Two years after the death of her father in 2022, Amanda Large received news that brought added grief and new unanswered questions: her father’s brain, which had been removed during an autopsy, had not been cremated and returned to her family along with his body.
Instead, it had sat in the back of a Victoria, B.C., hospital refrigerator for years, until it was discovered in 2024 by someone cleaning the fridge.
“There’s a lot that goes on when someone passes away, and having to relive all of that but having it be much more traumatic was really hard,” said Large.
“The situation was very preventable, and now I don’t know when or how I’m gonna heal from this.”
Large’s 55-year-old father, Philip Peter Billy, is from the Ehattesaht First Nation on the northwest coast of Vancouver Island. When members of the nation die, it’s important for them to be put to rest quickly — ideally within four days — and with their body fully intact, according to Nuu-chah-nulth Tribal Council president Judith Sayers.
Large and her family have pushed for answers and justice for her father since she found out about his remains last fall, including launching a civil lawsuit against Island Health and the B.C. Coroner’s Service.
The health authority, the coroner’s service and B.C. Public Safety Minister Nina Krieger declined to respond to questions from the CBC, citing the ongoing litigation.
Without any accountability or assurance of changes being made, Large also dreads the day this may happen again to another Nuu-chah-nulth Nations member — because it already has.
Three-year-old Margaret Thomas from the Tla-o-qui-aht First Nation drowned in 1997 when her parent’s pickup truck plunged off of a dock in Tofino. Her eyes were removed by a coroner during an autopsy and not returned with the rest of her body, which the family only found out when their funeral director asked if they’d donated her eyes.
It took three months — and the family hiring a lawyer — to get Margaret’s eyes back, too late to bury her with them, according to Canadian Press reports at the time.
“They took the most beautiful part of Margaret,” Leo Mason, Thomas’s grandfather, told The Canadian Press at the time.
Larry Campbell, then chief coroner, apologized to the family and said policies were changed to prevent eyes from being removed in an autopsy unless there is suspicion of shaken baby syndrome or evidence of traumatic injuries.
The toll these cases have taken on families has sparked new cultural protocol from local First Nations, Large said, including calling upon those who have experienced the loss of a deceased loved one’s body part by officials to support those newly affected when another instance arises.
While Large is grateful for the support she received from Margaret Thomas’s family, she feels the responsibility of having to respond to any future situations like this will make it more difficult for her to grieve.
“It’s gonna make it harder to move past this situation, because I don’t know when it’ll happen again, if it’ll happen again within my lifetime, but that’s something I have to carry, and my little brother has to carry,” said Large, whose brother is 11 years old.
‘A careless mistake’
Billy is described by his daughter as a gentle, kind father of four who enjoyed walks or sitting down to a meal with family. But his life, Large said, was a difficult one.
“He went to residential school, and he suffered at the hands of all these colonial systems that we have in place,” she said.
In 2017, a RCMP officer took Billy to the ground in order to arrest him, causing a traumatic brain injury, two broken orbitals, a broken nose and bruises. An Independent Investigations Office of B.C. report did not find reason to recommend charges against the officer to the B.C. Prosecution Service.
After Billy’s death in 2022, it was months before his body could be cremated due to the autopsy, and Large said the B.C. Coroner’s Service called her to confirm Billy’s brain and body were reunited before the cremation.
The coroner’s service reached out again in June 2024, after Billy’s brain was discovered in a fridge at Victoria’s Royal Jubilee Hospital. In emails shared with the CBC, the service asked to call Large to discuss “a very serious incident” that will be “some hard and frustrating news.”
When scheduling challenges came up — including the death of Large’s grandmother — the coroner wrote “its [sic] no rush” and “take the time that you need.”
In September, three months after the coroner’s service first reached out, they finally told Large the news about her father’s brain over a phone call.
In a later email, a coroner told Large that two coroners had received confirmation from hospital staff that the remains had been reunited, when actually “it was misplaced in a fridge and not returned to the body.”
“It was found now while the fridge was being cleaned out,” the coroner wrote.
Large was also initially sent a bill to cremate her father’s brain that totalled about $800 — which she says was later covered by the government.
Chrissie John, elected counsellor for the Ehattesaht First Nation and Large’s cousin, said this has hit hard for the nation of about 550 people.
“I think it does bring about a lot of feelings of the systemic racism that exists in the medical institutions and the experiences our people have had for generations, and this is another example, I think, that we’re feeling for our people who have not been treated with care,” she said.
Nuu-chah-nulth Tribal Council president Sayers, who represents the Ehattesaht and Tla-o-qui-aht nations along with 12 others on Vancouver Island, shared her frustration that Billy’s remains were misplaced for more than two years.
“It’s just devastating news that’s such a careless mistake,” she said. “I don’t understand how it could have been missed after all that time.”
Calls for reform
Aldo Fusaro, chief medical examiner for Washington state’s Whatcom County, said when body parts are misplaced following an autopsy, in his experience, it’s due to poor communication and record-keeping.
He, along with Island Health and the B.C. Coroner’s Service, declined to say how often a deceased person’s body parts are misplaced in their regions.
“It happens hopefully infrequently, [but] more frequently than any of us would want,” said Fusaro.
Sayers, John and Large say they’re still waiting for Island Health and the coroner’s service to take accountability and be transparent about what happened.
Sayers says stronger laws, training measures and penalties should be put in place — including, potentially, consequences for those involved in misplacing Billy’s remains.
“At this point, an apology is not going to change anything,” said Large.
Instead, she wants to see the policy for handling remains between Island Health and the coroner’s service, and how they’re changing it to prevent another person’s remains from being misplaced. She also wants more of a clear paper trail between health authorities and the coroner’s service when it comes to the handling of human remains.
In her civil lawsuit, she is also seeking damages for the trauma and emotional harm her family has experienced, along with the months she had to close her business in 2024 due to grief and distress.
Eric Clausen, the lawyer representing her and her brother, said the case has the potential to set a new legal precedent in the area of negligence and medical malpractice.
Meanwhile, Large and her family are in the process of putting Billy’s ashes to rest. In the first years after his death, stormy skies prevented them from travelling by boat to their traditional territory to scattering his body’s ashes — something Large is now grateful for. Billy’s cremated remains will soon be scattered together by his loved ones, after being reunited in a ceremony last fall.
“We did our prayers, we said another goodbye,” she said. “We had to apologize, you know?”
