and guidelines.”
The jury also called for the review to ensure the creation of evidence-based best practices and data-driven policies, procedures, and guidelines, among numerous other requirements.
The jury’s second recommendation is for a training review that should be undertaken within six months.
This review should involve adopting a training plan that examines training needs “based on best practices” and addresses onboarding, orientation and professional development. The recommendation highlights several priority areas for training, including overdose response training.
The third recommendation calls for Connective to prioritize hiring Indigenous employees and people with “lived experience” to work at the Whitehorse Emergency Shelter.
The fourth recommendation calls for the Yukon government to review Connective’s compliance with the jury’s first three recommendations within six months.
The other recommendations call for independent reviews of future deaths at the shelter, the creation of a safe space for “LGBTQ2S+ and female-identifying” users of the shelter and improved communication at the facility.
Another recommendation urges leaders from the territorial government and Connective to meet with the families of Warville, Tizya-Charlie, Hager and Skookum to “hear their concerns arising from the inquest.” This meeting should happen within two months.
In his closing remarks, Eglison thanked the jury and other participants in the inquest for their time and efforts. He also addressed the families of the four deceased women.
“I would also like to express my sincere condolences to the communities and families of the deceased. I can’t imagine the pain and the anguish that that’s caused. And I’ve certainly been moved by the words that I’ve heard from the families, and bless you all,” Eglison said.
Over the inquest’s three weeks, jurors heard from a variety of witnesses, including family members of the deceased, RCMP officers, shelter staff, paramedics and several expert witnesses.
Surveillance footage captured inside the emergency shelter that showed the final hours of the four deceased women’s lives was also aired.
Inquests held by the Yukon Coroner’s Service are intended to serve three primary functions: determine the facts related to a death (or deaths), make recommendations — if appropriate and supported by evidence — to prevent future deaths in similar circumstances and assure the community that the death (or deaths) is not being overlooked or ignored.
Before sending the jury away to conduct their deliberations, Eglison told jurors that coroner’s inquests are not intended to assign blame or guilt and that jurors cannot make findings of legal responsibility “nor express any conclusions of law.”
Although inquests into more than one death are unusual, the chief coroner can call a single inquest into more than one death if the facts and circumstances of the deaths are “sufficiently similar” to the extent that a “common inquest is the most efficient and effective way of inquiring into the deaths,” according to the Yukon’s Coroners Act.
“It is rare to investigate more than one or two deaths or certainly a single incident at one time. To my knowledge, this may be the first time that we have called an inquest into more than one death that do not occur at the same time,” Heather Jones, the Yukon’s chief coroner, told the News via email at the start of the current inquest.
Rapid access counselling is available in the Yukon from Mental Wellness and Substance Use Services by calling 867-456-3838. Additional support includes the Suicide Crisis Helpline (call or text 988), Hope for Wellness (1-855-242-3310) and the 24-Hour Residential School Survivor Crisis Line (1-866-925-4419). The Selkirk First Nation, the Little Salmon/Carmacks First Nation and the Vuntut Gwitchin Government are offering counselling and support specifically for their citizens.
Contact Matthew Bossons at matthew.bossons@yukon-news.com