An inquest jury that spent four weeks examining the cases of two Oji-Cree men reached its verdict in Thunder Bay, Ont., on Friday, ruling the 2014 death of Don Mamakwa had an "undetermined" cause and his uncle Roland McKay died in 2017 due to natural causes.
The jurors also released 35 recommendations, years after the two men were arrested and died after they were found without vital signs in police cells.
Mamakwa, 44, of Kasabonika Lake and McKay, 50, of Kitchenuhmaykoosib Inninuwug were found without vital signs in police cells after they were arrested for public intoxication.
Mamakwa's family had been looking for his death to be classified as a homicide, a decision that does not carry criminal liability.
The 35 recommendations, created with the goal of preventing future such deaths, are aimed at various agencies, including: paramedics, Thunder Bay police and its oversight board, and the Ontario government.
After the verdict was delivered, Mamakwa's family said they were happy with the inquest, and they hope the recommendations will help to save lives.
The all-white jury of four citizens, who began deliberating Friday, was tasked with answering key questions about the men's deaths — their names, place and time, cause and manner of death — as well as issuing recommendations designed to prevent future, similar deaths.
While the parties at the inquest largely agreed on the key questions and important recommendations, there was a divide on a few key issues, namely the manner of death for Mamakwa — whether it was homicide, natural or undetermined after presiding coroner David Cameron ruled earlier Friday that accident and suicide should not be considered.
2 men 'in our hearts and mind': jurors
Before delivering their verdict, a member of the jury read a statement aloud to the families to express their condolences.
"These past four weeks have been very difficult for everyone involved here. Your presence here every day reminds us Don and Roland were fathers, sons, siblings, and much more. But mostly, that they mattered," the statement said.
"We hope this brings you peace and closure, knowing the decisions made here were to the best of our abilities, with Don and Roland in our hearts and minds."
Before the jury delivered its findings, Mamakwa's sister, Rachel Mamakwa, said: "I think everybody [in our family] wants it to be homicide, and I hope it comes out that way. We want people to know that they are responsible for his death. He was neglected, and I don't want to see that ever again."
Over the four weeks, the jury heard evidence that Mamakwa's requests to go to the hospital were refused, his medical issues minimized, and ultimately, he was left unattended in the police cell for upwards of five hours.
The jury ruled Mamakwa died in the cell at 12:03 a.m. on Aug. 3, 2014, but his body was not found for hours later.
Mamakwa died of ketoacidosis, a serious complication of Type 2 diabetes, alcohol use disorder and sepsis (when the body's response to an infection damages its own tissues).
An emergency-room physician Dr. Alim Pardhan testified there was a 97 per cent chance Mamakwa would have survived the night if he was brought to the hospital instead of a police cell.
Earlier in the day, presiding coroner Cameron issued directions to the jury, saying the classification of "undetermined" would be appropriate if, after full investigation, there was not sufficient evidence for the death to fall under any one classification, or if there was equal, competing evidence for multiple death classifications.
The jury's 35 recommendations were issued to a range of parties, including Superior North EMS, Thunder Bay Police Services, the police oversight board, and Ontario's Ministry of Health.
Many of the recommendations are not a surprise, having come up a number of times during the inquest. Those include:
Developing a task force to create a safe sobering centre in Thunder Bay.
More training and co-ordination between police and paramedics at the scene of 911 calls.
Additional supports for people living with alcohol use disorder and other addictions, like expanded beds at the Balmoral Withdrawal Management Centre and at Shelter House's managed alcohol program.
Ontario's Ministry of Health adjust its funding formulas for health services to reflect the reality that Thunder Bay is a regional hub for services.
Each of the organizations issued the recommendations will have six months to implement them, and report back to Ontario's chief coroner. Their responses will be made public.
And many will be looking to see if and when those recommendations are implemented.
Some of the testimony
Alvin Fiddler, former grand chief of the Nishnawbe Aski Nation representing 49 First Nations in Treaty 9 and 5 in northern Ontario, testified during the last week of the inquest.
He pointed out there are still dozens of outstanding recommendations to address anti-Indigenous racism and prevent premature deaths of Indigenous people in Thunder Bay. Those recommendations have been made to a wide range of governments and agencies in the city through previous reports, inquests and inquiries.
"As I sit here today in 2022, it's like we've regressed so much. We are not even close to meeting those recommendations that have been made in previous reports," Fiddler said during his testimony.
The families and communities affected by Mamakwa's and McKay's deaths should be involved in conversations, they need to be heard, and they need to have confidence the recommendations will be implemented, he added.