Microsoft word - 3_ closing letter to the chief judge - forbister inquest.doc

750 - 500 Portage Avenue Winnipeg, Manitoba R3C 3X1Telephone: (204) 982-9130 Toll Free in Manitoba: 1-800-665-0531 Fax: (204) 942-7803 500 av. Portage, Pièce 750 Winnipeg (MB) R3C 3X1 Téléphone : (204) 982-9130 Sans frais au Manitoba : 1 800 665-0531 Télécopieur : (204) 942-7803
May 23, 2008
The Honourable Raymond E. Wyant
Chief Judge
Provincial Court of Manitoba
5th floor - 408 York Avenue
Winnipeg MB R3C 0P9
Dear Chief Judge Wyant:
Re: Inquest into the Death of Sherrill Wilfred Forbister
I am writing to advise of the results of the inquiries made by my office concerning the inquest
report dated August 21, 2007, issued by the Honourable Judge B. Colli into the death of Sherrill
Wilfred Forbister.
Mr. Forbister came to his death in Norway House, Manitoba on October 16, 2003 by means of an
alcohol and diphenhydramine overdose. This death resulted while in police custody.
The Chief Medical Examiner called for an inquest pursuant to subsection 19(3) of The Fatality
Inquiries Act. The inquest report was released on August 23, 2007.
As you are aware, it is the practice of my office to follow up on inquest recommendations if they
involve a provincial department, agency or municipality. In this case my office made inquiries
with Manitoba Justice, Manitoba Health, and the Manitoba Liquor Control Commission. The
following are the recommendations and the departments' responses.
RECOMMENDATION ONE:

Core policies of the RCMP, being those applicable to emergent circumstances in which human life or safety is or may be at stake, be identified for the purpose of developing formal training for all cadets and all field officers.
RECOMMENDATION TWO:

In future, no RCMP cadet be employed in an operational position of the force without verification of his/her understanding of core policy. Manitoba Justice provided the following information received from the RCMP: At the current time, we are in the process of identifying what we consider to be "core policies" that are applicable to emergent circumstances. This will be done through consultation with RCMP commanders, districts and Criminal Operations. Once "core policies" have been established, the RCMP will work with Training Branch and District Management Teams to ensure our personnel are conversant with these policies. Some training systems are already in place, particularly with new members who are required to complete exercises that require policy research as a component of recruit training.
RECOMMENDATION THREE:

Every step be taken to implement as soon as possible the recommendation of Judge Stewart in the St. Paul Inquest regarding the provision of adequate police resources in Northern Manitoba. The recommendation in the St. Paul inquest stated: This inquest recommends that the RCMP through its Division "D" executive committee meet with the Province of Manitoba, and thereafter the Government of Canada, to immediately fund an increase in resources to provide the community of Norway House and those other northern communities which have been identified under Band A Resource Division Priority with full police resources to augment the safety of those communities and the RCMP members serving there. Manitoba Justice provided the following information received from the RCMP: The 2007 provincial budget announced and approved 14 additional members to the Manitoba RCMP complement that will be in place by January 2008. From the number 2 positions will be allocated to Norway House. On-site infrastructure continues to be an issue at Norway House. The RCMP advises that 2 duplexes have been designed and are currently up for tendering. Once that process is finished, the duplexes will be transported to Norway House for member occupancy. It is anticipated that these units will be in place by January 2008. Manitoba Justice further advised my office on March 26, 2008 that: The RCMP has advised the Department that as a result of the 2007 provincial budget, two new positions have already been added to their existing Norway House establishment. Those new positions have increased the Norway House Detachment to 14. I can also advise you it is the intention of the RCMP to add a further two officers in 2008/2009. Along with Norway House, the Band A Resource Division Priority list referred to in your letter identified both Cross Lake and Little Grand Rapids as requiring increased resources. The Cross Lake Detachment currently has an establishment of 14 and Little Grand Rapids has an establishment of six. In 2008/2009, the RCMP intends to add one new position at each of those detachments. Manitoba Justice further clarified that the Band A Resource Division Priority list is one of many
tools that the RCMP uses to determine resource needs.

RECOMMENDATION FOUR:

The Department of Justice review with the Office of the Chief Medical Examiner that information at its disposal pertaining to deaths caused by alcohol poisoning to determine what information may be released to the public in compliance with privacy law. Emphasis should be placed on developing a policy of maximum disclosure that is consistent with the provincial privacy statute. The Office of the Chief Medical Examiner provided the following information to my office: Each year non-identifying statistical information related to deaths is published in the Annual Review of the OCME. Deaths as a result of poisoning, drug overdose or combination thereof are statistically combined and identified as "Drug/Alcohol Overdose". However effective with the 2007 Annual Review, which will be released at the end of 2008, we will provide a further breakdown of the statistical data on these deaths into the following categories: • alcohol poisoning/acute alcohol overdose; • specific drug overdoses; and, • combined alcohol/drug overdoses. Although the OCME provides statistical information throughout the year to all government agencies, departments and numerous other interested parties upon request, it is our intention to provide Manitoba Health and the Manitoba Liquor Control Commission with specific information on deaths arising from alcohol poisoning which, hopefully, will assist your departments in developing educational programs for Manitobans on the dangers of alcohol abuse.
RECOMMENDATION FIVE:

The Department of Health and the Manitoba Liquor Control Commission jointly develop a strategy for publishing that information accessible to the public on the deaths arising from alcohol poisoning to ensure its broad dissemination. The Manitoba Liquor Control Commission provided the following information to my office: I am aware that the MLCC has been mentioned in two of the judge's recommendations; however, these recommendations are beyond the jurisdiction of the MLCC. Recommendation Five calls for Manitoba Health and the MLCC to jointly develop a strategy for publishing information on the number of deaths that arise from alcohol poisoning. The MLCC does not collect such information, nor do we receive this information from either Manitoba Health or the Chief Medical Examiner's Office. It would therefore stand to reason that such statistics be released and promoted by the department or office with the responsibility for this information. Manitoba Health provided the following information to my office: The Office of the Chief Medical Examiner has made changes to its database allowing it to distinguish yearly between deaths from 1) alcohol poisoning, 2) other drug overdoses and 3) combined alcohol and other drug overdoses. Plans are underway to begin publishing this data in its annual report. MHHL [Manitoba Health and Healthy Living] has made plans also to post this information on the Mental Health and Addictions website. MHHL will work with members of the Addiction Agencies Network and other partners to encourage them to post and disseminate information on alcohol poisoning in the appropriate venues. MHHL has made contact with the Addictions Foundation of Manitoba (AFM) and work has been initiated to develop a Fact Sheet on "Alcohol Poisoning" similar to the Fact Sheet on "Binge Drinking" which is part of the Manitoba Addictions Awareness Kit sent to all schools in November, as well as available on the AFM website. AFM will work with its other partners to disseminate this information in other venues available to adults as well. Contact has been initiated with First Nations Inuit Health, Manitoba Region in order to discuss how we can work together to disseminate the information within its federal jurisdiction as well.
RECOMMENDATION SIX:

The Province of Manitoba and the Manitoba Liquor Control Commission consider providing some funding to Norway House First Nation in furtherance of that community's alcohol strategy or, if no cohesive strategy exists, provide seed money for the purpose of developing one. The Manitoba Liquor Control Commission provided the following information to my office: Recommendation Six speaks to possible funding by the Provincial Government and the MLCC for the development of a community alcohol strategy for Norway House First Nation. It is not the mandate of the MLCC to direct funding to specific communities to address alcohol-related issues. As you are no doubt aware, the MLCC's mandate is to return its profits to the Provincial Government, who in turn uses the revenue to fund health and social programs throughout Manitoba. While we are not in a position to provide direct funding to communities, the MLCC does direct a minimum of 0.2 percent of estimated gross profit toward social responsibility programs aimed at all Manitobans. In the past fiscal year, this amounted to over $550,000. These programs are developed in partnership with the organizations such as the Addictions Foundation of Manitoba and Healthy Child Manitoba who have the expertise in alcohol-related issues such as alcohol addictions and Fetal Alcohol Spectrum Disorder. With regard to alcohol poisoning, the MLCC's Be Undrunk program informs young adults, who are generally society's greatest risk takers, about the dangers of binge drinking or over-consumption of alcohol. This program was initiated by the MLCC in response to a number of tragic deaths of young adults due to over-consumption of alcohol. The program's web site and advertising deliver information that over-consumption of alcohol can lead to a variety of consequences, including death. This program has been well received by Manitobans and has been recognized internationally for excellence in public health advertising. The recommendations contained in the judge's report would best be delivered by the provincial department(s) with responsibility for health and social services. It is the MLCC's belief that we can best serve the people of Manitoba by continuing to raise awareness of the consequences of over-consumption of alcohol through a variety of public education and awareness programs directed to all Manitobans. Manitoba Health provided the following information to my office: Judge Colli stated that he did not make a recommendation to the federal government because he did not have the mandate to do so. MHHL has written to First Nations Inuit Health, Manitoba Region indicating our interest in meeting to discuss how we can work in cooperation to review and enhance substance abuse rehabilitation services for First Nations communities. A positive response has been received from FNIH indicating a contact for us, and a meeting will be set up in the near future. Manitoba Health notified my office on April 10, 2008 that a meeting has taken place with FNIH; Aboriginal Health Branch; and the Mental Health and Additions Branch. FNIH advised Manitoba Health that: • Norway House is under a Transfer Agreement • Norway House is in the process of a transfer to self-government • Community health assessments are provided and dollars are transferred for those health • Norway House has substantial resources and has directed significant resources to mental I am advised that FNIH is in the position to encourage the community to develop a community level addictions committee. FNIH will clarify what is occurring in Norway House respecting a drug and alcohol strategy and determine how provincial departments such as Manitoba Health can assist in the area of drug and alcohol prevention and public education. Based on our review of this matter, it would appear that Manitoba Health, Manitoba Justice and the Manitoba Liquor Control Commission have given reasonable consideration to the above noted recommendations. As such, our files concerning Sherrill Wilfred Forbister have been closed. Yours truly, Original Signed By Irene A. Hamilton Manitoba Ombudsman cc Ms Arlene Wilgosh, Deputy Minister of Health Mr. Ron Perrozo, Deputy Minister of Justice Mr. Don Lussier, President and Chief Executive Officer of MLCC Dr. A. Thambirajah Balachandra, Chief Medical Examiner

Source: http://www.ombudsman.mb.ca/uploads/files/general/17/3_closing-letter-to-the-chief-judge-forbister-inquest.pdf