24 recommendations made by jury in coroner's inquest into 2015 fatal police shooting in Kitchener

The five-member jury of a coroner's inquest looking into the 2015 police shooting death of Beau Baker in Kitchener, Ont., has made 24 recommendations for how to prevent similar deaths in the future.

The recommendations weredirected atspecific groups including the Regional Municipality of Waterloo, Waterloo Regional Police Service, Province of Ontario and Ministry of the Solicitor General.

The 24 recommendations will be forwarded to the chief coroner in Ontario.

Beau Baker, 20, was shot and killed by a Waterloo Regional Police Service officer in April 2015 outside Bakers' home on Brybeck Crescent in Kitchener, Ont. Baker had called 911 threatening to kill himself and harm others. Baker's family has said he had "documented mental health issues." Ontario's police watchdog, the Special Investigations Unit, said there were no reasonable grounds to charge the officer in Baker's death.

An inquest into Baker's death is mandatory under the Ontario Coroners Act. The inquest into Baker's death began on March 20, 2023 and is being held virtually out of Toronto. The jury in a coroner's inquest makes recommendations to prevent future similar deaths. Read all of CBC's coverage of the coroner's inquest here.

Dr. David Eden presided over the inquest. On Friday, he thanked the jury for their work and highlighted how important it was for Beau Baker's mother, Jackie Baker, to take part in the proceedings and "who advocated for Beau's memory with such courage and determination from the day of his death and throughout this inquest."

"Her active involvement is critical in shaping this inquest and her presence during this inquest reminded us that an inquest is not an abstract exercise, it's an inquiry into the death of a real, beloved person," he said.

"Beau Baker was a young man, a beloved family member and friend, who died tragically in an interaction with police. He had a serious, long-standing mental disorder which likely played a role in his death," said Eden.

Death by suicide: Jury

The jury was asked to determine the reason for Beau Baker's death. They could choose from four options:

• Homicide.
• Suicide.
• Accidental.
• Undetermined.

In its verdict Friday, the jury said the cause of death was suicide.

This decision was disappointing for Jackie Baker, she said in a statement Friday afternoon.

"We are deeply concerned by the message that the jury's verdict of suicide sends to other people experiencing crisis and interacting with police," Baker's statement said.

But Baker also said that if her son had access to the types of services the jury recommended, it would have "changed the trajectory of Beau's life."

"I hope the recommendations will be implemented and prevent another family from having to go through what we have gone through."

Asha James,lawyer for the Baker family in the inquest, saidBeau Baker's death should be a call to re-frame how we regard these kinds of cases.

"It is clear from this jury's verdict and recommendations that we need to change the way we look at those suffering with mental illness," James said. "It is a health issue instead of a criminal issue."

The jury had heard from several experts during the inquest. They heard Baker was dealing with mental health problems and in the year before his death, he visited emergency departments in Waterloo region 26 times for suicidal ideation, suicidal behaviour and non-suicidal self injuries.

The inquest also heard how Baker had been removed from his home twice as a child while his mother sought help for her addiction to alcohol. The second time he was removed from his mother's care, Baker was in a group home and the jury heard this was particularly tough for him. He also had a learning disability and used alcohol and marijuana, the jury heard.

Need for youth wellness hubs

The jury called on the Region of Waterloo and the province to create youth wellness hubs to better support young people. They jury offered eight guidelines for the hubs:

1. Operate with extended hours and in a transit-friendly location appropriate for youth aged 16 to 24.
2. House youth in youth friendly and non-clinical settings to support trust and comfort.
3. Have a 24-hour crisis line with sufficient funding and staffing "to ensure callers encounter no wait times."
4. Provide developmentally appropriate primary care, peer supports, mental health and addiction services.
5. Ensure voices of transition-aged youth are included in the design and delivery sites and services.
6. Conduct outreach through methods appropriate for transition-aged youth to ensure young people are aware of the services provided.
7. That the hubs be subject to "continuous research and evaluation to ensure that they operate in a manner that is evidence based."
8. Promote and communicate awareness of the program within the community.

Ten of the 24 recommendations were specifically for the Ontario government.

Some of those recommendations included:

• Fully funding the Children's Aid Societies for youth aged 18 to 23 as part of the Ready, Set, Go program.
• Providing adequate funding for community mental health and addiction services, "evidenced by no wait lists for assessment, treatment and relapse prevention services."
• Committing to moving away from licensing traditional group home settings and move toward fully funding "smaller, family model care settings with access to multidisciplinary care teams that wrap around a youth and respond to their individual needs" to improve outcomes.

24 recommendations

Below are the 24 recommendations from the coroner's inquest jury.

To the Regional Municipality of Waterloo:

1. Co-ordinate and lead all necessary local stakeholders in submitting an application with an evidence-based business plan to the Province of Ontario for the funding of one or more youth wellness hubs to be established in Waterloo region.

To the Province of Ontario:

2. Provide base funding for and facilitate the creation of youth wellness hubs across the province as introduced under Ontario's 2020 Roadmap to Wellness strategy.

3. Provide full funding to Children's Aid Societies for youth aged 18 to 23 in the care of a Children's Aid Society through the Ready, Set, GO program. To achieve the government's stated goals for the Ready, Set, GO initiative, full funding needs to be permanent and guaranteed for the duration of the program.

4. Adequately fundcommunity mental health and addiction services, evidenced by no wait lists for assessment, treatment and relapse prevention services. The Province of Ontario should increase system capacity to provide adequate levels of in-home and live-in intensive treatment services across the province.

5. Adopt a commitment to move away from licensing traditional group home settings and toward licensing and fully funding smaller family model care settings with access to multidisciplinary care teams that wrap around a youth and respond to their individual needs effectively to improve outcomes and support youth health and wellness.

6. Identify and implement critical linkages between its child welfare redesign strategy [the Ministry of Children, Community and Social Services] and its Roadmap to Wellness strategy [Ministry of Health] to streamline access and facilitate early intervention and wrap around services for children and families. The Province of Ontario should adequately fund and implement community-based prevention services to avoid intrusive child welfare involvement. This should include addiction and mental health services for parents.

7. Provide sustained and sustained funding for programs like IMPACT [i.e mobile crisis intervention teams and crisis called diversion programs] and specifically those initiatives in the Waterloo region for the Canadian Mental Health Association Waterloo-Wellington.

8. Support and implement Waterloo Regional Police Services's submitted 2021 Ontario Association of Chiefs of Police resolution, as endorsed and passed, as it relates to mental health (non-public safety) calls and authorities under the Mental Health Act.

9. Ensure that community based non-police crisis response teams are available 24/7 across the province and are sufficiently funded to provide effective response times.

10. Create or amend legislation and provide supporting funding that would allow for "situation tables" or "connectivity tables" within all communities to be mandated. Consideration should be given to authorizing the sharing of information to allow for the efficient identification of persons in crisis for referrals and support. The mandate of such tables should be data identification and support of those that may be receiving treatment while in crisis but not accessing or offered support in between those crises.

11. Use the model adopted by the Gerstein Crisis Centre to roll out similar programs across Ontario and continue support of the existing centre in the City of Toronto.

To the Province of Ontario and Municipal Governments:

12. Adopt a housing first commitment for youth 16 and over in the care of a children's aid society and receiving extended support from a society under the Ready, Set Go program by ensuring there's adequate funding and supply for affordable, supportive transitional housing up to and including young adults age 23.

To all police agencies, children's aid societies and healthcare clinics or healthcare professionals who are supporting a transition age that is 16 to 24 year old young person with complex needs:

13. Be empowered to initiate case conferencing and case management if such a process would be helpful in co-ordinating supports for the young person. Any case conference process should be strengths-based and place the young person and his or her family at the centre.

To Children's Aid Societies:

14. Ensure youth are being connected with a worker in the community in which they reside in order to maximize knowledge of and referrals to local resources and supports. In the case of interjurisdictional case management, information about available local services should flow regularly and freely between the collaborating agencies.

To police services that employ mobile crisis intervention teams (MCIT):

15. Ensure that such teams are promptly advised of any calls involving persons in crisis for which they are not part of the initial response by police, subject to applicable privacy laws and other statutory restrictions. This will ensure that the MCIT is available to engage in any follow-up with the person after the immediate crisis is resolved.

To the Ministry of the Solicitor General:

16. Support initiatives (including amendments to any adequacy standards or legislation) that would allow for the transfer of first response to mental health calls not involving safety concerns (such as a threat of violence to others or the person in crisis) to other community-based non police agencies.

17. Consult with mental health experts, people with lived experience and the police to create, maintain and mandate integrated use of force, mental health and de-escalation training for all police officers (after recruitment training). This training should be also be made available to crisis response workers who work with police to respond to persons in crisis.

To the Waterloo Regional Police Service:

18. Until such time as there is a provincially mandated curriculum as set out in Recommendation 17, undertake to have their in-service training with respect to use of force and escalation reviewed by peer run advocacy groups and other community based crisis and mental health service providers prior to the training being delivered. The Ministry of the Solicitor General should provide sufficient and consistent funding to allow the Waterloo Regional Police Service to engage in this type of training review and to allow for members from the same peer-run advocacy groups and other community-based crisis and mental health service providers to assist with the delivery of de-escalation training.

19. Ensure that any officer involved in the situation in which they are required to draw their firearm as a result of threat of serious bodily harm or death shall receive a documented debrief for the supervisor prior to their next shift.

To the Province of Ontario and medical schools in Ontario:

20. Take necessary measures to ensure that patients have timely access to child and adolescent psychiatrists, including but not limited to funding for additional residency positions dedicated to child and adolescent psychiatry.

21. Take necessary measures (i.e raising caps) to allow for training of additional primary care physicians and child and adolescent psychiatrists.

To the College and of physicians and Surgeons of Ontario:

22. Encourage physicians to remain up-to-date with evidence-based treatment plans and drugs related to mental health cases.

To the Ontario Ministry of Education:

23. Provide information on mental health supports available in the community through schools and incorporate age appropriate curriculum regarding mental health.

To all of the recipients named above:

24. Secure adequate funding and resources to implement these recommendations.