It has been almost a year since Brandon Duncan went to the Guelph General Hospital. He won’t do it again.
Mr. Duncan was not a well man. Not physically. Not mentally. He was 36 years old. According to some people who knew him, he weighed about 105 pounds soaking wet. He didn’t cast a dominant presence in a crowd. Not physically, anyway. The things he did would draw attention sometimes. When people act out the symptoms of their mental illnesses, it can be off-putting. Dominating and off-putting both attract attention, but they’re not the same thing.
Like just about everybody else in Guelph, I didn’t know Mr. Duncan. I never met him, and never will. The circles I run in and the circles he ran in never intersected. I know some people who did know him. I have heard some nice things said about him. I have heard some unkind things said about him. His friends liked him most of the time, and he liked them most of the time.
It was around noon on a Wednesday afternoon when Mr. Duncan went to the emergency department of Guelph General Hospital. It was a pleasant enough day. About 14 degrees with no rain. A good day to go to the hospital, get fixed up and get on with whatever life you have. From several accounts and perspectives, Mr. Duncan didn’t have much of a life, but the one he had was his.
Mr. Duncan sat in the waiting room of the emergency department of Guelph General Hospital for about 45 minutes before seeing a triage nurse. He was in a place where people should feel secure because we are surrounded by trained health care professionals. They are there to help us when things take a bad turn. We are also surrounded by several other people who are in distress and also need help. That adds to the wait time and stress levels and irritation.
That’s a difference between wait times inside an emergency room and outside one. On the outside, you become worried about the length of time it takes for help to arrive. On the inside, you become irritated.
At almost the same time, two uniformed Guelph police officers brought a 16-year-old boy to the emergency department. For the sake of privacy I’ll call him Joe Doe. Bringing distressed people to the hospital is one of the things police do.
Mr. Doe’s pain could have been emotional, mental, physical, or any combination of the above. It doesn’t matter now. He was being helped. The police were with him in a containment room.
The police were busy, the doctors and nurses were busy, Mr. Doe was being helped, his mother was waiting in a chair in the hall, and Mr. Duncan was somewhere in the queue.
When he showed the triage nurse what was wrong with his colostomy bag, she gave him a pair of blunt-nosed bandage scissors and directed him to the washroom. Maybe he was to cut off something that had to do with the colostomy bag, or a dressing that needed changing, or something else. It doesn’t matter by now because while he was in the washroom he cut an artery. Whether or not he did it on purpose we will never know because we can’t ask him.
Mr. Duncan was in the washroom for a couple of minutes. When he came out he was bleeding profusely and still had the scissors in his hand. He was confused and disoriented. He was upright and staggering about. One witness described him as “walking like a zombie.”
The well-ordered efficiency of the hospital emergency room was turned upside down. Some people took a look at Mr. Duncan and started screaming. Others were stunned into silence. Conversations ended in mid-word. People at the front of the triage list thought they were about to be bumped backwards by Mr. Duncan.
A young woman and her boyfriend were sitting in the triage hallway. Mr. Duncan grabbed the back of her neck. We don’t know if he did that in a threatening way, or if he was trying to catch his balance. In any event, she screamed. Her boyfriend dislodged the grip and pushed Mr. Duncan away.
The two police officers came out of the containment room to see what was going on. Someone at the scene took three cell phone photos. These constables are not delicate creatures. They look big enough and able to handle themselves in any bar room brawl. They were wearing their regulation body armour. Judging by the photo, between the two of them they should have been a match for a skinny little man half way down the road to bleeding to death.
The officers commanded Mr. Duncan to drop the scissors. He didn’t. He continued to stagger towards them. They drew their guns and ordered him to step back. He didn’t. Both police then fired their weapons, each putting three bullets into Mr. Duncan.
No more than four seconds after the police drew their guns, Mr. Duncan lay dead in a pool of blood on the floor of a corridor in the emergency department of a hospital.
It took almost 10 months for the Ontario Special Investigations Unit (SIU) to release a report saying the two officers used a reasonable level of force on Mr. Duncan. The exact words were that neither officer “exceeded the ambit of justifiable force in the circumstances and as a result, no charges will issue.”
One dead person. Two police officers. Four seconds. Six bullets. Ten months.
The SIU was set up in 1990 to investigate incidents involving police that result in a fatality, a serious injury, or an allegation of sexual assault. It is within the SIU mandate to lay criminal charges against police officers if investigators think the evidence points in that direction. They hardly ever do. As of 2015, the SIU had investigated 4,288 incidents. Charges were laid in 119 of them.
If the mandatory SIU investigation does not lead to charges being laid, that’s the end of it. Case closed, discussion over, everyone go home.
There is one other avenue available, but it’s seldom used in these sorts of cases. In a coroner’s inquest, a jury of five citizens hears evidence and arguments from witnesses and lawyers. The jury can make recommendations designed to prevent similar deaths from happening in the future.
This is the missing piece in the puzzle of Brandon Duncan’s death.
There are already certain situations in which an inquest must be held: a death on a construction site, or in a mine, pit or quarry; the death of a person who is in custody or being detained; the death of a psychiatric patient while being physically restrained in a psychiatric facility or hospital; and, under certain circumstances, the death of a child as a result of criminal activity by a person who has custody of the child. All other inquests are discretionary.
While the SIU can make a finding of legal responsibility, it cannot compel witnesses to testify. On the other hand, a coroner’s inquest cannot assign blame, but can compel witnesses to testify.
One advantage of a coroner’s inquest is that witnesses can testify and lawyers can present evidence without worrying about criminal charges lurking in the background. The aim is to identify system and process failures that may have contributed to a death.
A coroner’s inquest should be mandatory in all cases of a fatality resulting from an interaction between the police and the public. When the SIU completes its investigation and brings in its recommendations, follow it up with a coroner’s inquest.
It is the best way for a community to bring closure to a tragic event that should have been avoidable.
If you agree, send a letter to the Regional Supervising Coroner, Central West Region, Forensic Services and Coroner’s Complex, 25 Morton Shulman Ave., Toronto, ON M3M 0B1.
Or send an e-mail to OCC.CentralWest@ontario.ca.
Tell them you want an inquest into the death of Brandon Duncan in Guelph on 20 May 2015.