Whether acting as juror or witness at a coroner’s inquest, nurses play a vital role in the analysis of evidence and creation of recommendations that help build stronger health and social systems.

By Kimberley Kearsey

Like hundreds of other Ontarians summoned by the Ministry of the Attorney General for jury selection, RN Laura Jackson wasn’t quite sure what to expect when she arrived at Toronto’s Superior Court of Justice in the fall of 2015. She never gave much thought to being selected as a juror, nor did she know much about the troubled life and tragic death of a little girl named Katelynn Sampson. Over the next five months, as one of five jurors at a coroner’s inquest into the young girl’s murder, Jackson would put her life on hold to examine how the girl slipped through the cracks and died in 2008.

“It had such a huge impact on my life,” the mental health nurse says of her role as a juror, and her introduction to Sampson. “I think the first day in court we heard the 911 tape…a few days in, we heard from the forensic pathologist and saw the images of Katelynn. Seven years old and she had about 70 wounds on her body. Those images are still in my head.”

Sampson’s biological mother, who struggled with addiction, signed an informal agreement in 2007 to hand over legal guardianship of her daughter to her friends Donna Irving and Warren Johnson. The pair would later plead guilty to beating her to death, and are now in prison. Irving called the Children’s Aid Society asking to have the girl removed from their care just months before her death. Because Irving is half-Anishinabe, her call was passed along to Native Child and Family Services, creating another layer between Sampson and the support systems she needed to help her. The warning signs leading up to that call – and following it – were glaring. Worried school officials called Children’s Aid, but no action was taken.

The recommendations of a coroner’s inquest can lead to important modifications in policy and legislation, and Jackson is hopeful that will happen with at least some of the 173 recommendations she helped to develop when the Sampson inquest wrapped up in April 2016.

Advocating for children is the central lesson the 38-year-old RN says she’s taken away from her experience as a juror. In fact, it is the basis for the jury’s first and most important recommendation known as Katelynn’s Principle; the notion that every child be seen, heard and respected when it comes to any and all decisions about their care.

“This (inquest) was a huge chunk of my life,” Jackson says. “And it was not easy. We got close to 400 exhibits…there were 13,000 pages of disclosure…we had to sit through days and days of evidence.” She says they set a record for the amount of time it took to deliberate, but reflects back that there was no way they could have combed through all of the information in less time. “It had a huge impact on all of us and we wanted to get through it, but we also wanted to do it right. We had to make sure we understood everything.”

The experience was emotionally exhausting, Jackson adds, but “I’m glad I did it.”

“I think I’m a better clinician because of this experience,” she adds.

As an RN, Jackson understands accountability and knows the skill that goes into assessing people in need. That “…was absolutely useful,” she says, but stops short of suggesting her expertise had any direct bearing on the jury’s recommendations, since those were based entirely on the evidence presented in court. “You have to go through the inquest process with that neutrality,” she explains. You have to “go in with an open mind and let the evidence speak.”

The role Jackson played in the Sampson inquest is unique because her nursing background wasn’t a factor in her selection as a juror. Nursing background and skill comes into play far more often when RNs are involved in inquests as witnesses. This happens if the death of a patient is being investigated, and if the nurses involved in that patient’s care have information that will help in the investigation. “If you have knowledge of (the circumstances surrounding a death), you can be subpoenaed to attend,” explains Tim Hannigan, a lawyer for the Registered Nurses’ Association of Ontario (RNAO) who has helped its members through the inquest process.

Although the roles of juror and witness are equally important to the legal process, the latter is often associated with far more pressure and anxiety around what it means on a professional level.  “Anyone getting pulled into something like this is understandably nervous about it, and what the implications of it might be,” explains Hannigan. He eases some of that concern by clarifying a coroner’s inquest is not designed to lay blame. “It should not have a result that nurse A or nurse B is responsible,” he says. In fact: “If the jury were to try to assign blame, the coroner would not accept that.”

Dig a bit deeper and Hannigan does warn nurses that there may be implications from an inquest that affect them down the road. “Depending on how the evidence unfolds, there may be red flags raised about the behaviour of certain people involved. From the perspective of, say, a family…if they have a civil suit…(the evidence given at an inquest) may mean they double their focus on a particular person. (The inquest) may influence how the civil suit proceeds.”

Hannigan’s advice to nurses in this regard: “Approach everything as if it’s as serious as something that could be the focus of a coroner’s inquest. Always document as if you are one day going to be on the stand testifying about it.”

Wendy Fucile, RNAO past president and a nursing instructor at Trent University, has been in a number of leadership roles in the acute care setting and has provided testimony at several inquests. “I think coroner’s inquests are an incredibly important part of our system. It’s a privilege – maybe a bit scary, but still a privilege – to be able to be part of trying to make it better.”

That said, some inquests are harder than others, Fucile admits. Looking back to the 90s, when she was a witness at an inquest into the death of an elderly patient in Peterborough, Fucile recalls “…it was…as is every inquest I’ve been to…an incredibly sad moment. You have family that has lost someone. You have a life that is gone. Even though an inquest isn’t about laying blame…you always have staff who are second-guessing themselves and feeling a whole gamut of emotions. It is a difficult time for everyone.”

Fucile has discussed her experience at inquests with first-year nursing students who are often shocked that a nurse can be called upon to testify. It’s important that they realize this is a real possibility for any RN, she says. It’s also important that the nursing perspective has been heard during legal proceedings. Fucile was called upon as president of RNAO to provide testimony at the investigation into the 2005 death of Jeffrey James, a patient at Toronto’s Centre for Addiction and Mental Health. James was restrained for five days and died after being released from those restraints.

RNAO requested standing at the inquest in 2008 because of the significance the investigation had to the nursing profession in a broad sense. With its system expertise, and its well-established and internationally respected process around the development of best practice guidelines, RNAO felt it could come forward and suggest there were systemic issues of staffing, especially around continuity of care and caregiver. In addition, RNAO wanted to suggest it could source evidence and create a tool that could be used to improve the safety of patients.

“I think the degree to which you feel heard is the degree to which you see the recommendations (of the jury) acted on,” Fucile adds. “Any recommendation is just words on paper until someone does something with it.”

There is always a fear that the jury’s recommendations may end up on a shelf, collecting dust. That was the hardest thing about the inquest process for Jackson.

During the Katelynn Sampson inquest, recommendations made in 2014 by the jury examining the death of Jeffrey Baldwin were presented as evidence. Baldwin was another child who slipped through the cracks and died at the hands of his caregivers. “We know several recommendations just sat there,” Jackson laments. “We haven’t seen any changes.”

“I hope people pay attention,” she adds for the sake of another Jeffrey or Katelynn. “I hope these agencies actually step up to the plate. They’ve made some changes, but a lot of the (recommendations touch on) things they still need to do.”

The hardest part to accept is that they might not do anything, Jackson says, acknowledging the jury’s recommendations are not binding.

Kimberley Kearsey is managing editor/communications project manager for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. This article was originally published in the September/October 2016 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO).