Inquest to focus on problems with 911 system during 2013 Lake Wanapitei boating tragedy

A joint coroner's inquest begins today into the province’s 911 communication service. Details from two fatal events — a 2013 boating tragedy in Sudbury and a 2014 death in Casselman — will be explored to highlight problems and gaps in the communication system used to dispatch emergency services.

Proceedings to spend week in Sudbury before moving to Ottawa to focus on 2014 Casselman death

A coroner's inquest will look into concerns with Ontario's 9-1-1 communication system. The proceedings will focus on two sets of deaths — a boating tragedy in Sudbury and a death in Casselman. Stephanie Bertrand, Michael Kritz and Matthew Humeniuk died in 2013 when a boat struck an island on Lake Wanapitei. (Supplied)

A joint coroner's inquest begins today into the province's 911 communication service.

Details from two fatal events — a 2013 boating tragedy in Sudbury and a 2014 death in Casselman — will be used to highlight problems and gaps in the communication system used to dispatch emergency services.

"Not just the 911 system, but also what occurs after 911 is initiated," says Dr Dirk Huyer, Chief Coroner of Ontario.

He says the two cases share commonalities.

"We saw an opportunity to look at this jointly with similarities between the two sets of deaths. [The inquest] allows us to have a broader impact and a broader evaluation across the province," Huyer said.

The jury for the joint inquest is made up of three members from Sudbury and two from Ottawa.

They will spend this week in Sudbury and then be shuttled to Ottawa next week for the remainder of the proceedings.

The inquest is not about assigning blame says Prabhu Rajan, counsel to the coroner, but rather to address communication concerns and prevent similar tragedies.

"There may have been gaps in how the 911 calls were received and also dispatched and the nature and extent of the communication between the various services involved in these incidents, ie: fire, police, ambulance. And whether there was sufficient communication within and between these services," Rajan said.

Sudbury case

On the evening of June 30, 2013, a boat struck a small island on Lake Wanapitei, in Greater Sudbury.

There was a call made to 911, however, by the end of the ordeal 33-year-old Matthew Humeniuk and 34-year old Michael Kritz had died.

The third victim, 25-year old Stephanie Bertrand died of her injuries a week later in hospital.

There are still a number of questions about what happened that night and why it took so long for emergency responders to get to the scene.

Day 1 of the inquest is expected to include testimony from Rob Dorzek, the lone survivor of the boating fatality, as well as family members of the three victims.

Rajan says the 911 call made by Dorzek will be played just once during the inquest.

"We felt it was important for the jury to understand what happened, to get a sort of second-by-second experience of what happened."

"A pain worth bearing"

"Talking about it again, going over the stuff again is painful," says Julie Howarth, Bertrand's older sister.

"But it's a pain worth bearing if we can get some good positive change for such a provincial service."

The Bertrand family has prepared a statement to be read at the inquest.

Howarth works in emergency medicine in the eastern Ontario community of Pembroke, but even she admits she doesn't know how 911 works when an emergency call is made.

"911 is such a large part of people's lives, even though they don't know it. It's always there. It's in the background. It works for everybody and you don't hear a lot about scrutiny in 911 services, until they go wrong."

Howarth hopes the inquest will also provide closure for all the families and others who were involved in the boating tragedy.

"That it brings some sort of relief or some sort of end to the questions surrounding what happened that night, cause I don't think anybody really knows," she said.

Howarth also wants to make it clear that her family is not pointing blame at anyone.

"We don't blame 911, we don't blame the dispatchers, we don't blame the first responders. I think everyone that night was just doing the best that they could in a situation that no one had prepared them for."

Testimony, evidence to speak for itself

The members of the Sudbury Professional Firefighters Association will be following the inquest proceedings this week.

"It's an opportunity to make some needed improvement to the 911 system, in order to ensure the right resources are getting sent in a timely fashion to people's emergencies," president Kris Volpel said.

He is confident the testimony and evidence will speak for itself, and the jury's recommendations from the inquest will address systemic issues in the communication system.

"Emergency service workers in general, we train in different disciplines, and at the end of the day, when an emergency arises in our community we just want to be utilized the best way that the system can do that," Volpel said.

"We want to be sent promptly and we want to be sent when and where we're needed."

Faith in 911?

There still remains problems and concerns with the 911 service, even four and five years after the Sudbury and Casselman fatalities.

"You hear people feel that they're not sure if things have changed much since that happened and that is of course a concern to my team," Rajan said. 

"The whole point of an inquest is to ensure this doesn't happen again."

He adds the changes that come out of the inquest will "make sure that the residents in the area are as safe as possible and that they can have faith in the 911 system."

After listening to testimony in Sudbury and Ottawa, the five-member inquest jury will deliver its recommendations in Ottawa.

The entire inquest will be live-streamed on the Ministry of Community Safety and Correctional Services website.

"If you're in Sudbury and you wish to watch some of the proceedings in Ottawa you can do that, and vice versa," Rajan said.

About the Author

Angela Gemmill


Angela Gemmill is a CBC journalist who has covered news in Sudbury, Ont., for 14 years. Connect with her on Twitter @AngelaGemmill. Send story ideas to