New Whitehorse shelter operator removed crucial procedures, inquest hears

The non-profit organization that took over operations at the Whitehorse emergency shelter in 2022 discontinued some procedures at the facility, including an overdose response procedure, a coroner's inquest heard this week.

Testimony during this third and final week of the inquest focused on some of the changes made at the facility after Connective, the non-profit, took over operations from the Yukon government.

"We do not have clear guidelines ... we have a lot of grey (areas) in the program," Gigi McKee, the regional director for Connective, said at the inquest.

One of those changes saw shelter staff no longer doing regular bathroom checks. Two months after that change, a shelter guest was found dead in a bathroom of a suspected overdose, the inquest heard this week. Lawyers said nobody checked on that person for 45 minutes.

The procedure requiring regular bathroom checks was one the territorial government had adopted earlier when it was still operating the shelter. It was enacted following the deaths of two women in a shower room at the facility in early 2022.

Those two deceased women — Myranda Tizya-Charlie and Cassandra Warville — are the focus of the coroner's inquest, along with two other Indigenous women who also died at the shelter early last year: Josephine Elizabeth Hager and Darla Skookum.

The inquest's third week focused on some of the policies and procedures at the shelter, both before and after Connective took over operations in October 2022. The jury heard from some Connective managers and directors, as well as officials from the Yukon government.

The inquest heard that the deaths of the four people were reported at the shelter since Connective took over.

It also heard that, along with the policy on bathroom checks, the organization had scrapped another procedure, in place under the Yukon government, requiring staff to call emergency services or refer clients elsewhere if they weren't able to walk on their own because they were too intoxicated.

That echoed testimony from some shelter staff who said there was a lack of guidance under Connective about when to call for emergency services for a guest, and that it became routine to put intoxicated guests into a wheelchair and then into a bed instead of calling for help.

Connective director Chris Kinch testified that nothing had been done to provide more training for staff.

Meanwhile, he said the policy requiring that shelter guests be able to walk on their own wasn't always feasible. He also said the goal of the shelter was to be as accessible as possible. Kinch said Connective is moving away from using the term "low-barrier" when speaking about the shelter, and is rather using "accessible."

Kinch could not say what it would take for someone to be banned from the shelter. That was in response to questions about events before Hager's death.

The inquest heard that Hager had been sexually assaulted at the shelter by another guest and experienced an overdose not long before her death, and that that did not lead to any changes in how the shelter operated. Kinch, however, testified that a safety plan to monitor her with extra care had been drafted, but it had never been sent nor communicated among staff.

Kinch was unable to provide a clear answer on whether sexual assault would be considered enough to ban a guest from the shelter.

The inquest also heard that Connective had drafted policy to perform bed checks, but that policy was dropped because it was deemed "inappropriate" and disruptive of people's sleep.

Culturally appropriate space 

The three weeks of testimony have been wrenching for many of the friends and family of the four women who have been the focus of the inquest. Some of those friends and family members offered testimony about their loved ones, and the effect their deaths have had on them.

The third week also focused on whether the shelter was culturally appropriate to serve Indigenous guests.

The inquest heard from management that all staff received Yukon First Nations 101, a course available online through the Yukon University.

But most staff testified that wasn't enough and said they would benefit from more.

One of the last people to testify at the inquest was Zoë Dodd, who grew up in Yukon and is now an expert on harm reduction and shelter policies in Canada.

Dodd testified about some of the best practices developed at other emergency shelters, and she stressed the importance of including shelter clients when drafting policies for how those facilities operate. She spoke about the importance of having clear, defined rules and policy for both the staff and also the guests to follow. If not, she said, "you create an environment that is not healthy."

Shelters, she said, need to be welcoming for people who use them. That could include making the space culturally appropriate with Indigenous art, healing circles to grieve and posters promoting sexual health or naloxone.

Dodd also spoke about substance use at shelters, saying it will happen regardless of what policies or rules may be in place. She stressed that shelters must therefore focus on ensuring that people are safe, if and when they do use substances.

Part of that involves building strong relationships between guests and staff, understanding the people involved, where they come from, and what kind of trauma they may have experienced in their lives, she said. For women, trauma is often associated with sexualized violence — and it's important for shelter staff to recognize and acknowledge that, Dodd said.

"People need to feel that their lives matter," Dodd said.

"Grief and loss support is key."

Jury deliberates

Testimony at the inquest wrapped up on Wednesday and the jury began its deliberations on Thursday.

Deliberations lasted most of the day, with the jury returning shortly before 6 p.m.

Presiding coroner Michael Egilson gave a brief summary of some of the testimony heard over the last few weeks, before the inquest paused for jury deliberations. He reiterated that shelter staff testified they never received training on alcohol intoxication or procedures for putting intoxicated guests to bed. He also referred to some of the video evidence shown during the inquest.

The jury was asked to determine the time, cause and contributing factors surrounding the deaths of the four women.

However, the jury was not to determine fault or lay blame for any of the deaths. Nor is the jury required to issue recommendations, but if it does, those recommendations must be aimed at preventing similar deaths in the future.