Presiding coroner Dr. Michael Wilson opened the inquest into the deaths of five people during a blastomycosis outbreak in Constance Lake First Nation by telling those in attendance that he wants the truth to come out.
Families placed pictures of loved ones who passed of blastomycosis on a table before the podium in the community hall in the Oji-Cree First Nation west of Hearst, Ont., before the coroner spoke.
Luke Moore, Lorraine Shaganash, Lizzie Sutherland, Mark Ferris and Douglas Taylor died between Nov. 19, 2021, and Jan. 23, 2022.
Elders Florrie Sutherland and Stands in Water prayed and smudged everyone attending the inquest. They encouraged people to offer tobacco to a sacred fire outside as a means of communicating with the Creator.
Constance Lake lapped at the shore and the gentle flapping of a teepee harbouring a sacred fire provided a soothing background.
Inside the community hall, families and community members, current Constance Lake Chief Rick Allen, as well as several former chiefs, hospital representatives, and representatives for public health, Ornge and Indigenous Services Canada filled the hall, along with the lawyers representing each of them.
Five jurors sat solemnly.
Wilson introduced himself, and referring to the livestream of the event, told the audience that people around the world may be showing an interest and sending good thoughts to the community.
“Years have passed and we hope this inquest answers questions about their untimely deaths,” he said.
With some foreshadowing of what may be heard at the inquest, Wilson said a more equitable and responsive health system is part of “building a better future.”
He said part of the scope of the inquest will include how First Nations people were treated by the medical system when seeking help for their symptoms, and identifying how health-care emergencies in First Nations that are beyond their ability to respond might be better managed.
Wilson said despite the presence of lawyers, no one participating in the inquest should find fault or responsibility, but should explore the facts.
He said an inquest is an opportunity to make recommendations to avoid further deaths while not finding any legal responsibility or conclusions of law.
“The inquest ensures no death will be ignored,” said Wilson.
Shruti Ramesh is a lawyer with the coroner’s office, in a division working to repair the relationship between Indigenous people and the justice system.
“We have learned that every person in the community was impacted by this outbreak,” said Ramesh.
“We are so sorry for all of these losses and the losses that continue to this day.”
She started by summarizing evidence that has been gathered through visits to the community.
After reports of several community members feeling ill in November, three people died in three days between Nov. 19 and 21 after seeking help for symptoms in the emergency room at the Hearst hospital.
Doctors first ruled out COVID-19, then considered pneumonia.
Ramesh said the inquest provides the benefit of “slow hindsight” to understand the inequities of health care that First Nations experience in this province.
“We’re going to talk about issues that are going to be difficult to talk about, racism, but that doesn’t mean they shouldn’t be talked about,” she said.
She began by summarizing the evidence that had been gathered through visits to families.
Luke Moore
Ramesh said 43-year-old Moore first went to the emergency room at Notre Dame Hospital in Hearst on Nov. 9, 2021 ,complaining of cough, fever and chills. He was told he had the flu and discharged, she said. Two days later, he returned and an X-ray found pneumonia. Moore was given antibiotics and discharged.
On Nov. 17, he called an ambulance and was admitted to Notre Dame, where tests were ordered, including for fungal infections. The test for blastomycosis was ordered following the news that an unnamed person in the community had tested positive for the fungal disease. However, Moore continued to decline.
Doctors recommended urgent relocation to Sudbury and placed a request for transfer via Orng air ambulance. That request was declined because of bad weather and poor conditions at the Hearst airport that afternoon and overnight. Moore’s condition worsened and he died of cardiac arrest at 9 a.m. on Nov. 19.
Lorraine Shaganash
Nine hours following Moore’s death, Shaganash, 47, arrived at the Hearst hospital by ambulance. She had been feeling ill for three weeks. She was transported to Health Sciences North in Sudbury where she died on Nov. 20. Lab results found she died of blastomycosis in combination with acute respiratory distress syndrome.
Lizzie Sutherland
Sutherland, 56, first went to the emergency room at the Hearst hospital on Oct. 29 and was sent home with antibiotics. She returned on Nov. 15 because she still wasn’t doing well, and she was admitted, given antibiotics, and more tests were ordered including for blastomycosis.
On Nov. 19, doctors learned samples for the tests had not been collected and reordered them. Suspecting blastomycosis, Sutherland was started on the appropriate medicine. On Nov. 20, doctors ordered she be transported to hospital in Sudbury no bed was available.
Ornge air ambulance said it could transfer her the next day, but by then, her condition had become so perilous that doctors feared she would not survive the transport. Sutherland passed away at 12:45 p.m. on Nov. 21. An autopsy found blastomycosis and organ failure to be the cause of death.
Mark Ferris
Ferris, 67, went to hospital on Nov. 24 after feeling ill for a week. He was diagnosed with pneumonia and congestive heart failure. Tests were ordered, including for blastomycosis, but he had to stop taking the heart medications in order for the antifungal medications to be effective.
Ornge was contacted to take him to North Bay hospital, but it turned down the transfer due to weather. He was airlifted the following day but died on Nov. 30. Laboratory tests found cause of death to be blastomycosis and multi-organ failure.
Douglas Taylor
On Nov. 22, Taylor went to hospital to be tested for blastomycosis. The preliminary test came back positive and he started treatment. On Nov. 24, he returned to hospital complaining of shortness of breath. He was treated for congestive heart failure, which improved but his pneumonia didn’t. It was determined that the antifungal medication wasn’t being absorbed well because of his other medications.
On Jan. 21, he was in hospital asking to go home but doctors kept him in hospital. Overnight, Jan. 22-23, he said he had severe anxiety, and on Jan. 23, around 8 a.m. it was found he was not getting enough oxygen and he was given some. A few minutes later, a nurse found he had no vital signs and he was pronounced dead shortly after. Lab results found the cause of death to be respiratory failure due to blastomycosis.
Always with a smile. That was the character of Luke.– Arthur Moore, speaking about his son who died of blastomycosis, Nov. 19, 2021
The first family member to testify was former chief Arthur Moore, who lost his son, Luke. Moore described him son as an athletic and healthy young man with close family ties.
“Even when he was a baby, he was never bothered by immunizations or needles,” said Moore. “We never heard him cry. Always with a smile. That was the character of Luke. Always happy.”
At 6-foot-4, Moore’s father said, Luke was built like an athlete and always did things well, including playing hockey and basketball.
He remembered how Luke worked at the Thunder Bay athletic complex in his 20s and the elders adored him, bringing him treats when he opened the centre.
“It’s hard to talk about the love that we shared, because we used to communicate well and he was very honest about his feelings,” said Moore, choking up.
“The medical community needs to be more aware,” said Moore. “I feel the medical community did not meet that goal when it came to Luke. I want there to be a greater awareness (of blastomycosis) and not just pneumonia.”
Luke’s partner then spoke of how his death affected her and their children.
“He was my home,” said Joanne Martin. “He was the most loving and passionate man. He brought an incredible sense of peace to everyone around him.”
She described a generous man who offered food, drink and warm clothes to everyone around him, not expecting anything in return and who loved feeding his family, especially his grandchildren.
“Luke was endlessly patient and unselfish,” she said.
“He had a remarkable ability to lift others up,” she said. “And a special way to make others seen and valued.
“His absence has left a space that cannot be filled.”
Next, a lawyer read a statement on behalf of Kathleen Taylor, Douglas’s sister.
“Doug was kind and funny and we talked every day,” wrote Kathleen. “I didn’t expect my brother to pass away like that and I never got to say goodbye.”
She wrote that their last conversation was the night before he passed, but due to COVID restrictions, it was on the other side of a glass, so they couldn’t touch.
Now, she said, she avoids the hospital even though she has medical issues because of the bad memories.
Sutherland’s relatives spoke next.
Rick was her oldest brother, and his wife, Susan, spoke on their behalf.
She described Lizzie as a stubborn person who adopted two sons and was raising two grandchildren at the time of her death.
“What could have happened that could have helped her sooner?” she said. “Why was she not sent sooner to Sudbury? Why was she not a priority? Generational trauma does not excuse why the system continues to fail us.”
Why was she not a priority?– Susan Sutherland, Lizzie Sutherland’s sister-in-law
The sister of Lorraine Saganash, Candida Solomon, also wrote a statement that was read aloud.
“I felt I had no one to talk to when this was all happening,” she wrote, noting the community was in lockdown at the time of her sister’s death and her mother was in isolation in hospital, also diagnosed with blastomycosis.
“I couldn’t grieve with Lorraine’s children or grandchildren, or our brothers,” she wrote.
“We, as a family, miss her every single day and it’s a loss that will never be filled.”
Marlene Esquimeaux, Ferris’s widow, said they met when they were teenagers and were together for 37 years before they married.
She described how after he had a heart attack, she asked him if it was time to get married and he replied, “Do you think it’s safe now?” she said, laughing.
They got married in their 60s at a family reunion at camp, much to the surprise of everyone involved.
She was with him at the hospital in North Bay for the two days before he died, as his lungs filled with fluid from blastomycosis.
“We talked until we couldn’t anymore,” she said, and he instructed her to put his wedding ring on her finger.
“‘And don’t take it off and don’t let anyone else put rings on you,'” she said he told her as. She laughed, holding up her hand where the ring glistened on her thumb. “It’s been four years now.”
“I miss Mark every single day,” she said.
“I get scared sometimes it [blastomycosis] will resurface and no one knows who it will affect.”
The inquest continues Thursday with more from family members.
Twenty-five days have been set aside to hear from 30 witnesses.
