Christie Blatchford: Inquests make problems behind deaths seem more impossibly complex than they are
Christie Blatchford | February 14, 2014
Toronto was awash this week in coroner’s inquest verdicts — first the one that examined the Toronto Police shooting deaths of three floridly mentally ill people, then Friday the one into the 2002 death of Jeffrey Baldwin, the little boy who was starved to death by his maternal grandparents and who must have suffered so much, his baby heart broken by the people who should have loved him and wanted him fat and giggly.
Instead, they locked him in a squalid, unheated bedroom with a sister and led an entire houseful of morally defective adults to watch as Jeffrey wasted away and died before their very eyes.
In the first one — colloquially called the “JKE” inquest after the last names of the three poor ill people who were shot — the jury returned with verdicts of homicide in all three deaths and 74 recommendations.
No surprise on either front.
Reyal Jardine-Douglas, who was killed in 2010; Sylvia Klibingaitus, who died in 2011; and Michael Eligon, who was shot in 2012, all died by police bullets.
In the coroner’s system, all a homicide verdict means is that the actions of someone — in these cases, police officers, already cleared of wrongdoing by the province’s Special Investigations Unit — caused the deaths. Of course they did.
As for the sheaf of recommendations, most were aimed at police training; of course they were.
The inquest was only looking to the fatal interactions with police for answers, not to the grotesque failings of what is euphemistically called the mental health system.
It’s that joke of a system — how difficult it is to have seriously ill people committed involuntarily so that they can be treated; the difficulty in being seen if you’re really sick and not just a middle-class person who is one of the ‘‘worried well” as they’re called; the shameful number of severely mentally ill who live on the streets — which put those three people at risk.
As Gary Clewley, a lawyer for one of the police officers, puts it, “The reach of the inquest exceeded its grasp. It did so because the length of proceedings creates the impression, and an apparent necessity, to come up with something, anything, that will avoid similar deaths in the future.”
Mr. Clewley told the jurors that the most significant witness they heard from was the convenience store owner from whom Mr. Eligon stole two pairs of scissors after he walked away from a hospital after 36 or so hours of not being helped.
He was the only witness the advocacy group, the Empowerment Council, did not cross examine.
“There is a good reason,” Mr. Clewley said. “He treated Mr. Eligon exactly as it is urged the Toronto Police should have. He responded to the theft by asking, not demanding, that he return the scissors. When Mr. Eligon brandished the scissors in his direction, he armed himself (with an awning adjuster) but didn’t hit him with it. Instead, he continued his dialogue.
“He did not raise his voice; he was not wearing a uniform; there were no lights and sirens. He cannot be said to have precipitated anything.
“His reward: he was attacked and stabbed several times.”
As Mr. Clewley concluded in his closing address, the storekeeper “treated Mr. Eligon with moderation and respect, thereby exposing the limitations” of those who urged upon the police the kinder, gentler approach with those who are armed with edged weapons.
In fact, the vast majority of Toronto Police interactions with the mentally ill and emotionally disturbed end peacefully. Those terrible few which do not should be laid at the feet of people working in the shambles of the one system in this sorry story which doesn’t work.
In the Baldwin inquest, the jury also made a finding of homicide (the grandparents, Elva Bottineau and Norman Kidman, were convicted of second-degree murder seven years ago) and made 103 recommendations aimed at child-welfare agencies, several provincial government ministries, school boards, etc.
The theme was that the broader community — not just children’s aid societies — have a responsibility to protect vulnerable kids.
That’s true, but of course, Jeffrey could have been saved if just one single person at the Catholic Children’s Aid Society — the family’s worker, her bosses, someone — had checked the agency’s own files before handing over the little boy and three of his siblings to the grandparents.
No one did. No one realized Bottineau and Kidman were already convicted child abusers, and dangerous to vulnerable youngsters.
Inquests paint these deaths as impossibly complex problems requiring a whole-society fix. They aren’tHow about one recommendation: Check your files, and check thoroughly everywhere else, before handing over children to anyone – foster parents, foster homes, babysitters, day care operators, relatives.
In the JKE inquest, all three families had tried to get their loved ones help before they were shot, before the police were ever called for the last time.
How about one recommendation: Make it easier for seriously mentally ill to get help, especially if they are too ill to recognize they need it. Change that law.
It was the same at the recent Ashley Smith inquest, which for months examined the failings of the prison system where the young mentally ill woman who strangled herself with a homemade ligature died.
That jury also emerged with — surprise — a verdict of homicide and a stack of recommendations.
How about this one: Don’t let inmates keep ligatures in their cells.
Juries always mean well. They give up much to serve on inquests. But all the lawyers and their bafflegab, the months spent and all the witnesses paint these deaths as impossibly complex problems requiring a whole-society fix. They aren’t.
Don’t expect the only people not in the business of delivering mental health services — the cops — to do what psychiatrists, doctors, hospitals and clinics won’t do.
Don’t let children’s aid societies hand over babies, or approve the handing over of babies, to anyone they’ve not checked out.
Tell prisons to take away all weapons — including ligatures — from inmates.
Had these things been in place, odds are Reyal, Sylvia and Michael, Jeffrey and Ashley would all be with us still.
National Post
cblatchford@postmedia.com
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