Moses Beaver's sons tell inquest their requests for help for Oji-Cree artist were brushed off

WARNING: This story discusses sexual abuse, mental distress and suicide.

Over the past three weeks, the jury probing the inquest into the 2017 death of Moses Amik Beaver has heard numerous calls for better mental health care in remote First Nations and the Thunder Bay District Jail, as well as a reminder that much of what witnesses have recommended has been heard before.

Beaver, a Woodlands artist from Nibinamik, an Oji-Cree First Nation in northwestern Ontario, was 56 when he died by suicide while he was in custody. The inquest — which the Ontario Coroner's Act says is mandatory when a person dies in custody — is entering its fourth week. 

Since 2002, 13 people have died in the jail. At least seven of them were Indigenous. Inquests have been completed into 10 of those cases. The most recent was the joint inquest into the deaths of Don Mamakwa and Roland McKay that ended in November.

Those inquests have yielded hundreds of recommendations, but many of them have not been implemented, according to a CBC News review of the eight inquests completed from 2002 to 2020.

Anna Betty Achneepineskum, deputy grand chief of Nishnawbe Aski Nation, testified last week — as did Beaver's family — at the inquest into the artist's death.

Achneepineskum said she'd like to know why many of the recommendations that came out of previous inquests haven't been put in place.

Family says concerns dismissed by police, jail staff

Nishnawbe Aski Nation, which represents 49 First Nations in northern Ontario, has itself issued countless recommendations, resolutions and reports over the years related to the challenges facing First Nations, including mental health crises, Achneepineskum testified.

"We continue to advocate for the federal and provincial government to … address the disparity in terms of the lack of resources and services for First Nation citizens, because this is not just isolated to the citizens of Nishnawbe Aski Nation — this is right across Canada." 

That disparity, she said, is deeply entrenched at an institutional level.

"You have to remember that the Indian Act, which is one of the most, I would say, racial pieces of legislation, is the foundation of the policies that exist within any of the government departments where a First Nation citizen is involved," she said.

Beaver's eldest sons, Gershom, Shallum and Jerome Beaver, addressed the jury together on Thursday. They spoke of their father's kindness, his land-based skills and his artistic talent.

Since my father's [2017] death, the legal system and how Indigenous people are looked after when they are ill hasn't changed.- Gershom Beaver testifies at his father Moses Beaver's inquest

They showed videos of their dad explaining how to smoke meat and describing what he liked about holding art workshops at schools, before the three displayed some of his artwork on a large screen at the front of the room.

The brothers also spoke of the trauma their father endured, including several losses in his family and his experiences at day school, where they say he was sexually abused.

Gershom said he and Shallum tried to get their father out of the Thunder Bay jail and into the hospital multiple times in 2017, but staff seemed to brush off their concerns.

When Shallum was previously in the Thunder Bay jail, he said, an inmate two blocks down from him died by suicide. That experience fuelled his fears his father might suffer a similar fate.

"I knew how important it was that he got the right help," Shallum said.

The brothers were told their father was on a suicide watch as of Feb. 9, 2017, but the Correctional Service Oversight and Investigations (CSOI) report on Beaver's death shows he was taken off suicide watch on Jan. 24, 2017, and then removed from enhanced supervision on Feb. 8, 2017.

"Since my father's death, the legal system and how Indigenous people are looked after when they are ill hasn't changed," said Gershom.

Nibinamik First Nation, 385 kilometres northeast of Sioux Lookout and 500 kilometres north of Thunder Bay, also faces multiple challenges, including a lack of mental health training with no centre to facilitate it, a small, aging nursing station, and hazardous housing conditions.

"Eighty per cent of the homes we have in our community are not livable and would be condemned anywhere else in Canada outside of a reserve," Gershom said. "When it rains outside, it rains inside. The mould is so bad that my brother almost lost three fingers on one of his hands and my dad needed a puffer to breathe."

Gershom said he moved to Thunder Bay a decade ago because of how the mould affected his son.

"Anishinabek are faced with grief and trauma with little to no help; we just continue walking and hope for the best."

Concerns with Beaver's treatment in jail: CSOI report

Last week, the jury saw the CSOI report, completed in May 2017, into Beaver's death. Among the concerns documented were:

• Beaver did not see a psychiatrist until three weeks after he was brought to the Thunder Bay jail.
• Jail staff's log books did not meet ministry standards with respect to entry recording.
• There was an overall lack of documentation and attention to detail on Beaver's health-care file by registered nurses and primary care physicians.
• After Beaver's suicide watch was lifted, his reintegration plan was not properly filled out.
• Beaver's breathing should have been assisted with ventilation when he was found unresponsive at the jail.

Although Beaver died by suicide while in administrative segregation, the CSOI report does not include a review of the jail's policies and procedures related to segregation, the coroner's jury heard.

Audit of former recommendations needed: NAN

Achneepineskum's recommendations for the jury include properly resourced safe rooms in First Nations, sustainable funding for Telehealth Ontario and in-person care, and access to not only western medicine, but to traditional knowledge keepers and elders.

She also raised the idea of having mobile mental health teams visit First Nations for a week at a time to provide thorough assessments and referrals to other services.

But as the jury prepares its own set of recommendations, Achneepineskum said there must be accountability for what hasn't been implemented in the past — and answers as to why.

"We would be able to have a very thorough audit and we would be able to utilize that as we continue to lobby for funding and resources, and also getting our communities to buy in and embrace certain initiatives," she said.

A primary goal of coroner's inquests is for the jury to come up with recommendations to prevent deaths in similar circumstances from happening.

"[Moses] being deprived of proper medical services — including a comfortable house, a safe house for him to be able to live in — impacted him," Achneepineskum told the jury.

"Just remember that he was a person that needed help, and that he was a father, and a grandfather, and a husband and a son."

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.

Support is available for anyone affected by their experience at residential schools:

A national Indian Residential School Crisis Line has been set up to provide support for former students and those affected. People can access emotional and crisis referral services by calling the 24-hour national crisis line: 1-866-925-4419.