More than 6 years later, Moses Beaver's means of death 'undetermined', inquest jury finds

WARNING: This story discusses mental distress and suicide.

The jury overseeing the inquest into the death of Moses Beaver has deemed the means of his death to be undetermined — which is the finding his family was hoping for.

The inquest into the 56-year-old Oji-Cree Woodlands artist's death began on April 17, more than six years after he was found unresponsive in the Thunder Bay District Jail. Inquests are mandatory under the Ontario Coroners Act when a person dies in custody.

A jury of three white women, one white man and one Indigenous woman heard from 32 witnesses about the mental health crisis Beaver experienced in Nibinamik First Nation, and the crisis he continued to experience at the Thunder Bay District Jail leading up to his death.

Deliberations began Wednesday and the jury delivered their verdict Friday: Moses Beaver died on Feb. 13, 2017 just after 10 p.m. at the Thunder Bay Regional Health Sciences Centre, with the means of his death labelled "undetermined."

During closing submissions, one of the family's lawyers, Caitlyn Kasper of Aboriginal Legal Services, explained why the family believes a finding of undetermined is most fitting.

"In this case, the family says there is evidence that points to suicide but also much that points away from it," Kasper told the jury Wednesday. "It is the submission of both the family and our interpretation of the evidence before you that if not for the severity of his illness, Moses would not have chosen to end his life."

The jury heard testimony that Beaver attempted suicide twice in Nibinamik before being brought to the Thunder Bay District Jail on Jan. 18, 2017.

But they also heard from Beaver's eldest sons that their father was against suicide. Writings found in his jail cell also indicated he understood the devastating impact of suicide, the jury heard.

"It is in some ways a deeply unsatisfying verdict because it does not deliver the certainty that we might have hoped for. On the other hand, though, it is an honest and a fair verdict, and one that may best reflect the limits of the evidence that you have available to you," Kasper said.

"What we do know is that his life was invaluable and that his loss had a profound impact on those who loved him."

The jury delivered 63 recommendations to prevent future deaths similar to Beaver's — including ways to make sure someone in his condition is transported to hospital, not jail. 

Improving mental health care for Indigenous people

It isn't mandatory for an inquest jury to provide recommendations, but the jury did receive more than 50 suggested ones from counsel before deliberations began.

The very first recommendation serves as a legacy for Beaver, who taught art workshops in schools. It asks the provincial and federal governments to fund an art program at Nibinamik Education Centre, and an additional school in Nishnawbe Aski Nation territory on a rotational basis, where an artist helps students create work that expresses traditional knowledge. 

The rest of the recommendations were focused on improving mental health care within remote First Nations and correctional settings like the Thunder Bay District Jail and the new Thunder Bay Correctional Complex that is scheduled for completion in fall 2026.

They include providing more resources for mental health treatment within First Nations, making mental health transports more direct and dignified, and ensuring all parties involved follow a common protocol so everyone knows their role and can be held accountable for it.

We have all been deeply impacted and will carry a piece of him with us.- Statement from the jury overseeing Moses Beaver's inquest

That would prevent situations like Beaver's, where the jury heard that delays, misinformation and miscommunications between the community, Ornge and police ultimately resulted in Beaver being transported to jail instead of a hospital.

The jury also recommends Indigenous Services Canada engages with First Nations about building safe or secure rooms — while ensuring there's enough physical space, staff and training to facilitate them — so someone like Beaver, who was shifted between a small, aging and understaffed nursing station and his family's house, has somewhere to go where they cannot harm themselves or others.

Furthermore, the jury recommended Nishnawbe Aski Nation, which oversees 49 First Nations across Treaty 9 and 5, receive funding to develop a culturally-safe mental health care plan for remote First Nations in northwestern Ontario.

Better care, conditions in corrections

Ongoing mental health and cultural awareness training was another big ask, especially for front-line workers in correctional settings.

Particularly when it comes to Indigenous inmates, whom witnesses testified make up to three-quarters of the Thunder Bay District Jail's population and experience more frequent and complex mental health and addictions issues.

There was a big focus on Indigenous-run, Indigenous-led solutions. The jury recommended improving inmates' access to native inmate liaison officers, Elders and other Indigenous service providers.

At the new correctional complex, they suggested building a dedicated outdoor cultural space and a mental health unit, with cells that do not lend themselves to self-harm.

After hearing repeated testimony about the overcrowded and understaffed jail, the jury also recommended at least five hours of stimulating activity a day for inmates and an hour of outdoor time.

As for accountability, recommendations around health accreditation to improve the standard of care in correctional settings for Indigenous people were also made, along with the suggestion of an Indigenous Advisory Committee looking at the provision of health care and correctional services.

The recommendations were issued to several parties, including:

• Governments of Canada and Ontario.
• Indigenous Services Canada.
• Nishnawbe Aski Nation.
• Nishnawbe-Aski Police Service and OPP.
• Ministries of Health, Attorney General and Solicitor General.

NAN welcomes jury's recommendations

Nishnawbe Aski Nation issued a release Friday following the jury's verdict, supporting the recommendations made.

"Over the past several weeks, this inquest has revealed systems designed with fatal flaws that ignored the realities of the people and communities they should have served. Under-resourced systems left an entire community with only two nurses and no police officer.

"In the final weeks of Moses' life he was, though innocent, imprisoned by a justice system that did not care for his life or treat his illness," said deputy grand chief Anna Betty Achneepineskum in the release.

While the jury's verdict is not legally binding — which means no one is required to follow the recommendations — the Office of the Chief Coroner does ask those who received recommendations to respond within six months on whether they were implemented and if not, why.

However, perhaps the most meaningful recommendation, No. 63, is for the Office of the Chief Coroner for Ontario to conduct an annual review of past inquests that deal with mental health and addiction issues experienced by First Nations people — looking at recommendations made in the past and the patterns across those that haven't been implemented.

"We urge the governments of Canada and Ontario to review the recommendations and to make it a priority to implement the recommendations so that no First Nations individual is denied the required care when in extreme crisis," Achneepineskum said. 

The jury also delivered a statement following the verdict.

"Although we didn't have the privilege to meet Moses in person, we have been honoured to learn about who he was, how important he was to so many, and what an asset he was to his community," one of the jurors read to Beaver's family through tears.

"We have all been deeply impacted and will carry a piece of him with us. Our hearts are heavy with the events that Moses had to endure and the tragedies you've all experienced. It is our hope that these recommendations honour his memory for you."

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).
• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling on the website.
• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.
• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.