Coroners inquests are failing to prevent more police shooting deaths

Recent examination into Andrew Loku killing reveals that we’ll have to look beyond recommendations from the Office of the Chief Coroner for real systemic changes in policing to occur



“We speak for the dead to protect the living.” So goes the motto of the Office of the Chief Coroner for Ontario, whose job it is to conduct inquests into police custody deaths with a view to improving public safety.

But rather than functioning as a powerful tool for impartial investigation and making systemic changes in laws and policies governing the conduct of police, inquests are failing in their mandate to prevent deaths.

As a lawyer who has represented community groups and family members at inquests of persons killed by police over the past several years, I am reminded of the problems that beset cases like Andrew Loku’s as the inquest into his police shooting death came to an end recently. 

Police killings reveal a clear pattern that involve several familiar elements.

The police typically attend to potentially volatile calls for service without planning any strategy for handling the situation beforehand. Confronted with an individual experiencing a mental health crisis, officers fail to use de-escalation techniques taught to them in training. All too often, especially in cases involving encounters with Black men, officers resort to fatal force within seconds of their arrival on the scene.

And the deceased is always blamed for instigating his own death. The officers who have killed do not admit to making any mistakes nor do they ever testify that they have learned anything that would lead them to handle a similar situation differently in future.

Police are not the only ones who routinely obstruct critical lines of inquiry at inquests.

According to the Ministry of Community Safety and Correctional Services’s website, “An inquest allows juries to make useful recommendations to prevent other deaths in similar circumstances. This preventative function is a very important aspect of inquests because it encourages changes that will result in a safer province.”

But while the stated purpose of inquests is to find solutions to systemic problems, coroners who preside over cases have barred lawyers from introducing evidence or raising questions that have the potential to upset the status quo. They’ve also prevented them from proposing recommendations relating to systemic racism in policing, whether regular patrol officers should be armed or the effectiveness of the civilian-led police watchdog Special Investigations Unit (SIU) – not to mention, proposing changes to the inquest system itself.

This repeated interference from coroners blocks exploration of fundamental change to the system and sends a powerful message to police that the system is not in need of reform. In this way, police killings of Black people and persons with mental health issues are normalized and even sanctioned.

Officer Andrew Doyle, who shot Loku within 21 seconds of his encounter with him in the hallway of his apartment building, testified that if confronted with the same situation again, he would act no differently. That there is no institutional pressure for change and no consequences for officers’ failure to use their training means we can expect such tragedies to repeat themselves. Indeed, last week’s fatal police shooting in Montreal of Pierre Corolian, a Black man who reportedly had mental health issues, attests to that.

To be sure, there is a long history in this regard.

In 1996, Sergeant Ben Troina shot 22-year-old Tommy Anthony Barnett to death 19 seconds after he observed Barnett walking in the middle of Bathurst near St. Clair Avenue West. The SIU cleared Troina of any wrongdoing saying the officer was acting “within the scope of his duties in seeking to stop and investigate Tommy Barnett who was impeding the flow of traffic.”

The coroner at that inquest ruled not to allow questions on race or police treatment of persons perceived to have mental health issues, even though the officer testified he thought Barnett was mentally ill and there had been eight shootings of Black men by Toronto police in a four-year period prior to the Barnett incident.

Fast forward to more than 20 years later, counsel for the Black Action Defense Committee had to bring a motion at Loku’s inquest to allow the issue of racism to be explored.

Is the inquest system interested in learning from the past and improving practices?

For some, inquests have historically been a forum for vindicating police where jurors “can make some benign recommendations that have no teeth,” as lawyer Davies Bagambiire has said.

To be sure, many recommendations from inquests past, which the police are free to adopt or reject, remain unrealized.

As a society we need to be asking (and answering) deeper questions about what community safety should look like. And we need tools that can deliver transformative justice.

As many have observed, if psychiatric nurses and social workers and street outreach volunteers can routinely diffuse potentially volatile situations using de-escalation techniques, could we not employ them in rapid response teams?

If the City of London, England can police a metropolis many times larger than Toronto without arming patrol officers with guns, couldn’t we?

Right now the government seems to be buying a temporary solution with inquests to quiet activists in the streets who point out the system’s practical and moral failings.

If the Coroner’s Office speaks for the dead, the dead are in need of better representation.

Kikélola Roach is a lawyer and the Unifor Sam Gindin Chair in Social Justice & Democracy at Ryerson University.

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