Coroner's inquest into 911 system moves from Sudbury to Ottawa

After spending last week in Sudbury focusing on emergency response to a 2013 boat collision, a coroner's inquest turns to Ottawa to hear about the 2014 death of a Casselman woman.

After hearing testimony about Sudbury tragedy, inquest to hear about 2014 Casselman death

Josee Lafleur, a Sudbury manager at the Central Ambulance Communications Centre, is joined by Jesse O'Shell, assistant deputy chief of fire and John Valtonen, police inspector and manager of police and fire dispatch in Sudbury, at an inquest on Friday. (Supplied/

After spending last week in Sudbury focusing on emergency response to a 2013 boat collision, a coroner's inquest turns to Ottawa to hear about the 2014 death of a Casselman woman.

The inquest is examining problems with Ontario's 911 system.

Communication problems hindered the emergency response when a boat struck an island in Lake Wanapitei in June of 2013.

Of the four people onboard, only one was able to call 911 for help, but that help came too late, and three people died.

The proceedings will now focus on the death of Kathryn Missen of Casselman, near Ottawa.

"We'll of course turn primarily to the facts of Miss Missen's death for the first couple of days, but then we move into more broader policy issues," counsel to the coroner Prabhu Rajan said.

In 2014, Missen called 911 when she was having an asthma attack. However because she couldn't speak, the call taker assumed there was trouble on the line and closed the call. Missen was found dead in her home two days later.

"Can we improve? Absolutely"

Police, fire and EMS officials in Sudbury said improvements have already been made at the local level.

"We learn from every experience," assistant deputy fire chief Jesse O'Shell said.

He was part of a panel of call centre managers for each of the emergency services in Greater Sudbury, who spoke at the inquest on Friday.

Each stated that since the tragedy on Lake Wanapitei there have been upgrades to technology and mapping, improved staffing levels at the dispatch-call taking centres. Communication has also improved between the three services: police, fire and EMS.

"Today, if this incident were to occur that  I would be fairly confident that fire would have a response that would be initiated almost immediately, that EMS would have a response initiated based on what the CACC dispatchers or communicators are taking. That if required police services would be notified," O'Shell said.

A joint emergency services operational advisory group has been created. O'Shell said they meet bi-weekly and continuously look at after-action reports to discuss issues and improve response.

"There are so many different pieces that we put into place as we learn and grow so that everything from the initial call to 911 to what the Computer-Aided Dispatch, the CAD system does, to how the information gets to our responders, how the information is passed between agencies," O'Shell said.

"Is there room to improve? Absolutely. Can we do better? Always."

Training first-responders

The three services in Sudbury have even used elements from that fatal boat crash for training purposes.

"It was remote area, it was on water. However it was to search for missing people, and so we utilized different pieces of that: volunteer response, police response, ambulance response, on water, a difficult to reach area, poor cell phone reception," O'Shell said about the 2015 training exercise on Joe Lake in Hanmer.

He says every year there is also a large-scale exercise, as well as a tabletop exercise that involved multi-agency response to a specific scenario.

Following each model simulation, O'Shell told the inquest that a report is provided to the advisory group that includes positives, negatives, best practices and how they can do better in the future.

"So that we, in turn, can do better."

Recommendations to come 

According to Rajan, the counsels involved in the inquest will come up with suggested recommendations for the five-member jury later this week. Those recommendations are expect to be issued next Monday.

Rajan says there needs to be seamless communication between the three emergency services without failing the individuals on the other end of the 911 call.

"While intentions were good, communications were not. I think there needs to be better communication both within each particular service, but without a doubt between all three services."

With files from Angela Gemmill