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Coroner's inquest into 2021 George Gordon FN death concludes

Jury makes 12 recommendations to RCMP, Provincial ministries.

REGINA –  A jury of four women and two men have come to a decision after four hours in deliberation, having heard witness testimony in the three-day coroner’s inquest of Ray Bitternose.

Just after 1:15 p.m., Coroner Blaine Beaven charged the jury, advising them on what questions they need to answer and how to reach a conclusion on them. Relying solely on evidence presented during the trial, the jury was tasked with answering key questions about the death of Bitternose.

On July 6, 2021, Punnichy RCMP members responded to a report of a person with a weapon, threatening to shoot people. That man was Bitternose, who had been the subject of a mental health warrant just one day prior, prompting RCMP to search for him after receiving a call from a concerned family member. Officers could not find Bitternose, who was reported to be on foot travelling north towards Punnichy.

When RCMP arrived on July 6, they found Bitternose standing at the end of the driveway to House 351 on George Gordon First Nation with a rifle in hand. After an attempt to de-escalate the situation through verbal means, Bitternose raised the rifle and pointed it at an officer. That officer shot Bitternose in the upper abdomen area. RCMP arrested the man and began lifesaving measures, making attempts to call for emergency support.

EMS arrived on scene to Bitternose awake and breathing, but with a shallow pulse. They documented his time of death to be 3:08 p.m. after lifesaving measures were unsuccessful.

The medical cause of death was a gunshot wound to the abdomen.

The jury was also tasked with finding by what means Bitternose’s death occurred. An argument for suicide could be made as heard in evidence presented. Bitternose asked an attending RCMP member several times to shoot him.

Beaven noted the evidence could support suicide, but also that the jury may find homicide as another option, given the actions of the officer physically shooting Bitternose. If two or more means of death are thought to have occurred, then the means of death would be considered undetermined.

The jury decided the means of death to be undetermined.

Once those questions were answered, the jury can decide whether or not recommendations are to be made in order to try and prevent similar deaths. As Beaven noted, it’s a chance to “try and take a tragic event and make something positive from it.”

The foreperson presented the list of 12 recommendations the jury created, which will be forwarded to the agencies mentioned.

“In the interest of avoiding similar deaths in the future, we recommend the following,” the foreperson said.

With respect to communication:

1. The RCMP should develop a policy for the use of the WatchGuard system and microphone pack, including when it must be used, when and how that information can be accessed, and how its stored and retrieved. The policy should include mandatory use of microphone pack by officers while on duty.

2. SaskTel must review service delivery for essential telecommunication services such as 911 to determine if the increased or alternate resources could reduce service interruptions.

3. The RCMP should ensure that all handheld radio equipment functions properly in detachment service areas.

4. The RCMP should record all calls that come in to the detachment.

5. The RCMP should review resourcing at its call centre to determine if calls are being answered in a timely way.

With respect to training:

1. The RCMP should review and standardize the inventory of weapons at each detachment and ensure all officers are trained on their storage, retrieval and use.

2. The RCMP should create a policy for mandatory training and on-boarding that new staff at each detachment must complete prior to initiating duties.

3. The RCMP should ensure all officers are trained on First Aid measures for traumatic injuries and have access to adequate First Aid supplies.

With respect to policies:

1. The RCMP should establish criteria for exercising due diligence while conducting wellbeing checks. The individuals who brought the concern to the RCMP should be notified of the outcome and referred to other mental health resources if no further assistance can be offered by the RCMP

2. The Ministry of Justice should review the Mental Health Services Act and determine - in consultation with RCMP and other law enforcement agencies - if a longer affective period for mental health warrants would improve enforcement.

With respect to resourcing:

1. The RCMP needs to prioritize staffing at the detachment level.

2. The Ministry of Corrections, Policing and Public Safety should create a dedicated unit or task force with peace officer or other expert members such as social workers, elders, outreach workers or clinicians to assist with the enforcement of mental health warrants and offload the burden of resourcing and expertise from individual detachments.

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