Policy and Political Action

Policy & Political Action

EC7.10 Implementation of Coroner's Recommendations from the Faulkner and Chapman inquests

The Registered Nurses' Association of Ontario (RNAO) had the privilege of being designated by the Coroner as a person permitted to make submissions at the inquest into the death of Grant Faulkner and the inquest into the death of Bradley Chapman. RNAO was in the coroner's court and heard testimony each day from June 11-20, 2018 for the Faulkner inquest and November 26-December 20, 2018 for the Chapman inquest. RNAO's perspective is informed by having heard the compelling evidence at both inquests and knowing that these inquests were the first in more than a decade to focus on the deaths of individuals who were homeless in Toronto. In order to prevent additional tragic deaths, RNAO urges the City of Toronto to accelerate implementation and ensure follow-through of recommendations from both inquests.

RNAO appreciates that the City of Toronto is already a leader in demonstrating the effectiveness of a harm reduction approach, including supervised consumption services (SCS) such as The Works, as a means to prevent deaths from an increasingly toxic drug supply. As Toronto's medical officer of health, Dr. Eileen de Villa, testified at the Chapman inquest and in the media, the opioid overdose crisis "is the defining health crisis of our time"(Pagliaro & Mathieu, 2019). It is also greatly appreciated that the City has taken action on many of the juries' recommendations as documented in Attachments 1 and 3 of the August 21, 2019 staff report by the General Manager of Shelter, Support & Housing Administration. Even so, given that the opioid crisis in Toronto resulted in 308 deaths in 2017 and at least 294 deaths in 2018 (City of Toronto, 2019f) and that there continues to be around two deaths per week of people who are homeless in Toronto (City of Toronto, 2019e), much more and quicker action needs to be taken.

The jury representing the views of the public at the Chapman inquest urged all recipients of the recommendations to recognize "the urgent nature of the opioid overdose crisis and should consider and implement recommendations with the utmost urgency." Their last recommendation #55 asked that the recipients of the recommendations report back to the Office of the Chief Coroner and parties to this inquest in six months, and "annually for 5 years, in an open letter, regarding the progress made with respect to these recommendations" (Office of the Chief Coroner, 2018). Attachment 3 (City of Toronto, 2019b) of the staff report contradicts the spirit and wording of this last recommendation by saying "at this time, there is no request by the Chief Coroner or requirement to report annually to the Office of the Chief Coroner or any other party." While it may be technically true that the City has not received additional correspondence to that effect, it is clear that the intention of the jury was to ensure - in addition to urgency - accountability and transparency in the implementation of their recommendations in order to address the systemic failings that contributed to the death of Mr. Chapman.

In addition to making public the results of the recommendations arising from the Faulkner and Chapman inquests annually for five years, RNAO requests that fact-checking be done so that reporting reflects reality. An example from the Chapman inquest, page 2, Attachment 3, is "Toronto Public Health also posts data online about the deaths of people experiencing homelessness on a quarterly basis." While online quarterly reporting was confirmed by Toronto Public Health at the April 2018 Board of Health meeting (Medical Officer of Health, 2018), the online webpage says that "updates will be posted every six months." A review of the online webpage on September 5, 2019 could not find a quarterly update or even one for the last six months as the last data point was December 2018 (City of Toronto, 2019e). This lapse is all the more striking in that the initiative to collect data on the number of individuals in Toronto who died while being homeless arose from a motion by Councillor Ainslie (Ainslie, 2016) following media accounts of the death of Bradley Chapman (Ormsby & Wallace, 2016). It is critical that the City improve, rather than backtrack, on accurate data collection and public posting in order to understand and prevent deaths of people who are homeless.

A second example of how reported plans and actions stray from reality may be found on page 7 of the Faulkner inquest, Attachment 1 (City of Toronto, 2019a). This report says, "starting summer 2019 residents are able to access cool spaces through the City's Heat Relief Network by visiting one of 300+ air conditioned locations throughout the city" though an interactive map on the City's website (City of Toronto, 2019c). Information is not the same as access as those with limited means often may not have a phone to find out when the cool space is open (usually not at night). Many of the listings such as splash pads and shopping malls are unwelcoming or evenly actively hostile for people perceived to be homeless (Crowe, 2019; McCabe, 2019; Sharpe, 2019). It also seems cruel to direct people who are homeless to "services that already serve vulnerable populations such as shelters, drop-ins and respite centres" (City of Toronto, 2019a) when all of those services are routinely operating at or over capacity (City of Toronto, 2019d).

As a provincial organization representing registered nurses, nurse practitioners, and nursing students with a home office in Toronto, we share the common objective of a city and a province where all people can live in health and dignity. We urge more action and a greater sense of urgency from the city of Toronto on addressing homelessness, lack of affordable housing, and a public health approach to drug policy. We will continue to encourage your leadership and transparency in addressing this complex challenge.


Warm regards,


Doris Grinspun, RN, MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT

Chief Executive Officer, RNAO


For Learning from the deaths of Grant Faulkner and Bradley Chapman - Presentation to the Economic and Community Development Committee speaking notes, please click here.

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