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A jury has delivered its recommendations in a coroner’s inquest that examined how systemic racism affected the treatment of two Indigenous men who died in the custody of the Thunder Bay Police Service.

After four-weeks of hearing from witnesses and examining other evidence, the jury in Thunder Bay found that Roland McKay, a 50-year-old man from Kitchenuhmaykoosib Inninuwug, died from hypertensive heart disease and that his death was from natural causes.

In the case of 44-year-old Donald Mamakwa from Kasabonika Lake First Nation, the jury concluded the circumstances of his death were undetermined. Mr. Mamakwa’s family had been pushing for a homicide ruling but was satisfied that it wasn’t ruled an accident, said Asha James, the lawyer who represented both families in the inquest.

“It was clear to the family that the officers should have – not just the officers but the paramedics as well – should have at least known that there was a potential of death without him getting the proper medical intervention,” Ms. James said in an interview. One of the recommendations to the police force and Ontario’s Solicitor General calls for police college and service training in medical issues that can mimic intoxication.

Mr. Mamakwa died on Aug. 3, 2014, after being found unresponsive in a Thunder Bay police station cell.

Mr. McKay died on July 20, 2017, also after he was found unresponsive in a cell.

Both men had been arrested for public intoxication and neither was properly medically assessed or at all, according to testimony at the inquest. Video evidence played during the inquest show how Mr. Mamakwa was having difficulty breathing hours before he died, amid alleged mistreatment from officers and jailers who processed him. An emergency-room doctor testified that there was a 97-per-cent chance Mr. Mamakwa would have survived if he had received appropriate medical treatment.

The men were also deemed too intoxicated by the police and were not given the opportunity to contact lawyers when arrested.

Mr. Mamakwa and Mr. McKay had been in the city for medical-related reasons at the times of their deaths. Thunder Bay has long served as a regional hub for surrounding rural and remote communities, with many people coming from First Nations for medical, education, social and personal reasons.

The jury heard evidence from members of both men’s families who travelled hundreds of kilometres to attend. They also heard from the front-line officers and paramedics who responded and attended to the men prior to their deaths, as well as medical experts, racism experts, the acting chief for Thunder Bay Police, the police board administrator and secretary, and local social services.

The recommendations in the joint inquest are the latest in a mounting pile of evidence related to years of previous inquests, investigations and reports focused on how the embattled Thunder Bay force polices and interacts with Indigenous people.

Ms. James said that, with the amount of scrutiny of the police service and its board, the timing of this inquest and its recommendations are crucial. She said calls from the community to disband the force will persist if this latest report gets shelved.

“If they can’t meet some of these really simple requirements, it only goes to show that they just do not have the ability to provide the policing services to the full community of Thunder Bay,” she said. Ms. James added that if the police force and board are unable to follow up on the jury’s recommendations, she expects there will be more calls saying that the force cannot continue in its current form.

In its report the jury said its recommendations are based on principles of trauma-informed approaches and practices, as well as the inclusion of a diverse group of Indigenous communities and agencies reflecting the cultural and traditional needs of Indigenous people in the city.

Some of the recommendations are directed at the province’s ministries of children, community and social services, and health, and the local Thunder Bay Regional Health Sciences Centre to develop models for sobering centres and increase the number of detox beds and treatment facilities in the city.

Citing a lack of appropriate training, cultural competency and resources by the Thunder Bay Police to provide appropriate services to individuals suffering from alcoholism and chronic housing insecurity, the jury recommended the continued use of local programs such as the Street Outreach Service, which was recently cut from the operations of Shelter House, a local service for the precariously housed.

Like recommendations made in previous reports, there is a call for mandatory training for all first responders related to the impact of systemic and structural racism. Ms. James said the families were pleased with certain elements of the recommendations, including that the success of training cannot be determined by the police and paramedics themselves.

“It’s for the community to tell those agencies whether or not their training is sufficient and to ensure that it’s ongoing, like throughout the life of your career,” she said.

The jury recommended the Thunder Bay Police board’s governance committee oversee the implementation of and timeline for the recommendations and make them public to ensure accountability.

Among the recommendations was that the Ministry of Health adjust the funding formula for the Thunder Bay Regional Health Sciences Centre to reflect the population of Thunder Bay and surrounding areas who use the city as a hub for medical services.

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