Building a better future: Inquiry reveals deaths at Constance Lake First Nation during blastomycosis outbreak

Presiding Coroner Dr. Michael Wilson, opening the investigation into the deaths of five people during a blastomycosis outbreak at Constance Lake First Nation, told attendees he wants the truth to come out.

Before the coroner spoke, families placed photos of their loved ones suffering from blastomycosis on a table in front of the stage in the community hall at the Oji-Cree First Nation west of Hearst, Ontario.

Luke Moore, Lorraine Shaganash, Lizzie Sutherland, Mark Ferriss, and Douglas Taylor died between November 19, 2021, and January 23, 2022.

Elder Florrie Sutherland and standing in water Prayed and humiliated everyone who participated in the investigation. He encouraged people to offer tobacco to the sacred fire outside as a means of communicating with the Creator.

Lake Constance rested on the shore and the gentle flutter of a teepee sheltering a sacred fire provided a soothing backdrop.

Inside the community hall, families and community members, including current Constance Lake Chief Rick Allen, as well as several former chiefs, hospital representatives and representatives from Public Health, Orange and Indigenous Services Canada filled the hall, as well as lawyers representing each of them.

The five jurors sat seriously.

Wilson introduced himself and, referring to the livestream of the event, told the audience that people around the world would be showing interest and sending good ideas to the community.

“Years have passed and we are hopeful this investigation will answer questions about their untimely deaths,” he said.

With some foreshadowing of what might be heard at the inquiry, Wilson said a more equitable and responsive health system is part of “building a better future”.

He said the scope of the investigation will also include how First Nations people were treated by the medical system when they sought help for their symptoms, and identifying how health care emergencies in First Nations, which are beyond their ability to respond, can be better managed.

Wilson said that despite the presence of lawyers, anyone participating in the investigation should not find fault or responsibility, but rather find the facts.

He said the investigation was an opportunity to make recommendations to avoid further deaths without finding any legal responsibility or finding any conclusion of law.

“The investigation ensures that no deaths will be ignored,” Wilson said.

Shruti Ramesh is a lawyer at the coroner’s office, in a division working to improve relationships between indigenous people and the justice system.

“We have learned that everyone in the community has been affected by this outbreak,” Ramesh said.

“We are deeply sorry for all these losses and the continuing losses today.”

He began to summarize the evidence collected through community visits.

Following reports of several community members feeling ill in November, three people died in three days between November 19 and 21 after seeking help for symptoms at the emergency room of Hearst Hospital.

Doctors first ruled out Covid-19, then considered pneumonia.

Ramesh said the investigation offers the benefit of “slow hindsight” to understand the health care disparities experienced by First Nations in the province.

“We’re going to talk about issues that might be hard to talk about, racism, but that doesn’t mean they shouldn’t be talked about,” he said.

He began to summarize the evidence that had been collected through meeting the families.

luke moore

Ramesh said Moore, 43, first went to the emergency room at Notre Dame Hospital in Hurst on Nov. 9, 2021, complaining of a cough, fever and chills. He was told he had the flu and was discharged, he said. Two days later, he returned and was found to have pneumonia on X-ray. Moore was given antibiotics and discharged.

On November 17, he called an ambulance and was admitted to Notre Dame, where tests, including a fungal infection, were ordered. Testing for blastomycosis was ordered following news that an unidentified person from the community had tested positive for the fungal disease. However, Moore’s decline continued.

Doctors recommended immediate transfer to Sudbury and requested transfer via Orang Air Ambulance. That request was denied due to bad weather and poor conditions at Hearst Airport throughout that afternoon and overnight. Moore’s condition deteriorated and he died of heart failure at 9 am on November 19.

Lorraine Shaughnessy

Nine hours after Moore’s death, Shaganash, 47, arrived at Hearst Hospital by ambulance. She had been feeling ill for three weeks. He was taken to Health Sciences North in Sudbury where he died on November 20. Lab results revealed that she died from blastomycosis with acute respiratory distress syndrome.

Lizzie Sutherland

Sutherland, 56, first went to the emergency room at Hearst Hospital on October 29 and was given antibiotics and sent home. She returned on 15 November as her condition was still not improving, and she was admitted, given antibiotics, and more tests, including blastomycosis, were ordered.

On 19 November, doctors discovered that samples had not been collected for tests and they were reordered. Suspecting blastomycosis, Sutherland was given appropriate medication. On November 20, doctors ordered him to be taken to hospital in Sudbury, where no beds were available.

Orange Air Ambulance said it could transfer her the next day, but by then, her condition had become so dangerous that doctors feared she would not survive transport. Sutherland died at 12:45 pm on 21 November. An autopsy found blastomycosis and organ failure to be the cause of death.

mark ferris

Ferris, 67, went to the hospital on Nov. 24 after feeling ill for a week. He was diagnosed with pneumonia and congestive heart failure. Tests were ordered, which also included blastomycosis, but he had to stop taking heart medications for the antifungal medications to be effective.

The Orange were contacted to take him to North Bay Hospital, but the hospital declined the transfer due to the weather. He was airlifted the next day but died on 30 November. Laboratory tests found the cause of death to be blastomycosis and multi-organ failure.

Douglas Taylor

On November 22, Taylor went to the hospital to be tested for blastomycosis. The initial test came back positive and his treatment started. On November 24, he returned to the hospital complaining of breathing problems. He was treated for congestive heart failure, which improved but the pneumonia did not improve. It was determined that the antifungal medication was not being absorbed well due to her other medications.

On January 21, he was in the hospital and asked to go home but the doctors kept him in the hospital. On the night of 22–23 January, he said he had severe anxiety, and on 23 January, at around 8 am, it was discovered that he was not getting enough oxygen and he was given some oxygen. After a few minutes, a nurse found that he had no vital signs and he was pronounced dead shortly after. Lab results revealed the cause of death to be respiratory failure due to blastomycosis.

always with a smile. That was Luke’s character.– Arthur Moore, speaking about his son who died of blastomycosis, November 19, 2021

The first family member to testify was former Chief Arthur Moore, who lost his son Luke. Moore described his son as an athletic and healthy young man with close family ties.

“Even when he was a kid, he never had trouble with vaccinations or needles,” Moore said. “We never heard him cry. Always smiling. That was Luke’s character. Always happy.”

The 6-foot-4 Luke was built like an athlete and always did well, including playing hockey and basketball, Moore’s father said.

He remembered how Luke worked at the Thunder Bay Athletic Complex when he was 20 and when he opened the center the older people respected him and brought him treats.

“It’s hard to talk about the love we shared, because we communicated well and he was very honest about his feelings,” Moore said, crying.

“The medical community needs to be more aware,” Moore said. “I think the medical community failed to meet that goal when it came to Luke. I wish there was more awareness (about) blastomycosis, not just pneumonia.”

Luke’s partner then explained how her death affected him and their children.

“That was my home,” Joan Martin said. “He was the sweetest and most passionate person. He brought an incredible sense of peace to everyone around him.”

He described a generous man who gave food, drink and warm clothing to everyone around him, expecting nothing in return and who loved feeding his family, especially his grandchildren.

“Luke was extremely patient and selfless,” she said.

“He had an amazing ability to lift others up,” he said. “And a special way of showing up and valuing others.

“His absence has left a void that cannot be filled.”

Afterward, an attorney read a statement on behalf of Douglas’s sister, Kathleen Taylor.

Kathleen wrote, “Doug was kind and funny and we talked every day.” “I didn’t expect that my brother would pass away like this and that I would never get a chance to say goodbye.”

She wrote that their last conversation was the night before he passed away, but due to Covid restrictions, it was on the other side of the glass, so they couldn’t touch.

Now, she said, she avoids going to the hospital despite medical problems because of the bad memories.

Sutherland’s relatives spoke next.

Rick was her oldest brother and his wife Susan spoke on their behalf.

He described Lizzie as a stubborn person who had adopted two sons and was raising two grandchildren at the time of her death.

“What could have happened that could have helped him get help sooner?” He said. “Why wasn’t she sent to Sudbury sooner? Why wasn’t she a priority? Generational trauma is not an excuse for why the system continues to fail us.”

Why wasn’t that a priority?-Susan Sutherland, Lizzie Sutherland’s sister-in-law

Lorraine Saganash’s sister, Candida Solomon, also wrote a statement that was read aloud.

“I felt like I had no one to talk to when all this was happening,” she wrote, noting that the community was in lockdown at the time of her sister’s death and her mother was isolated in the hospital, having also been diagnosed with blastomycosis.

“I cannot mourn with Lorraine’s children or grandchildren or our brothers,” she wrote.

“We, as a family, miss him every day and it is a loss that will never heal.”

Ferris’s widow, Marlene Esquimo, said they met when they were teenagers and were together for 37 years before marrying.

She told how after his heart attack he asked her if it was time to get married and she replied, “Do you think it’s safe now?” He said laughing.

They married at the age of 60 in a family reunion ceremony at the camp, surprising everyone involved.

She was with him in the hospital in North Bay two days before he died, as his lungs filled with fluid due to blastomycosis.

She said, “We talked until we couldn’t anymore,” and she instructed him to put her wedding ring on her finger.

“‘And don’t take it off and don’t let anyone else put the ring on you,'” she said, he told her. She laughed, raising her hand where the ring glittered on her thumb. “It’s been four years now.”

“I miss Mark every day,” she said.

“I sometimes fear that it (blastomycosis) will reemerge and no one knows who it will affect.”

Interrogation of family members continues on Thursday also.

Twenty-five days have been set aside for the hearing of 30 witnesses.