Justice After Death

The Office of the Chief Coroner plays a vital role in Ontario.

By Brittany Ramgolam | Featured image via iStock

On December 13, 2017, 25-year-old Ali Zaraeeneh entered an RBC in Vaughan, Ontario brandishing a handgun. He took more than a dozen bank staff and customers hostage in a terrifying ordeal that lasted an hour. Emergency Response Unit officers, an armoured vehicle and a helicopter surrounded the bank as negotiators responded to the incident. After Zaraeeneh refused to comply with an order from York Regional Police to surrender, he was fatally shot. Officers said they were forced to use lethal force to ensure the safety of the hostages.

It was revealed after the fact that Zaraeeneh suffered from mental health problems.

The police were cleared of any wrongdoing in relation to the young man’s death; however, under Ontario’s Coroners Act, a mandatory inquest was convened. The five-day hearing wasn’t held until July 26, 2021, at which time a jury was asked to propose what recommendations, if any, could be adopted to prevent a similar fatal shooting of a person with mental health issues in the future.

Toronto’s Office of the Chief Coroner has a mandate to research unusual deaths, workplace accidents and police abuses through inquests. They make sure that, “No death will be overlooked, concealed, or ignored,” according to the mission statement on their website. The Chief Coroner Office’s goal is to impact Ontario laws by evaluating past events and recommending solutions for the future. It’s an important service that few Ontarians likely know about.

However, there has long been public interest in what a coroner’s job entails. In 1966, CBC launched a TV program called Wojek, that featured a crusading coroner (played by John Vernon) of that name. It was one of the network’s highest-rated programs at the time. Between 1976 and 1983, Quincy M.E. starring Jack Klugman, aired on NBC. The main character was a forensic pathologist who helped the Los Angeles County Coroner’s Office solve crimes.

The CBC has a new program, Coroner, which has been running since 2019. It follows a coroner who investigates suspicious, unnatural or sudden deaths in Toronto, which is as close to Dr. Dirk Huyer’s reality as it can get.

Huyer has served as the Chief Coroner of Ontario since July 2013. In 2019, just as the COVID-19 pandemic emerged, a new member joined Huyer’s team. Seconded from the Toronto Police service, Kristopher Somwaru, then 38, was assigned to provide support.

Somwaru was born into a strict household in Georgetown, Guyana, the capital of the small country located north of Brazil, on December 8, 1980. Early on, he learned to take life’s responsibilities seriously. “I made sure my brother got to and from school and had food. It was part of the culture at the time in Guyana,” Somwaru says. “Around age 11 or 12, I realized I had to grow up faster than most.”

After he immigrated to Canada with his family in 1995, his maturity served him well as he went through school, eventually joining the Toronto Police Service, and then the coroner’s office, in 2005.

Somwaru works under Prabhu Rajan, who is chief counsel to the Chief Coroner, and one of his trusted lawyers. Rajan attended the University of Manitoba in 1991 and received his degree in Criminology. After graduating, he went to Osgoode Law School at York University in 1994.

“What Somwaru does is incredibly important work. He contributes to society and helps make real change happen,” says Rajan. “It does not always work out, but you can’t give up, you have to keep trying.”

It takes a strong personality to work at the Office of the Chief Coroner. “[Somwaru] sees it to the end, and always has a plan to get there,” says Constable Lee Rinkoff, who currently works with Somwaru.

Two types of inquests can be held: discretionary and mandatory. “A discretionary inquest is when a committee comes together to decide whether to look at death or not,” says Rinkoff. “Usually, doctors bring [discretionary cases] to our attention.”

A mandatory inquest, on the other hand, is held when someone dies as a result of police involvement or in a workplace. Settings may involve the Ministry of Labour, correction facilities or similar locations.

The process of an inquest is as follows:

1. Death occurs and legal proceedings happen unrelated to the Office of the Chief Coroner.

2. A case is brought to the attention of the Office of the Chief Coroner. A team is assembled to review whether it is mandatory or discretionary.

3. Once the case is opened, constables like Somwaru are responsible for creating a timeline of the event and gathering all necessary evidence and information. Somwaru and his colleagues are tasked to read and analyze all documents, files, databases and media related to the case.

4. Before its formation, the jury must go through a questionnaire to ensure they have no biases towards the case.

5. The lawyer in charge of holding the inquest then reviews the information presented by the police constables. That crucial information is shared with a jury in a courtroom.

6. After the hearing, the jury comes up with recommendations that they assess might prevent a similar occurrence taking place.

A recent case involved 19-year-old Quinn MacDougall, who was killed on April 3, 2018 by an undercover police officer dispatched to protect him. The Hamilton teen called 911 in a state of panic after receiving multiple death threats through Snapchat that same day. He faced mental health issues and suffered from paranoia. When MacDougall noticed a man dressed in all black outside his house observing him, his fears took over and he picked up a weapon. MacDougall gripped a 6-inch knife and charged the undercover officer, Constable Marcello Filice.

The officer instinctively reached for his gun and shot the boy, who later died in the hospital. Filice did not face any consequences for his actions, as they were deemed to have been in self-defence.

An inquest into the MacDougall case started on February 28, 2022. The evidence gathered by Somwaru for the prosecution sought to present the mistakes made by the Hamilton Police Service. After the inquest, the jury made numerous recommendations that could prevent situations like these in the future, especially in respect to how police interactions with people dealing with mental health issues could be improved.

Many Chief Coroner cases involve mental health issues. A tricky topic, but one Somwaru is not afraid to touch upon. “It’s a crisis and society doesn’t have a handle on it,” he says. When asked what could be done, he thinks for a minute: “That’s the million-dollar question.”

Many things can affect someone’s mental health, like losing a child or your husband raping you. In the early 2000s, a woman experienced both those things. Her husband assaulted her not long after her daughter’s death. Somwaru was first to arrive after the 911 call, and she was mentally distraught and considered taking her life. Somwaru took the victim aside and assured her that her mental health was his utmost priority. She later thanked him, admitting his thoughtfulness had stopped her from committing suicide.

Another case is of note: In 1995, Jeffrey Arenburg murdered Brian Smith, a former hockey player and notable TV sportscaster, because Arenburg was having schizophrenic episodes in which he believed broadcast towers were projecting directly into his head. He thought the only way to stop it was to murder the speaker, Smith. This tragedy started an inquest that led to a major change in Ontario law. Bill 68, otherwise known as “Brian’s law,” put Community Treatment Orders, or CTOs, into place. In Ontario, patients may be subject to this if they meet criteria defining them as unable to understand the consequences of their decisions.

Today, every province in Canada has a CTO law or equivalent, with the exception of New Brunswick.

The Arenburg case can be considered the first in a slew of mental health-related inquests the Office of the Chief Coroner has held. “If we all agree that the system needs fixing, a logical starting point, to me, is to define the act,” says Dr. James Young, who was in charge of the 2000 inquest.

“Addressing mental health issues in our society is a complex matter and much work remains in improving the lives of those dealing with mental health issues,” says Rajan.

Varied Matters

At the Office of the Chief Coroner every case is different, so the steps and outcomes will always vary from one another.

In 2017, for example, the hostage situation case involving Zaraeeneh, 25, was important given its uniqueness. The young man held people hostage inside an RBC. At that point, the man had been struggling with mental health disorders for years. With the police’s proper training in hostage scenarios or with mentally ill persons, the outcome could have been different. In fact, the inquest deemed the death unnecessary.

In this case, no legislative changes have been made yet. However, the jury has suggested hospitals and general practitioners work together to better support these conditions, according to the Ministry of the Solicitor General’s website. “Family physicians [should] enhance their awareness of community resources available to assist families struggling to support a loved one who is experiencing mental health challenges.”

By August 3, 2021, the jury had made a total of six recommendations to the Ontario College of Family Physicians and two recommendations to the Ontario Hospital Association.

The jury also said that, “Family physicians facilitate access to assertive multidisciplinary mental health outreach teams for people experiencing, or at great risk of experiencing, their first episode of psychotic symptoms.”

Inquests are established primarily to recommend solutions that might prevent similar tragedies occurring in the future. The workload is heavy, and no case is the same. The Office of the Chief Coroner does its part to make changes, but the rest is up to the politicians. Change sometimes occurs but it often takes considerable time and sometimes it doesn’t happen at all.

Freelance writer Brittany Ramgolam can be reached at ramgolambrittany@gmail.com.

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