27 recommendations but no call for legislation in Ontario's 911 inquest

The jury in the joint coroner's inquest looking into Ontario's 911 system has returned with 27 recommendations.

Jury looked at 2 fatal cases including a 2013 boat crash in Greater Sudbury

The jury in a coroner's inquest into Ontario's 911 system returned 27 recommendations after testimony in two cases, including a 2013 boat crash. Stephanie Bertrand, Matthew Humeniuk and Michael Kritz died in the tragedy on Lake Wanapitei in June 2013. (Supplied)

The jury in the joint coroner's inquest looking into Ontario's 911 system has returned with 27 recommendations — 19 of those are directed to the government of Ontario, while the remainder are for municipalities that provide 911 service to their residents.

For the past two weeks, the five-member jury heard testimony about two different fatal tragedies.

The first involved a 2013 boat crash on Lake Wanapitei in Greater Sudbury, that left three people dead.

The other case involved Kathryn Missen, who had an asthma attack and died at her home in Casselman in 2014.

Kathryn Missen died in 2014 after her call to 911 for help was bungled by overlaps and delays in getting emergency responders to her home in Casselman. (Missen family )

In both cases someone called 911 for help, but the help came too late.

Among the jury's recommendations addressed to the government of Ontario to improve 911, is the creation of an independent body to provide oversight to all 911 operations to investigate, respond to and resolve complaints.

It also recommends that all three emergency services taking calls operate with the same computer system.

But the recommendations, which are non-binding, fell short of calling for provincial legislation to overhaul the system as proposed to the jury by the lawyer to the coroner and the family of the Ottawa woman who died.  

"Obviously we thought it was a good idea and we thought it was reflected by the evidence," said Prabhu Rajan, counsel fo the coroner. "But that being said I don't make the decisions the jury does."

Rajan had told the jury while fire, police and paramedics all have protocols on how to respond to emergencies, there is no one ministry or government body that says the 911 system is ours.

Hopeful problems will be addressed

Missen's family also advocated, where appropriate, that the OPP do away with a two-tiered 911 system where calls are handled by a primary responder and then handed off to a secondary operator.  

Missen's 911 call first went to an OPP 911 operator in North Bay before being passed to two operators at the OPP detachment in Smiths Falls where the call sat for an hour and a half before being dispatched  to an OPP constable. 

"That is a bit of a disappointment that they didn't pick up that directly," said Brenda Missen, Kathryn's sister.  

But she is hopeful the problems with how her sister's 911 call was handled will be addressed if operators downstream have access to the audio of the 911 caller so they can judge for themselves the seriousness of the emergency. 

The jury has recommended that. 

As the inquest into Kathryn Missen's death came to a close, her sister Lynne Missen Jolly and her daughter Harriet Clunie reflected on what she might think of it. Kathryn Missen died during an asthma attack after calling 911 on Labour Day in 2014. 0:24

​The government has until December 2019 to report back to the ministry about efforts to implement the recommendations.

The recommendations directed toward municipalities, including appropriate training and staffing levels at call taking and dispatching call centres.

They have until December 2021 to work to get their recommendations in place.

With files from Angela Gemmill


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