WARNING: This story discusses mental distress and suicide.
Calls to improve mental health care resources in remote First Nations in northwestern Ontario continue to be at the forefront of the inquest into the death of Moses Amik Beaver.
The 56-year-old Woodlands artist from Nibinamik, an Oji-Cree First Nation, died in Thunder Bay, Ont. in February 2017 after he was found unresponsive in his cell in the Thunder Bay District Jail.
It remains unclear exactly how Beaver died; the jury is expected to hear more on Beaver’s official cause of death in the coming weeks.
More than six years later, an inquest into his death – which is mandatory under the Ontario Coroner’s Act when a person dies in custody – has started putting together the pieces of how and why Beaver came to his death.
The jury consists of one white man, three white women and one Indigenous woman.
Beaver is one of 13 people who have died in the Thunder Bay District Jail since 2002. His inquest comes on the heels of an inquest completed in November into the deaths of Don Mamakwa of Kasabonika Lake and Roland McKay of Kitchenuhmaykoosib Inninuwug.
Who was Moses Beaver?
The jury first heard from Melanie Huddart-Amik, the mother of Beaver’s youngest son, who explained the story behind his name Amik. It was his great grandfather’s surname, before missionaries anglicized it to Beaver.
While Beaver has been described as an artist with mental health issues, Huddart-Amik said it is important for the jury to know he was much more than that.
Beaver was the family patriarch, a beloved father of four “with land-based skills second to none.” He could survive alone in the wilderness with a single tool. He made sure everyone in the First Nation had working smoke detectors. He taught Huddart-Amik how to swaddle their son in a tikinagan, or cradleboard, and treat diaper rash with bear grease, she told the jury.
He was also someone who experienced “almost insurmountable loss in his lifetime,” she said, contending with several deaths in the family as well as intergenerational trauma.
“Moses in many ways was larger than life itself but he was a human being who, like anyone else, struggled and made mistakes but who strove to be a better person,” Huddart-Amik said. “He forged on in a quest to improve, to learn more and become a solid role model that his sons and community could be proud of.”
How Beaver ended up in the Thunder Bay District Jail
Jurors heard detailed accounts of what transpired between Jan. 14 and 18, 2017 in Nibinamik, when Beaver was experiencing a mental health crisis.
The initial plan was for Beaver to get psychiatric care at the Thunder Bay Regional Health Sciences Centre, registered nurse Paul Hesche told the jury. Hesche was the charge nurse at Nibinamik’s nursing station in 2017 but has since retired.
After the Thunder Bay Regional Health Sciences Centre said it could not receive Beaver, he was to be sent to Sioux Lookout Meno Ya Win Health Centre, which is not a schedule 1 psychiatric facility. The hope was that after receiving medical clearance in Sioux Lookout, Beaver could be sent for treatment in Thunder Bay, Hesche said.
But there were barriers to getting Beaver transported to Sioux Lookout, including a lack of available security to assist in his medical evacuation, winter weather delaying the Ornge air ambulance service, and a higher-priority call for Ornge in another First Nation that bumped Beaver down the triage, the jury heard.
While Beaver awaited transportation, community members acted as security for him due to a lack of police officers. By the time a member of the Nishnawbe Aski Police Service came, Beaver had been in distress for days.
He was ultimately charged with two counts of assault and one count of breaching a court order, and was placed in custody before being brought to the Thunder Bay District Jail on a Nishnawbe Aski Police Service plane, the jury heard.
During that five-day period, Beaver attempted suicide twice, first at a residence and then in a Nishnawbe Aski Police Service cell, witnesses told the jury.
Recommendations for more efficient, effective care
There has been a clear consensus from all witnesses that mental health care must be improved in remote First Nations.
Safe rooms, also called secure rooms, came up numerous times as a potential solution. These spaces provide a secure environment for mental health patients where they cannot harm themselves or others and can be monitored by medical professionals.
Nibinamik’s nursing station is staffed by two nurses. Doctors, including witness Dr. Megan Bollinger of Sioux Lookout, travel to the First Nation to provide care but are not always available.
Hesche and Bollinger said having a safe room in Nibinamik sounds great in principle, but would require more staff, security and infrastructure. Staff would also require training in mental health awareness and de-escalation.
“It’s very easy for someone to say outside of the northern community, we should do this, we should do that,” Hesche said. “Our reality is different than Sioux Lookout and Thunder Bay and Lake of the Woods, and that needs to be taken into consideration.”
Hesche called for continued investments to improve phone and internet technology in Nibinamik, and for a greater security/police presence.
Members of the Nishnawbe Aski Police Service echoed the latter sentiment in requesting more resources to better deliver services. As Det. Insp. Brad Duce said of Beaver’s case, “there was just no mode of keeping him safe” before he was placed into custody.
Calls for action must prioritize patient first, says doctor
One of the biggest challenges Dr. Bollinger has seen while working in remote First Nations is strained communications between service providers. Often, patients are caught in the crosshairs of two systems, she said, neither of which will take responsibility for a situation. In the end, that only burdens the patient and their community further.
Bollinger’s recommendations included:
- Improve communications between First Nations leaders and families, health care providers, air ambulance personnel, police, and correctional services staff
- Make telehealth and remote psychiatric evaluations more accessible
- Make medical records more accessible to health care providers
- Ensure psychiatric care that is culturally-sensitive and trauma-informed
- Facilitate more direct medical evacuations to psychiatric facilities
More resources needed for medical evacuations, jury hears
According to Dr. Bruce Sawadsky, chief medical officer for Ornge, a pilot project began last April with a team dedicated to mental health patient transfers only. The team is on call from 9 a.m. until 9 p.m. every day.
About 300 mental health patients have been transferred over the past year, he told the jury.
To continue, the pilot project must receive permanent, secure funding. Ideally, Sawadsky said there would be a second aircraft to provide 24-hour coverage for mental health transfers. This would be a suitable recommendation for the jury to consider, he said.
The geography of northern Ontario and its unpredictable weather are obvious barriers to transporting patients, but Bollinger said people must keep in mind the systemic reasons behind why First Nations are so detached from centralized resources.
“There’s a reason why there are all of these geographical challenges,” Bollinger said. “There’s a colonial history to these issues, and so we are turning geography into a proxy for race and patients are not getting the services they deserve.”
During week two of the inquest, the jury is expected to hear from witnesses who observed Beaver at the Thunder Bay District Jail and who provided him care there.
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