After decades of study on homicides resulting from domestic violence in Ontario, and after hundreds of recommendations to stop them have been filed, the people taking part in next week's inquest into the murders of three women around Renfrew County in 2015 remain optimistic that this time, the change they're looking for will come.
In addition to three previous coroner's inquests tied to intimate partner violence dating back to 1998, Ontario has a committee whose sole focus is to review domestic killings of women, men and children every year, and report back to the chief coroner's office with recommendations to prevent future deaths.
But data on the response to the committee's recommendations appear to be unavailable, even by request. And no changes recommended by either the committee or inquest juries are legally binding.
Survivors' advocates participating in this latest inquest say they could resign themselves to defeat, but won't.
"They've made the decision to participate not because they think it's a perfect solution or because they think it will magically result in change, but because they can't afford not to," said Kirsten Mercer, the Toronto-based lawyer and women's advocate who will represent End Violence Against Women Renfrew County at the inquest, which starts Monday.
The coalition of community organizations and stakeholders is one of three parties granted standing for the public examination of the murders of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam on Sept. 22, 2015, by Basil Borutski, who had known all three of them.
The other two are Valerie Warmerdam — Nathalie's daughter — and the Ontario government.
WATCH | Valerie Warmerdam speaks to reporters following Borutski's sentencing in 2017:
This inquest's focus is on intimate partner violence in a rural context, particularly the challenges posed by distance and isolation, spotty cell service, a lack of public transportation and law enforcement that's often far away. Rural culture is also more accepting of guns, and in small communities privacy is hard to come by and services for domestic violence victims aren't as plentiful or nearby as in cities.
The coalition has set up a team it hopes will help push change forward when the latest raft of recommendations comes through (recommendations aren't a guarantee of coroner's inquests but are likely).
Committee proposes change every year
Ontario's Domestic Violence Death Review Committee was the first in Canada when it was established in the early 2000s following recommendations from two big inquests into the 1996 murder of Arlene May and 2000 murder of Gillian Hadley, whose estranged partners killed them before killing themselves.
There has been a consistent failure by systems to respond as they should despite the amount of information that they already have. - Pamela Cross, lawyer and women's advocate
Since then, the committee has made more than 400 recommendations in annual reports stemming from reviews of more than 250 cases up to 2018, the last year its annual report was released. (Its 2019-2020 report is not yet finished, according to the chief coroner's office.)
The recommendations run the gamut: justices of the peace being made to review domestic homicide cases in which perpetrators had been released on bail; making firearm possession applicants include a medical waiver giving investigators access to mental health information; public service announcements warning people about the danger posed by actual or pending separation, when many domestic killings occur; and swift and certain enforcement action when offenders make excuses and fail to attend partner assault response programs.
'You can keep recommending change until hell freezes over, but if nobody actually makes the change happen, what's the point?' - Leighann Burns, family lawyer who works with domestic violence survivors
Many of the proposed changes are relevant in the case of Borutski, who flouted court orders to attend partner assault response programs for the one year, nine months and 12 days he wasn't in jail leading up to the murders.
He killed the three women while on bail for choking one of them, after an Ontario Court justice and assistant Crown prosecutor had told court on the record that Borutski had little to no regard for court orders and wasn't getting help.
No legal obligation to follow through
But the domestic death review committee's recommendations are not binding, nor are the recommendations made in coroner's inquests.
Committee work and inquests are intended to be "collaborative, fact-finding" processes, according to the chief coroner's office, and the office "cannot make findings of guilt or blame or imply responsibility on any person(s) or agency, organization, or other entity."
After inquests, the Office of the Chief Coroner hands recommendations off to relevant organizations for implementation. Recipients are asked to respond within six months to say whether recommendations were implemented or not, and if not, to state their rationale.
After Domestic Violence Death Review Committee recommendations, organizations are similarly asked to report back within six months.
No one is obligated to make change happen, or even to respond.
Review committee data in shadows
One recurrent feature of recent death review committee reports is this line, repeated over and over: "No new recommendations."
Put another way, "We've filed recommendations about this, and a year or years later, are seeing the same thing."
The chief coroner's office did not provide any examples of implemented death review committee recommendations, and did not answer questions about why that information is not available, despite a government website stating that responses to committee recommendations are available upon request.
As for why the office would not provide any statistics about the number of committee and inquest recommendations that are implemented, it said "tracking is complicated, as recommendations may be narrowly focused or very far-reaching, be directed to one organization or jointly to many, leading to a wide range of complexity.... Further, as respondents of recommendations are not compelled to respond, a number of responses are not received."
Implemented inquest recommendations to do with domestic violence include "Crimestoppers taking domestic violence-related calls; specialized courts; education for crown attorneys, police and judges; improved communication; additional crown attorneys and the creation of the death review committee," the office said.
'Doomed to fail'
Leighann Burns has been working with survivors of intimate partner violence in the Ottawa region for more than 30 years, most recently as a family lawyer, and participated in the 1998 Arlene May inquest.
"It was not the change that we had hoped would come," she said of that process. And nearly 25 years later, she's not holding her breath for much more.
"You can keep recommending change until hell freezes over, but if nobody actually makes the change happen, what's the point?" Burns said.
"... Unless you build in some mechanism to ensure accountability ... that you don't just keep making recommendations that go off into the ether and nobody does anything, all of it is doomed to fail. That's the missing piece that has been missing from all of it from the beginning. And it's not like it hasn't been asked for.
"It's the same reaction to the same problem over and over and over again."
(A September 1999 chief coroner's office report after the May inquest stated that of the 213 recommendations made, 156 had been/would be implemented, 13 had alternates implemented, 38 were under consideration, two weren't applicable and four responses couldn't be evaluated because they were too vague or otherwise undiscernible. It's unclear whether any further tracking took place after the 1999 report.)
This time around, the coalition of organizations working to help domestic violence survivors in and around Renfrew County hopes recommendations will stick.
Funded by grants from the Canadian Women's Foundation, End Violence Against Women Renfrew County was able to hire lawyer and women's advocate Pamela Cross to conduct a series of meetings with county residents earlier this spring and report to the inquest on their concerns and wishes.
Cross — who in 2018 resigned from Ontario's Provincial Roundtable on Violence Against Women alongside her co-chair for what they described as a lack of government response to their inquiries — will also attend the inquest, summarize the proceedings, analyze any recommendations and create strategies toward implementation.
"Violence against women, intimate partner violence, sexual violence in this country is rampant. It's only gotten worse over the last two and a half years. There has been a consistent failure by systems to respond as they should despite the amount of information that they already have," Cross said.
"We ... can and must hold the decision-makers accountable so that they can't keep not implementing these recommendations."
'A lot of ... changes need to happen within the justice and policing system. Is there the wherewithal to make that happen? I don't know.'
- JoAnne Brooks, co-ordinator of End Violence Against Women Renfrew County
JoAnne Brooks, who leads End Violence Against Women Renfrew County, is pleased to have Cross and Mercer working for the coalition, but doesn't know what the future holds.
"If there is not the wherewithal to enforce those recommendations, it feels that things are stalled," said Brooks, who is soon to retire as director of the Women's Sexual Assault Centre of Renfrew County.
"My hope, really, is that even if one thing can change, that will be for the betterment of women experiencing intimate partner violence.... But who knows if that will happen. A lot of ... changes need to happen within the justice and policing system. Is there the wherewithal to make that happen? I don't know."
WATCH | JoAnne Brooks in 2017 discusses the effect the murders had on the community:
A complicated issue
Part of the problem is that domestic violence is a complex issue, one whose fixing requires deep analysis of not only our institutions, but ourselves: how children are raised to navigate relationships, getting them help if they need it, and getting parents the assistance they need to better help their kids.
"If there was any one thing that could have changed the course of events in Renfrew County for these three women, it probably involved this perpetrator getting a whole different kind of support decades and decades and decades ago," said Mercer, the lawyer representing End Violence Against Women Renfrew County at the inquest.
"I don't know that there's any one thing that any justice system, partner or community agency, or any of his exes could have done to save Carol, Anastasia and Nathalie. But we do know that these problems were decades in the making, and so real solutions have to kind of be farther upstream for them to be impactful."
Sentenced to die in prison
In 2017, Borutski was sentenced to life in prison with no chance of parole for 70 years for the murders, long after he is expected to die. By then he would be 127 years old.
But the Supreme Court of Canada recently declared unconstitutional the 2011 Criminal Code provision that allowed judges to impose consecutive periods of parole ineligibility for multiple murderers, instead of concurrent periods.
The law had been applied in some of the country's most notorious cases, including Borutski's.
The May 27 ruling means any person in Canada who received consecutive periods of parole ineligibility totalling 50 years or more can now apply to be allowed to seek parole after 25 years.
It's not clear whether Borutski — who refused to participate in his trial, is now 64 and remains in federal custody — will apply.