Coroner Whistleblowers Rebuffed by Les

A whistle blowing former coroner who helped expose the failure of the BC Coroners Service to investigate 713 child deaths says he and colleagues have tried, but failed, to convince the BC government that other serious, systemic problems hobble the Coroner's Service.

Dr. Richard Crossland, who belongs to a group of coroners and ex-coroners calling themselves The Committee for Competent Death Reviews, says their efforts reached a clear dead end in a December meeting with Solicitor General John Les.

Crossland and colleagues had sent a five-page letter to Les detailing their claims of serious flaws in the funding and functioning of the Coroners Service.

Les met with members of Committee for Competent Death Reviews and flatly rejected their concerns, presenting them with their own letter amended with his rebuttals.

The Tyee has obtained that document signed by Les and publishes it here.

"I have not been able to find any evidence that the Coroners Service acted in any way inappropriately, or put anyone at risk, as a result of operational decisions made by Chief Coroner Terry Smith," wrote Les, adding, "I have full confidence in his abilities."

Les was civil but closed to any further discussion at the meeting. "He said in essence, 'It doesn't matter what you say. This is my response," Crossland told The Tyee.

Five areas of concern

Crossland remains adamant that the Coroners service is seriously underfunded, underpowered and risks losing credibility with the public.

The concerns in the letter from Crossland's group were loosely grouped under five headings: incomplete investigation of deaths, incomplete inquiry reports, absence of inquests, morale and retention of experienced coroners, and financial issues.

In at least two of those areas, the committee made a case that the Coroners Service faces serious public confidence issues, apart from the ignored children-death files.

The committee reminded that the Medical Investigation Unit had been closed, suicide analysis discontinued, autopsies radically reduced, cause of death guessed at in a number of instances, inquiries restricted in length and content, virtually no recommendations accepted, long delays in coroners' reports, and a failure to hold inquests apart from those required by law - despite the public request and apparent need.

The committee's letter also noted that doctors and mayors are no longer allowed to be appointed as coroners, because of a claimed conflict of interest.

And the committee also questioned the spending of some $800,000 on portable computerized equipment for coroners, in spite of cutbacks in autopsies for financial reasons.

Explosive leak

Last spring the Committee for Competent Death Reviews drafted a letter seeking to alert Les to the fact that the Coroners Service was severely backlogged on investigating children's deaths. The reason, noted the committee, is that the BC Liberals had abolished the job of the Children's Commissioner and passed over the files on the deaths of hundreds of children from the commissioner to the B.C Coroners Service for review -- without giving it the extra money or resources to handle the task.

The letter was leaked to the NDP, which hammered the issue in the Legislature. It emerged that the children's files were simply warehoused on the direction of some individual so far unidentified, and the reviews were not conducted.

The provincial government has now handed the Coroners' Service an extra $1.4 million to review the children's deaths; and it has commissioned highly-regarded government-systems investigator Ted Hughes to look into what happened in the back-burnering of those death and recommend improvements to the system.

Also, after logger death rates spiked, the Coroners' Service has promised inquests into "some" loggers' deaths, and a restructuring of the service to try to guard against disastrous systemic failures, with experts brought in to take charge of different sections or areas of interest.

Slashed coroner ranks

Despite the rebuff from the Solicitor General, Crossland says even more sweeping changes are needed to restore thoroughness and effectiveness to the Coroners Service.

He claims that the ranks of coroners in BC have been slashed in the past five years from more than 200 down to 120.

And those working in the field have less expertise backing them up, Crossland says. His committee committee argued for a beefing up of the sharply pared back Medical Investigation Unit, which a coroner could call for help when stumped by a case.

Crossland worries that the lack of medical experience among coroners, combined with financial and time crunches at the Coroners Service, is having the effect of "a rush" to apply the label of cardiac death or brain death in any cases not obviously a suicide, murder or accident.

Similarly, says Crossland, the chief coroner decided two years ago to pare back the four page "psycho social summary" previously required in all suicide cases. As a result, family members and the public are deprived of vital context. "What was the lead up? Why did this person choose this day? What was the cause? Addiction to gaming? Mental health? We need this kind of information to become better at suicide prevention," says Crossland.

Conflicts of interest?

Crossland is a practicing physician and was a coroner for 22 years before new regulations prevented medical doctors from being coroners. The intent was to prevent conflicts of interest in investigating medical malpractice. Crossland says physician coroners could exclude themselves from such cases, and points out that many current coroners are ex-police officers who might face conflicts of interest when investigating deaths in police custody.

Crossland may find small comfort in the fact that finally a coroner's inquest is probing the death of toddler Sherrie Charlie, four years after she was killed by an uncle in whose care she'd been placed by social workers. A key concern in the letter sent to Solicitor General Les by the Committee for Competent Death Reviews cites the decline of inquests into deaths by various causes, whether industrial accidents or disease related.

"I can recall presiding at inquests where absolutely important stuff came out," Crossland says. As one example he offers the discovery that the Red Cross blood supply was contaminated, a fact that came to light, Crossland says, during a coroner's inquest into an AIDS related death.

Campbell River journalist Quentin Dodd is a regular contributor to The Tyee. David Beers is founding editor of The Tyee.