Wednesday, October 5, 2016

here are the fatality reports that I dig out / so that all who are blind might now see the disconnect

we write out the stories
on the Internet
and wait for change to come
(one day)
we understand that there are two sides
to every story
and that to be fair
these are adverse situations
for citizens
and government workers
but what can you do?
the fatality reports don't say
what is the way out
and so we explain

we write out the stories
on the Internet
and we watch the government of Alberta
as it tries to do the game
of spinning the stories
into fine cobwebs
meanwhile in BC the advocate is being weakened
with a report by a former government employee
(how independent is that?)
and we understand that the BC advocate is seen
as being too effective for the citizens
that she defends  Mary Ellen Turpel-Lafond actually works for the citizens 
we understand that information is currency
and in Alberta we have restrictions in place in every way possible.

we write out the stories
on the Internet
and pass them to others who are innocent
we see the government at all levels
speak about democracy and positive politics
but Harper's kingdom has been inherited
by the NDP and Liberals   who play the PC games
we understand that the only way to change the system
is to change ourselves    we stay calm as abuse and death happens
to avoid being labelled as adversarial opponents
we write out the facts that government itself has presented to the public
and we wonder to ourselves       are we so attenuated to the failures
that we no longer protest?        here are the fatality reports that I dig out 
so that all who are blind might now see the disconnect 

http://www.news1130.com/2015/12/14/bc-childrens-advocacy-not-oversight-report/

BC children's representative should focus on advocacy, not oversight: report

Posted Dec 14, 2015 11:41 am PDT
Last Updated Dec 14, 2015 at 12:06 pm PDT
BC's child advocate Mary Ellen Turpel-Lafond (CP Photo)
VICTORIA – A leaked report looking into BC’s Ministry of Children and Family Development after recent high-profile failures has criticized the provincial children’s watchdog while praising the ministry for its work amid starved resources.
The report by long-time government bureaucrat Bob Plecas says deaths and serious injuries to children in care are rare, but there is a great appetite for piling on workers and the ministry for both “perceived and real failings.”
Plecas says the relationship between the ministry and the office of the Representative for Children and Youth has become strained, and the watchdog’s numerous recommendations over the years have overwhelmed the ministry.
He says the oversight role by Mary Ellen Turpel-Lafond should be taken over by the ministry, while she should instead focus on advocacy.
The report also advises a multi-year plan to address the ministry’s problems including boosting staff resources, implementing quality assurance, providing oversight and putting the financial resources in place.
The Children’s Ministry has faced mounting criticism recently in the wake of a scathing report into the short, tragic life of a young Aboriginal woman, the deaths of children in care, and the case of a mother whose estranged husband was allowed unsupervised visits despite sexually abusing their four children.
The representative for children and youth has responded to this report by saying independent oversight of our province’s child welfare system remains a necessity.
Turpel Lafond claims without the public accountability her office provides, deaths of children in government care would not have been exposed.
She highlights the case of Paige, a 19 year old aboriginal woman who Turpel-Lafond says was the victim of indifference from social workers. She believes without this scrutiny, many problems would go on unaddressed.

https://www.justice.alberta.ca/programs_services/fatality/Pages/fatality_reports.aspx?WT.svl=programs


Fatality inquiry reports

The presiding judge provides the Minister with a written report after an inquiry is complete.
This report:
  • identifies the deceased
  • outlines the date, time, place and circumstances of death
  • may recommend how to prevent similar incidents
  • cannot make any findings of legal responsibility

Reports

2016
2015

To obtain older reports

     Contact:
     Jennifer Fuchinsky
     Fatality Inquiry Coordinator
     Email
     780-422-4077
     780-310-0000 (toll-free in Alberta)

Alberta Hospital: 

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Payne.aspx/DispForm.aspx?ID=284

 
Report to the Minister of Justice and Solicitor General - Public inquiry into the death of Shaunnie Rebecca Payne

August 30, 2016
The report concluded the 31-year-old’s cause of death was clozapine toxicity.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-payne.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Rosie.aspx/DispForm.aspx?ID=270

Report to the Attorney General - Public Fatality Inquiry into the death of Nathan Rosie

April 26, 2016
The report concluded the 34-year-old’s cause of death was blunt force trauma.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-rosie.pdf




Rockyview General Hospital (RGH):

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Ma.aspx/DispForm.aspx?ID=280

Report to the Minister of Justice and Solicitor General - Public inquiry into the death of Lianjie Ma

June 23, 2016
The report concluded the 49-year-old’s cause of death was drowning.


Royal Alexandra Hospital Death:


Report to the Attorney General - Public inquiry into the death of Shantha Rasiah

January 02, 2015
The report concluded that the 26-year-old died of hypoxic brain injury caused by cardiac arrest caused by a combination of pneumonia and proliferative glomerulonephritis.



Continuing Care System Deaths

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Eliason.aspx/DispForm.aspx?ID=243

Report to the Attorney General - Public Fatality Inquiry into the death of Verna Esther Eliason

June 29, 2015
The report concluded the 78-year-old died of natural causes.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-Eliason.pdf


Abuse and Deaths in Foster Care in Alberta:

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Cardinal.aspx/DispForm.aspx?ID=277

 
Report to the Minister of Justice and Solicitor General - Public inquiry into the death of J'Lyn Michelle Cardinal 

June 02, 2016
The report concluded the 4-year-old’s cause of death was cranial trauma with a large blood clot pressing on the surface of the brain.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-cardinal.pdf

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Holmes.aspx/DispForm.aspx?ID=269

Report to the Attorney General - Public Fatality Inquiry into the death of David Holmes

April 12, 2016
The report concluded the 35-year-old’s cause of death was complications of thermal injuries.





 
Report to the Attorney General - Public Fatality Inquiry into the death of BB

February 12, 2016


Report to the Attorney General - Public Fatality Inquiry into the death of Tylan Mason Poucette

February 01, 2016

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-shiningstar-bird.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Sullivan.aspx/DispForm.aspx?ID=248

 
Report to the Attorney General - Public Fatality Inquiry into the death of Delonna Victoria Sullivan

August 10, 2015
The report concluded the 4-month-old died of sudden unexplained death in infancy.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-sullivan.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-JustineCymoneCochrane.aspx/DispForm.aspx?ID=239

Report to the Attorney General - public inquiry into the death of Justine Cymone Cochrane

May 04, 2015
The report concluded the 15 year-old was a victim of homicide.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-justine-cochrane.pdf



 
Report to the Attorney General - Public Fatality Inquiry into the death of Edwin Cattlemen

March 06, 2015
The report concluded the 16-year-old died accidentally.



Fatality report doesn’t mention Alberta teen was ward of the province

Published on: March 6, 2015 | Last Updated: March 6, 2015 10:54 PM MDT
Interim Liberal leader David Swann.
Interim Liberal leader David Swann. LEAH HENNEL
EDMONTON – A fatality inquiry report into the death of an aboriginal teen makes no mention of the fact that he was a runaway ward of the province, and provides no recommendations to prevent similar deaths in future.
Edwin Fenton Cattleman was 16 when he got drunk and high at a house party in Maskwacis, then fell down a set of stairs attached to an outside deck and died from severe head trauma.
Provincial court Judge Gordon Yake said RCMP initially believed the death was suspicious and conducted an investigation, but they concluded Cattleman died by accident.
“In light of the circumstances of the death of the deceased, I have no recommendations,” Yake wrote.
The report was issued nearly four years after Cattleman’s death on May 24, 2011.
An internal government report obtained by the Journal shows Cattleman had been in and out of care since he was one year old, and had 35 legal statuses and 20 different placements since birth.
He had been subject to a permanent guardianship order for 10 years, which means the province had been acting as his parent for most of his life.
Akamkisipatinaw Ohpikihawasowin Child and Family Services had placed him with his grandmother, but he ran away from home about a week before he died.
Interim Liberal leader David Swann said the judge’s failure to acknowledge the province’s direct involvement in the child’s life and the systemic failures that led to his death is “unacceptable,” and reveals serious flaws in the province’s child death investigation system.
“I would call that incompetent,” Swann said. “This is not a legitimate review process.
“The whole fatality review inquiry process needs to be examined, and at the very least we need to understand what value they add, and what expertise is really needed to do an examination of causes and solutions.”
Swann also said four years is too long to wait for a fatality inquiry report, calling the delay “another black mark.”
The judge’s report also makes no mention of the circumstances under which Cattleman was discovered. The internal report does.
“Once RCMP responded, they located a lone male with severe head injury,” the internal report says. “There was no one else in the home.”
He died alone.












Deaths of Citizens in Police Custody:

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Collins.aspx/DispForm.aspx?ID=283


Report to the Minister of Justice and Solicitor General - Public inquiry into the death of Shaun Robert Collins

August 05, 2016
https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Wodaje.aspx/DispForm.aspx?ID=282

Report to the Minister of Justice and Solicitor General: Public inquiry into the death of Mehari Wodaje

July 12, 2016
The report concluded the 46-year-old's cause of death was intentional self-harm by hanging.



https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-wodaje.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Kushniruk.aspx/DispForm.aspx?ID=281

 
Report to the Minister of Justice and Solicitor General - Public inquiry into the death of Donald Kushniruk

July 04, 2016
The report concluded the 49-year-old’s cause of death was ligature strangulation.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-kushniruk.pdf



https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Bearhead.aspx/DispForm.aspx?ID=279

Report to the Minister of Justice and Solicitor General - Public Fatality Inquiry into the death of Lucille Josephine Bearhead

June 22, 2016
The report concluded the 34-year-old’s cause of death was methadone toxicity.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-bearhead.pdf






https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Mallett.aspx/DispForm.aspx?ID=271

Report to the Attorney General - Public Fatality Inquiry into the death of Harold Gerard Mallett

April 28, 2016
The report concluded the 62-year-old’s cause of death was asphyxia by hanging.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-mallett.pdf

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Kipling.aspx/DispForm.aspx?ID=267

Report to the Attorney General - Public Fatality Inquiry into the death of Laurent Barry Kipling

March 18, 2016
The report concluded the 35-year-old's cause of death was a blunt cranial trauma.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-kipling.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-louie.aspx/DispForm.aspx?ID=265

Report to the Attorney General - Public Fatality Inquiry into the death of Tung David Louie

February 02, 2016
The report concluded the 38-year-old’s cause of death was a stab wound to the chest.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-louie.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-morison.aspx/DispForm.aspx?ID=261

Report to the Attorney General - Public Fatality Inquiry into the death of Kenneth Morison

January 28, 2016

The report concluded the 33-year-old’s cause of death was hanging.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-morison.pdf

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-rawlings.pdf

Report to the Attorney General - Public Fatality Inquiry into the death of Jonathan Rawlings

January 05, 2016
https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Lewis.aspx/DispForm.aspx?ID=254

Report to the Attorney General - Public Fatality Inquiry into the death of Corey Jason Lewis

January 04, 2016


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-skoropad.aspx/DispForm.aspx?ID=264


Report to the Attorney General - Public Fatality Inquiry into the death of Russell Mark Skoropad

January 02, 2016
https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-Kenyon-Kerfoot.aspx/DispForm.aspx?ID=256

 
Report to the Attorney General - Public Fatality Inquiry into the deaths of Stephen Michael Kenyon (21 years old) & Bradley Kenneth Kerfoot (30 years old)

December 15, 2015
The report concluded the 21-year-old and 30-year-old’s cause of death was blunt trauma resulting from a motor vehicle head-on collision.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-kenyon-kerfoot.pdf

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Lapensee.aspx/DispForm.aspx?ID=252

Report to the Attorney General - Public Fatality Inquiry into the death of Brian Lapensee

December 03, 2015
The report concluded the 52-year-old’s cause of death was chronic alcoholism.




https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Stewart.aspx/DispForm.aspx?ID=247


 
Report to the Attorney General - Public Fatality Inquiry into the death of Barry Raymond Stewart

August 04, 2015
The report concluded the 59-year-old died of crush injuries to the head.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-stewart.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Puri.aspx/DispForm.aspx?ID=246

 
Report to the Attorney General - Public Fatality Inquiry into the death of Deu Raj Puri

July 31, 2015
The report concluded the 26-year-old died of multiple gunshot wounds.

Report to the Attorney General - Public Fatality Inquiry into the death of Deu Raj Puri - 42 KB  Download Adobe Acrobat Reader



https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-puri.pdf



https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-KinlingRobinFire.aspx/DispForm.aspx?ID=245

 
Report to the Attorney General - Public Fatality Inquiry into the death of Kinling Robin Fire

July 28, 2015
The report concluded the 39-year-old died of gunshot wounds to the chest.



https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-kinling-robin-fire.pdf




https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-buluk.aspx/DispForm.aspx?ID=242

 
Report to the Attorney General - Public Fatality Inquiry into the death of Morbe Anthony Buluk

June 26, 2015
The report concluded the 18-year-old died of a blunt head injury.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-buluk.pdf

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-BernardEmeryGirouxJr.aspx/DispForm.aspx?ID=241

Report to the Attorney General - Public Fatality Inquiry into the death of Bernard Emery Giroux Jr.

June 25, 2015
The report concluded the 37-year-old died of a gunshot wound to the thorax.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-bernard-giroux.pdf

https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-spiewak.aspx/DispForm.aspx?ID=240

 
Report to the Attorney General - Public inquiry into the death of Peter Dominik Spiewak

May 26, 2015
The report concluded the 31-year-old died of multiple gunshot wounds.

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-spiewak.pdf



https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-fournier.aspx/DispForm.aspx?ID=238

 
Report to the Attorney General: Public inquiry into the death of Rodney Fournier

April 07, 2015
The report concluded the 29-year-old died of chronic ethanol abuse and ethanol toxicity.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-rodney-fournier.pdf

.
https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/report-Ditchburn.aspx/DispForm.aspx?ID=237

Report to the Attorney General - public inquiry into the death of Jason Joseph Ditchburn

April 02, 2015
The report concluded the 29-year-old died of acute hydromorphone toxicity.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-ditchburn.pdf



https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/fatality_darby_mahon.aspx/DispForm.aspx?ID=232

 
Report to the Attorney General - Public Fatality Inquiry into the death of Darby Mahon

February 09, 2015
The report concluded the 49-year-old died of multiple gunshot wounds.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality_report_Mahon.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/FatalityInquiryMccoy.aspx/DispForm.aspx?ID=231

 
Report to the Attorney General - Public Fatality Inquiry into the death of Murray Francis McCoy

January 27, 2015
The report concluded the 56-year-old died of multiple gunshot wounds.


https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-mccoy.pdf


https://www.justice.alberta.ca/programs_services/fatality/Publications_Sudden_death_investigation/Report-CorwinAllanPeeace.aspx/DispForm.aspx?ID=230

Report to the Attorney General - Public inquiry into the death of Corwin Allan Peeace

January 08, 2015
The report concluded the 40-year-old died of gunshot wounds of the chest.
Appendix A - 14.7 MB  Download Adobe Acrobat Reader
Appendix B - 11.1 MB  Download Adobe Acrobat Reader

https://www.justice.alberta.ca/programs_services/fatality/Documents/fatality-report-peeace.pdf











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