The Newfoundland and Labrador government and RCMP won't speak about what measures, if any, they will take to address the concerns of a judge who described a recent occupational health and safety investigation into a fatal accident as "completely inadequate."

A Trepassey man died two years ago, after he fell through a skylight while working on the roof of a building in the town. The police report said no harness was in use at the time of the accident.

His employer, Southern Construction (1981) Ltd. was charged with four occupational health and safety violations.

In September, Judge James Walsh dismissed the charges.

While the judge noted that the company was "safety conscious" and had a safety plan in place, he also took aim at the investigation by the Mounties and provincial occupational health and safety officials.

Service NL Minister Sherry Gambin-Walsh declined interview requests, noting that the matter is under review.

The RCMP did not respond to repeated messages from CBC News.

Meanwhile, experts say work needs to be done nationally to educate investigators, and labour groups are lobbying for action to ensure that similar mistakes don't happen in the future.

'Rough estimates and speculation'

CJ Curtis was just 20 when he died, in June 2015.

"In my opinion, this matter was very poorly investigated," Judge James Walsh told the court in dismissing charges against Curtis's employer, Southern Construction.

"There is no evidence before me that the accident scene was secured for investigative purposes immediately after the incident. The scene needed to be preserved."

Walsh added that neither the RCMP nor occupational health and safety investigators took measurements of the various points at the incident site.

"The evidence before me is full of rough estimates and speculation," Walsh said.

Judge James Walsh

Judge James Walsh described the occupational health and safety investigation into a 2015 fatal accident as “completely inadequate.” (Glenn Payette/CBC News)

He also noted that no photos were taken at the scene until more than eight hours after the incident occurred.

"This investigation was completely inadequate," Walsh said.

"The event of June 16, 2015, in which Mr. Curtis lost his life, is tragic. The Crown has, I conclude, conceded that the company had done what it was required to do with regard to his safety."

The judge added: "Southern Construction presents as a good corporate citizen that is very safety conscious. It has a safety plan in place. It ensured that its workers received proper safety training. It ensured that proper safety equipment for each worker was on site."

Review to examine whether changes necessary

While Service NL Minister Sherry Gambin-Walsh wouldn't do an interview, her department provided emailed statements with more information about the timeline of what happened that day.

Service NL says the incident occurred at around 8:35 a.m., and its occupational health and safety division was notified nearly four hours later, at 12:20 p.m. From the time the investigators were notified to when they arrived in Trepassey, another 3½ hours had elapsed.

According to Service NL, "the officers then proceeded to carry out their investigation in accordance with established policies and procedures for such an incident."

Sherry Gambin-Walsh Service NL CBC

Sherry Gambin-Walsh is the minister of Service NL, which oversees occupational health and safety regulations in Newfoundland and Labrador. (CBC)

The department says it will "reach out to first responders to discuss the issues of timely notification in cases involving workplace incidents and co-ordination in relation to scene management."

Service NL added that "further review of the court ruling will be required to gain a full understanding of what led to the dismissal of the charges, and whether any changes to procedures are necessary."

The current status of that review, and when it will be completed, is unclear.

The RCMP has not responded to repeated messages from CBC News.

'Long process' to educate investigators

A professor who specializes in the use of the criminal code in the context of occupational health and safety incidents says police across the country are ill-equipped to investigate fatal workplace accidents.

Steven Bittle says it's something that law enforcement officials readily acknowledge.

Bittle, who teaches at the University of Ottawa, says labour groups such as the United Steelworkers union have made efforts to try to educate investigators.

But Bittle says more needs to be done.

"Come up with protocols between regulators and police on how to investigate and secure the sites and all that, but I mean that's a long process," he noted.

"And I don't think we've seen the results of that yet."

'There needs to be some work done'

Back in Newfoundland and Labrador, labour leaders say the Trepassey incident is not the first time questions have been raised about how police and safety investigators interact.

Mary Shortall, president of the Newfoundland and Labrador Federation of Labour, notes that workplace incidents are governed by the occupational health and safety act and regulations, as well as the Criminal Code.

"There needs to be some work done between police forces and government, through their occupational health and safety divisions, to understand the procedure, to train investigators, to look at workplace fatalities from that point of view," Shortall said.

'There needs to be some work done between police forces and government, through their occupational health and safety divisions, to understand the procedure, to train investigators, to look at workplace fatalities from that point of view.' - Mary Shortall

"And to send a clear message out to employers who are negligent — that there's a price to pay, that's not just a dollars and cents price to pay."

Shortall points to Alberta, where the province and 10 police services — including the RCMP, and forces in Edmonton and Calgary — recently signed onto protocols for investigating serious workplace incidents.

"Where the fatality has happened will be a crime scene, and it will remain a crime scene until those investigators have ruled out criminal negligence," Shortall said.

"And at that point, the [occupational health and safety] division will come in and proceed with their investigation. But that takes some understanding between both parties, to make that work."

Mary Shortall NLFL CBC

Mary Shortall is president of the Newfoundland and Labrador Federation of Labour. (Bruce Tilley/CBC)

The Criminal Code was amended in the wake of the Westray Mine disaster, which happened in Nova Scotia a quarter-century ago.

Those changes came into effect in 2004, clearing the way for criminal charges to be laid in cases of extreme negligence where an employee is seriously or fatally injured.

But Shortall says that's never happened in Newfoundland and Labrador.

She says there isn't a problem with the legislation — the problem is with how it's being enforced.

Shortall says they have already held meetings with the Royal Newfoundland Constabulary on the topic, and also intend to speak with the Mounties.

CBC News Investigates