RELEASE DATE: November 4, 2015

Manitoba
THE PROVINCIAL COURT OF MANITOBA

IN THE MATTER OF:

The Fatality Inquiries Act, C.C.S.M. c. F52

AND IN THE MATTER OF: An Inquest into the Death of ERRABELLA
ANGEL HARPER

Report on Inquest and Recommendations of
Judge Tracey Lord
Issued this 30th day of October, 2015

APPEARANCES:
Counsel to the Inquest: Ms. N. Roch
Counsel for St. Theresa Point First Nation:
Mr. N. Boudreau and Mr. C. Shefman

 Page  2

RELEASE DATE: November 4, 2015

Manitoba
THE FATALITY INQUIRIES ACT, C.C.S.M. c. F52
REPORT BY PROVINCIAL JUDGE ON AN INQUEST
INTO THE DEATH OF: Errabella Angel Harper
An inquest respecting the death of Errabella Angel Harper was held
on March 17, 18, 19, 2014 in St. Theresa Point, Manitoba and December
15, 16, 17 and 18, 2014 in Winnipeg, Manitoba.
This report contains my findings and recommendations. Attached is a
schedule of all exhibits required to be filed. Pursuant to the provisions of
subsection 33(3) of The Fatality Inquiries Act, I am ordering that all exhibits
be returned to the Exhibit Officer, Provincial Court of Manitoba, to be
released only upon application with notice to any party with a privacy
interest.
Dated at the City of Winnipeg, in Manitoba, this 30th day of October,
2015.
“Original signed by Judge Tracey Lord”
Judge Tracey Lord
Copies to:

Dr. A. Thambirajah Balachandra, Chief Medical Examiner
Chief Judge Ken Champagne, Provincial Court of Manitoba
The Honourable Gord Mackintosh, Minister Responsible
for The Fatality Inquiries Act
The Honourable Julie Frederickson, Deputy Minister of
Justice & Attorney General
Russ Ridd, Director of Regional Prosecutions
Lorraine Prefontaine, Director of Special Prosecutions and Appeals
Ms. N. Roch, Inquest Counsel
Mr. N. Boudreau and Mr. C. Shefman, Counsel for St. Theresa Point First Nation

Inquest Report – Errabella Angel Harper

 Page  3

INTRODUCTION AND CHRONOLOGY OF PROCEEDINGS
By letter dated June 20, 2011 the Chief Medical Examiner for the Province
of Manitoba directed that an Inquest be held into the death of Errabella
Angel Harper (age 2 ½ months), pursuant to sections 19(1) and (2) of The
Fatality Inquiries Act. The death occurred on January 16, 2011 in the
community of St. Theresa Point, Manitoba.
By letter dated June 21, 2011, the Chief Medical Examiner also directed
that an Inquest be held into the deaths of Demus James( age 73), Throne
Kirkness (age 2), and Kayleigh Okemow (age 3) pursuant to the same
sections. These deaths occurred on March 14, 2011 in God’s Lake First
Nation, Manitoba.
These deaths all occurred as a result of house fires occurring in First
Nation communities.
It was further recommended by the Chief Medical Examiner that these
deaths be the subject of one Inquest pursuant to section 26(2) of The
Fatality Inquiries Act, due to the closely related timing and circumstances
surrounding each of the house fires.
A Standing Hearing respecting both Inquests was held on February 24,
2012. At that time, Ms. K. Gilson requested, and was granted standing on
behalf of God’s Lake First Nation. She subsequently advised on July 8,
2013 that she was no longer retained to act in this proceeding.
No other parties sought standing with respect to either Inquest at the
Standing Hearing, including the Government of Canada.
The Inquest was set to begin in St. Theresa Point on July 18, 2013. On July
17, 2013, Mr. Boudreau requested, and was granted standing on behalf of
St. Theresa Point First Nation. As a result, the proceedings set for July in
that community were adjourned, and re-set for March 17-19, 2014 in St.
Theresa Point.
The joint Inquest hearings sat on the following dates:
July 30, 31, August 1, 2013 and March 3, 2014 in God’s Lake,
March 17, 18 and19, 2014 in St. Theresa Point, and
December 15, 16, 17 and 18, 2014 in Winnipeg.

Inquest Report – Errabella Angel Harper

 Page  4

While the two Inquests were held together, the experiences of the
communities of St. Theresa Point and God’s Lake First Nations and their
responses to these tragic deaths are unique and as such will be dealt with
in separate Inquest Reports.
SCOPE OF INQUEST
The Chief Medical Examiner called these Inquests for the following
reasons:
[1]

To determine the circumstances relating to the deaths; and to determine
what, if anything can be done to prevent similar deaths from occurring in
the future with regard to, but not limited to, the following:
a) installation of fire and smoke alarm systems and carbon monoxide
detectors in all residences on Manitoba First Nations;
b) regulation, monitoring and maintenance of wood stoves in all
residences on Manitoba First Nations;
c) regulation, monitoring and maintenance of baseboard heaters in all
residences on Manitoba First Nations;
d) provision of adequate firefighting equipment and personnel for all
Manitoba First Nations; and
e) regular inspection for fire hazards in all residences on Manitoba
First Nations.
Section 33(1) of The Fatality Inquiries Act sets out the duties of the
presiding judge upon completion of the Inquest:
[2]

Duties of provincial judge at inquest
33(1) After completion of an inquest, the presiding provincial judge shall
(a) make and send a written report of the inquest to the minister setting
forth when, where and by what means the deceased person died, the
cause of the death, the name of the deceased person, if known and the
material circumstances of the death;
(b) upon the request of the minister, send to the minister the notes or
transcript of the evidence taken at the inquest; and

Inquest Report – Errabella Angel Harper

 Page  5
(c) send a copy of the report to the medical examiner who examined the
body of the deceased person;
And may recommend changes in the programs, policies or practices of
the government and the relevant public agencies or institutions or in the
laws of the province where the presiding provincial judge is of the opinion
that such changes would serve to reduce the likelihood of deaths in
circumstances similar to those that resulted in the death that is the
subject of the inquest.

It is not the function of the presiding judge to lay blame with anyone who
may have been involved in the deaths.
In the 2005 Inquest Report into the death of Glenn Fiddler, prepared
by Provincial Judge Sidney Lerner, the role of the Inquest judge as it
relates to deaths occurring on First Nation communities was examined.
[3]

[4]

At paragraphs [301] and [302], Judge Lerner noted the following:
[301] ...a Provincial Judge presiding at a provincial inquest is without
jurisdiction to make recommendations to the Federal Government
specifically directed to the policies, procedures, and management of
Federal departments and agencies.
[302] However, a provincial Inquest does have the jurisdiction to make
inquiries into the material circumstances of the death of one of its citizens,
including as noted above, a death occurring on First Nation land. While
there is a jurisdictional limitation with respect to the nature of the
recommendations that may be made as a result of that inquiry, it does not
restrict the fact finding aspect of the inquiry from identifying, without
recommendation, the problems or deficiencies within Federal departments
and agencies that may have formed a part of the material circumstances
of death.

SUMMARY
Errabella Angel Harper age two and one-half months died in a
house fire on January 16, 2011 in the community of St. Theresa Point
Manitoba. There is no issue that the cause of her death was the result of
the fire.
[5]

St. Theresa Point is one of four First Nation communities that
comprise Island Lake Manitoba. It is located approximately 500 km north
east of Winnipeg and has a population of almost 4000 people. St. Theresa
[6]

Inquest Report – Errabella Angel Harper

 Page  6

Point is accessible by boat or helicopter in the summer months and by
winter road in the winter season. The community can be accessed year
round by air flights that land on St. Mary Island and Stevenson Island. The
community is policed by Band Constables and by the Island Lake Royal
Canadian Mounted Police (RCMP) detachment located some distance
away on Stevenson Island.
WITNESSES
Leslie Harper (Evidence given March 17, 2014)
Ms. Harper is a resident of St. Theresa Point First Nation. Ms.
Harper has six children and is the grandmother of the deceased infant
Errabella. In January of 2011, Ms. Harper lived in her parents’ former
residence with her daughter Ashley, (Errabella’s mother) and her other
children, Angela (13), Martha (10), Jay(6), Michael (5), and Ashley’s other
daughter Quallyn (1). Ms. Harper’s parents lived in a newer home located
next door.
[7]

Ms. Harper testified that the house itself was older in age and of
wood construction. It was heated primarily by a wood stove located in the
living room. Electric heaters were also used for added heat in the
bedrooms. There were three bedrooms in the home. Ms. Harper and three
of her children slept in one bedroom, her daughter Ashley slept in a second
bedroom with Quallyn and Errabella, and Angela had her own room.
[8]

Ashley’s bedroom contained a single bed and a basinet for
Errabella. In addition to the electric space heater, the bedroom window was
covered on the inside by blankets to keep out drafts.
[9]

The house did not have smoke detectors, a fire extinguisher or
running water.
[10]

When Ms. Harper awoke on January 16, 2011, at approximately
8:30 a.m., all of the children were still sleeping. She said that the
woodstove was not lit, but had been the night before. Ms. Harper indicated
that the fire went out sometime between midnight and 2:00 a.m.
[11]

She noted that her daughter Ashley was not at home that morning,
as she had spent the night prior at Ms. Harper’s other daughter Valerie’s
residence drinking. Ms. Harper went to Valerie’s residence and told Ashley
[12]

Inquest Report – Errabella Angel Harper

 Page  7

to go home, as she was going next door to her parents’ residence to cook
and clean for them as she did every day.
At 10:00 a.m. Ms. Harper went back to her own house. Ashley had
still not returned, and the children were still sleeping. Ms. Harper returned
next door to continue to care for her parents.
[13]

Ms. Harper testified that just before noon, her daughter Martha
came next door to her parents’ house. She was crying and told her that the
house was on fire. By the time Ms. Harper ran home the house was already
burning and a number of people were there trying to help get the children
out.
[14]

Her granddaughter Quallyn was out of the house when she arrived,
but Errabella was not. She testified that she recalled seeing someone
running from the house to the road holding Errabella. She recalled that
someone drove her to the nursing station. When she arrived she learned
that Errabella was dead.
[15]

Her older daughters Ashley and Valerie also arrived at the nursing
station. Ms. Harper advised that they were both drunk on super juice.
[16]

Ms. Harper testified that she lost all of her belongings in the fire and
that she had no insurance coverage. At the time of her testimony she had
not been allocated another house for herself and her children, and was
unsure if she was even on the list to receive one. She advised that it was
her understanding that there were no houses available for single parents in
St. Theresa Point. Further, she explained that because her band
membership is actually associated to Wasagamack First Nation due to her
marriage, rather than St. Theresa Point, she may not even be eligible to
receive a house. After the fire, she and her children lived with her parents
for a year and at the time of giving her evidence she was house-sitting at
her in-laws in Wasagamack while they were out of the community.
[17]

Abraham and Nadine Monias (Evidence given March 17, 2014)
Mr. And Mrs. Monias are residents of St. Theresa Point First Nation.
Just before noon on January 16, 2011, they were travelling down the main
road of the community on their way home from church services. They saw
light grey smoke coming from the door of the Harper residence, and Mrs.
Monias observed four children running from the house. She testified that
they all appeared to be under the age of twelve and also appeared to be
[18]

Inquest Report – Errabella Angel Harper

 Page  8

sleepy. She and her husband both also saw a young girl approximately 13
years old standing outside the house. The girl was repeating the words
“baby, baby”. They stopped their vehicle to help. There was no firefighting
equipment present, but people were throwing snow on the house in an
attempt to put the fire out. Both Mr. and Mrs. Monias attempted to get
inside the residence through the door, but were unable to do so due to the
thick black smoke and flames inside. A second door on the opposite side of
the house was locked. Attempts were made to break that door in, but it
appeared to be blocked from the inside.
The young girl outside the residence told them which bedroom the
babies were in. They tried to open the window to the bedroom but it was
covered by several blankets from the inside. Ultimately the window was
broken to gain access and another individual used a chainsaw to cut a hole
in the side of the house. Someone was able to pull a chair with a blanket
attached out through the hole in the house. Mrs. Monias described how the
blanket was handed to her and that the blanket contained a baby. She said
that the baby was alive but not making any sounds. She took the baby to
the truck and ultimately to the nursing station. Mrs. Monias testified that the
house burned very fast. By the time they learned where the babies were
located, it was too late.
[19]

Both Mr. and Mrs. Monias testified that in January of 2011 when a
fire occurred in the community, the practice was to call a Band Constable.
[20]

Mr. Monias was unsure as to whether there was a fire department in
the community in January 2011, but confirmed that a fire department now
exists. He knows there is a number to call to reach the fire chief. The
number is written on the side of a building in the community. Mrs. Monias
confirmed this and said that she knows the number to call in case of fire.
[21]

Timothy Mason (Evidence given December 17, 2014)
Mr. Mason was a Band Constable for the First Nation of St. Theresa
Point on January 16, 2011. At the time of the fire he was at work in the
Band Constable office, which was across the road from the Leslie Harper
residence. Just before noon he was alerted to the fact that there was a fire
across the street. He saw black smoke coming from the residence and
observed a number of individuals already present trying to put out the fire.
[22]

Inquest Report – Errabella Angel Harper

 Page  9

He and two others kicked in the door facing the road, but they were
not able to successfully enter the residence due to the heat and smoke.
[23]

When he learned that there were children inside the residence, he
tried to go back in to find them. He ultimately was able to crawl into the
house through a broken window, while someone held his feet from the
outside. He testified that as he was entering, he could hear crying coming
from within the smoke-filled room. There was white smoke at the floor level
and black smoke higher up. Mr. Mason crawled along the floor until he
bumped into the bed. On the bed he found a baby, sitting upright. He took
the child from the bed and handed her out the window to someone outside.
Mr. Mason said that this child was quiet, and was not the baby whose cries
he had heard.
[24]

Mr. Mason was unable to breath at this point and was pulled out of
the house through the window and into the snow outside. He noted that his
hair and clothing were singed from the heat inside the house. It is at this
point that a hole was cut in the side of the house with a chainsaw at the
location where Mr. Mason believed he had heard the sound of a baby
crying.
[25]

Mr. Mason testified that shortly after, a makeshift bed was pulled
from the house through the hole in the wall. The makeshift bed was made
of a blanket tied between two chairs. There was a baby wrapped up in the
blankets who was then taken away.
[26]

Mr. Mason said that he will never forget this day. He said that he did
not consider the possibility that he could have been hurt when he went into
the burning house. He said that it still haunts him even now when he hears
a baby cry. He is no longer a Band Constable and now works at the nursing
station.
[27]

Constable Mark Stienwandt (Evidence given December 15, 2014)
Constable Stienwandt was on duty on January 16, 2011 at the
RCMP detachment on Stevenson Island, and received the report of the fire.
The call came into the RCMP detachment from a community member at
12:20 p.m. There is no 911 system in St. Theresa Point.
[28]

Constable Stienwandt then drove to St. Theresa Point on the winter
road arriving at approximately 12:49 p.m. Both children had been removed
from the residence and taken to the nursing station by the time he arrived.
[29]

Inquest Report – Errabella Angel Harper

 P a g e   10

He promptly notified the Office of the Fire Commissioner (OFC), who
advised that they would be attending to investigate. Manitoba Hydro was
also contacted and arrived to disconnect the active lines.
Constable Stienwandt indicated that the house was fully engulfed in
flames when he arrived. There was no fire truck present, however the
community water truck was on scene. He noted however that the fire
hydrant located nearby was not being used. He further indicated that the
community had a fire truck at the time, but that it was not in use because it
had not been properly maintained.
[30]

Later that afternoon he spoke with Errabella’s mother, Ashley
Harper. Ms. Harper had been detained in the Band cells as she was
intoxicated. When he met with her, he noted that she smelled strongly of
super juice, which is a type of home brew made from fermented yeast and
sugar. Ms. Harper was lodged under The Intoxicated Persons Detention
Act for approximately three hours. The Constable confirmed that while St.
Theresa Point is a “dry” reserve, intoxication by alcohol is a frequent
occurrence in the community.
[31]

Constable Stienwandt also interviewed witnesses including Leslie
Harper and her children Angela and Martha, and testified about the content
of the statements of Angela and Martha.
[32]

In her statement Angela (age 13) told the officer that she had been
sleeping in the bedroom with the two babies, Quallyn and Errabella that
morning. She awoke to her brother and sister screaming. She saw flames
and smoke and ran outside. She tried to get her nieces out of the room
through the window but was unable to open it from the outside. Her sister
Martha ran next door to get their mother.
[33]

Martha (age 10) advised Constable Stienwandt that she woke up
that morning when she heard her brother crying. There was smoke and fire
as high as the ceiling. She said that they all ran outside and she ran to her
Granny’s to get her mother.
[34]

Constables Aaron Bailey and Erdman Wiebe (Evidence given March 17,
2014)
Constables Bailey and Wiebe were tasked with attending the
nursing station to take custody of Errabella’s remains. The child’s face and
[35]

Inquest Report – Errabella Angel Harper

 P a g e   11

chest were described as being very badly burned. These officers also
conducted interviews and took statements from witnesses to the fire.
Constable Bailey testified that in 2010 the community had a fire hall
and some equipment, but that it was not always maintained. He was
unsure if there was a fire truck in the community in January 2011. Both
officers confirmed that there was no formal means of communication
between firefighters in the community and the RCMP.
[36]

Constable Bailey confirmed that there was no 911 coverage in St.
Theresa Point and that emergency calls had to be made directly to the local
detachment phone number. Calls coming in after hours were, and still are,
rerouted to the dispatch centre in Winnipeg.
[37]

The ability of the RCMP to respond to calls to St. Theresa Point is
dependent on the season. During the winter months they are able to
respond as required by travelling to the community on the winter road.
During the summer months they must travel by boat to the community, and
it is only safe to do so during daylight hours. Helicopters are also used at
other times of the year, but also cannot fly at night.
[38]

The RCMP historically had an office in the community of St.
Theresa Point until the summer of 2010 when the building and equipment
inside were damaged by incidents of mischief.
[39]

David Schafer (Evidence given on August 1, 2013 and December 18, 2014)
Mr. Schafer is employed with the OFC, and as of March 2012 was
the Acting Fire Commissioner of Manitoba. He has extensive training and
experience which is detailed in his CV (Exhibit 9) in the areas of fire
management and natural resource management. Among many other
duties, Mr. Schafer has been an instructor with the OFC in the public fire
protection program, operations coordinator with the OFC and has operated
the Manitoba Emergency Services College which is the training branch of
the OFC.
[40]

An investigation into the cause of the fire on January 16, 2011 at the
Harper residence was conducted by OFC investigator Rick
Vandekerkhove. Mr. Schafer relayed the results of that investigation in his
testimony and advised that the fire was caused by a malfunction of the
wood heating system. At tab 5 of Exhibit 6 the conclusion of the
investigation was that the fire was accidental in nature.
[41]

Inquest Report – Errabella Angel Harper

 P a g e   12
Due to the degradation found within the chimney system a failure
occurred allowing the release of super heated gases from the burning
of wood. The release of heat within the attic area caused the insulation
and wood framing system to reach their ignition point and sustain
burning. The fire within the attic area would have gone unnoticed until
it broke through into the living compartment area of the residence and
shortly thereafter through the roof of the house.

Mr. Schafer confirmed that this could be consistent with Leslie
Harper’s testimony that the fire was out when she awoke in the morning.
[42]

The remainder of Mr. Schafer’s evidence as it relates to fire
prevention, fire protection, and recommendations for St. Theresa Point will
be dealt with later in this report.
[43]

Jack Flett (Evidence given on March 18, 2014)
In January of 2011 Mr. Flett was the Band Councillor in charge of
Capital and Infrastructure in St. Theresa Point. This portfolio included both
housing and fire prevention. Mr. Flett advised that in 2011 the Band
population was 3,952 people, 90% of whom lived on reserve. He estimated
that the community needed between 800 – 900 houses to accommodate its
population. At the time of his testimony there were 568 houses in the
community, with each house accommodating an average of 15 – 17
people. He further advised that there were 300 families on the waiting list
for houses.
[44]

He explained that the First Nation receives funds to build houses
and it is the Band that owns the homes not the residents. Mr. Flett said that
of the existing houses, between 30 and 60 are still heated by wood stoves,
and between 60 and 100 houses are heated by baseboard heaters. The
remainder have furnaces.
[45]

Mr. Flett described the older homes in St Theresa Point as being of
poor quality, being made of low quality construction materials and having
inadequate doors, windows and insulation. As a result residents often
improvise to keep their home warm, which causes fire hazards.
[46]

He further testified that the newer homes in the community are of
much better quality. For example, a new house must now be built on a
concrete pad and must have a furnace for heating. The cost to build a new
house in the community is approximately $175,000. Mr. Flett expected that
the Band would be able to build only five houses in 2014.
[47]

Inquest Report – Errabella Angel Harper

 P a g e   13

Mr. Flett advised that at the time of the fire in 2011, homes in the
community heated by wood stoves were not being inspected and that the
resident of the home was responsible for upkeep and maintenance of the
stove and chimney. Further he said that while a Band Council Resolution
existed to allow for entry into a Band owned home at anytime, it was not
being used to conduct home inspections.
[48]

Mr. Flett testified that in the summer of 2013, all of the homes in the
community were inspected by a journeyman in the community, and all
deficiencies were noted. At the time of his testimony he was still awaiting a
report about those deficiencies.
[49]

Moving forward, Mr. Flett explained that the Band intended to enter
into tenancy agreements with residents when a new home is supplied. It is
expected that the Band will take responsibility for maintenance of wood
stoves in the future, and will supply smoke detectors and fire extinguishers.
The resident will however be required by the tenancy agreement to
maintain and use the supplied smoke detectors or be evicted.
[50]

After the fire at the Harper residence, the Band Council met to
determine what led to this tragedy and to determine how to prevent it from
happening again. To that end, much has changed in St. Theresa Point
since 2011.
[51]

The community has a new fire hall and two fire trucks. There is now
a volunteer fire department with a volunteer fire chief, Mr. Christopher
Knott.
[52]

Mr. Flett advised however that the Fire Prevention and Fire
Protection budget of $70,000 per year received from the Federal
Government does not fully cover the costs of this volunteer fire department.
The fire department has itself undertaken fundraising in the community to
cover additional costs for equipment such as two way radios, uniforms and
training.
[53]

Oscar McDougall (Evidence given on March 18, 2011)
At the time of his testimony, Mr. McDougall had been the Director of
Capital Projects since April 1, 2008. In this capacity he was involved with
fire prevention, fire protection, home inspections and maintenance of the
water plant in St. Theresa Point.
[54]

Inquest Report – Errabella Angel Harper

 P a g e   14

Mr. McDougall testified that at the time of the fire there was no
program in place to address home inspections on the First Nation and that
this has not changed. In his opinion three experienced individuals would
be required to conduct the necessary home inspections in the community,
at a cost of $1000 per unit. He further testified that as of the time of his
evidence there was no organizational plan in existence regarding buildings
and housing.
[55]

Mr. McDougall is in charge of the water plant in St. Theresa Point.
There is only one plant that serves the entire community, and only half of
the houses in the community have running water. He explained that the
farther a residence is from the plant, the lower the water pressure it
receives.
[56]

He explained that when all of the houses in the community have
water services the available pressure from the one plant will be affected. In
his view the capacity of the water plant will have to be doubled.
[57]

Mr. McDougall testified that the Federal Government allots St.
Theresa Point two million dollars per year to deal with minor capital
projects. This budget line is meant to deal with the upkeep of existing
assets, with only one million being allotted to housing issues.
[58]

It is Mr. McDougall’s opinion that the community will need 900
houses over the next twenty years to accommodate their needs. In the last
year the Band was able to build five houses.
[59]

Mr. McDougall advised that the community had a fire hall in the
past, but that it burned down in 2009, along with the fire truck. Insurance
covered the loss of the building, but not the loss of the truck. The fire hall
was rebuilt in 2010 and a new/used truck was purchased in late 2010.
[60]

The truck that was purchased had some issues because it was
used, and was taken out of the community for repairs during the winter of
2011. As a result they were required to use the water truck to deal with the
fire at the Harper residence in January of 2011. In fact, it was Mr.
McDougall that drove the water truck to the Harper residence that day.
[61]

Mr. McDougall said that at the time of the fire there was no official
fire department, but some planning was underway. He had asked
Christopher Knott to be the fire chief, and noted that Mr. Knott did not have
to be asked twice to take on a job in the community.
[62]

Inquest Report – Errabella Angel Harper

 P a g e   15

Mr. McDougall indicated that he had been in contact with Ivan
Mason of the Island Lake Tribal Council, regarding the new fire department
in St. Theresa Point, but that there had been difficulty in making and
maintaining that contact.
[63]

To date the funding to get the Fire Department up and running in
terms of equipment, uniforms and a water pump to be used in the lake, has
come from the current fire budget of $70,000.
[64]

For the 2014/15 year the Band had not identified any further
equipment needed. They will however need to maintain the fire truck and
have fuel readily available. The fire department will also have to have the
old truck repaired and brought back to the community on the next winter
road.
[65]

Mr. McDougall also advised that after the fire in 2011 the community
received a donation of a fire truck from Prince Edward Island. Unfortunately
the truck was of a “vintage” nature and parts were not available for repairs.
[66]

In his view the one fire truck that the community has is not adequate
to meet the community’s needs. They do however have five water trucks
which have been modified to provide good water pressure.
[67]

In terms of the road infrastructure to support these trucks, Mr.
McDougall said that there are no real roads in the community and that they
are very expensive to maintain and are usually just surfaced with crushed
gravel, which impacts the overall longevity of equipment.
[68]

Christopher Knott (Evidence given on March 19, 2014)
Mr. Knott is the water and waste plant manager in St. Theresa
Point. In October of 2010 he also took on the position of volunteer fire chief
in addition to his regular job. He has been a firefighter since 1987, when
the original fire department existed in the community. The original fire
department only lasted until 1992 when funding became as issue. Mr. Knott
confirmed that between 1992 and 2010 there was no fire department in St.
Theresa Point. In 2010 when he became fire chief the plans for a new fire
hall were already underway, but the community was still relying on the
water trucks instead of a fire truck.
[69]

Inquest Report – Errabella Angel Harper

 P a g e   16

Mr. Knott took his firefighting training in Brandon, through the Office
of the Fire Commissioner (OFC)and also through Ivan Mason of the Island
Lake Tribal Council.
[70]

He further indicated that the community of St. Theresa Point is also
associated with the Manitoba Association of Native Firefighters (MANFF).
[71]

At the time of his testimony, Mr. Knott said that there was no written
procedure or operating guidelines respecting fire protection for the
community, and there was no written fire protection plan. He confirmed his
awareness that such a plan was being worked on with the assistance of
MANFF. He also said that although the community had not made contact
with the OFC as a resource that they would do so. He further testified that
there was no fire prevention program in existence in the community, and he
was not aware that the OFC provided public education regarding fire
prevention or that they also provide a five day training course in public
education with materials for distribution.
[72]

Mr. Knott testified that there is a position of fire protection officer
existing in the community, and that Colin Manoakeesick, who is the deputy
fire chief, will do home inspections to look for fire hazards and work with the
housing manager, Shane Flett, to address them. Mr. Manoakeesick has
received some firefighting training but does not have his full Level I
designation.
[73]

Mr. Knott indicated that the firefighting budget for St. Theresa Point
is $65,000 - $70,000 and is administered by “Capital Projects”. He said that
the entire budget goes to equipment and training.
[74]

Mr. Knott testified that his fire department operates on what he
referred to as an “all hazards” response basis and that they now have
training and equipment enabling them to enter buildings to rescue people,
as well as the training to respond to hazardous material situations. They
have also had training at the airport to respond to crash landings and have
had CPR, first aid training and certification on an annual basis. They are
not however trained in water or ground rescue.
[75]

The staff of the St. Theresa Point fire department has a complement
of 21 members; Mr. Knott as the chief, two deputy chiefs, two fire truck
drivers and two teams of firefighters. In addition there are three positions to
deal with administrative matters and dispatch functions. The fire hall is to
[76]

Inquest Report – Errabella Angel Harper

 P a g e   17

be staffed twenty four hours a day. All staff attend regular meetings. All of
the firefighters are identified within the community by virtue of their
uniforms. A Band Council Resolution exists recognizing that if volunteer
firefighters are called away from their jobs to fight a fire, they will still be
paid. The resolution also gives the fire chief the authority to compel people
in the community to assist the fire department when a fire occurs.
In case of fire, personnel are contacted by using eight mobile radio
units which are distributed among the personnel to receive calls from the
dispatcher. There are eight to ten firefighters on call at a time, working four
to eight hour shifts. When a fire occurs, Mr. Knott as chief is briefed by the
deputy chief on duty and takes attendance of the firefighters present.
[77]

At the time of his testimony none of the twenty one firefighters had
achieved their Level I training. Mr. Knott indicated that he needed to update
his Level I status as well.
[78]

In terms of equipment, Mr. Knott said that their current fire truck is
on loan. They have complete gear and all of the other equipment that they
require, including oxygen tanks and self contained breathing apparatus.
[79]

To access water the fire department uses the community water
supply. There are fire hydrants on the main road of the reserve and in the
north end of the community. Mr. Knott said that for firefighting purposes the
water pressure is 90% adequate.
[80]

Regarding the prevalence of fires in St. Theresa Point, Mr. Knott
said that between March and November of 2013 there were thirteen or
fourteen house fires in the community and one hundred and six fires in
total.
[81]

Ivan Mason (Evidence given on December 17, 2014)
Mr. Mason is employed by the Island Lake Tribal Council (ILTC) in
the capacity of emergency services officer, and lives in St. Theresa Point.
In this position he acts in an advisory capacity, working with the Island Lake
First Nations to develop emergency procedures surrounding fire safety and
protection. In this role he also consults with the OFC and Manitoba
Conservation and sometimes MANFF. At the time of his testimony he had
been on leave from this position for eleven months. He indicated that
during his leave, Calvin Mason had been filling in for him, but was now also
on leave.
[82]

Inquest Report – Errabella Angel Harper

 P a g e   18

In terms of his training, Mr. Mason advised that he has his Level III
firefighter training as well as officer level training. He has not however
renewed his Level III training, so it is not current. With this training, he
could do fire prevention inspections and provide emergency services. His
role with St. Theresa Point has been to identify areas of concern, offer
advice to the fire department and provide some training. He is also a
volunteer firefighter in the community. In this capacity he responded to the
fire on January 16, 2011 at the Harper residence and was involved in
removing the infant Errabella from the burning house. He confirmed that
the community’s fire truck was not operational at that time, as it was frozen
due to improper storage conditions.
[83]

Mr. Mason testified that he makes a point of responding to all fire
calls in St. Theresa Point because he is concerned that the fire chief and
his firefighters lack formal training. He feels that he takes on the role of
officer at the scene and provides direction. After each fire that they respond
to, a debriefing is held with those who attended the call to discuss any
issues or concerns that arose during the call.
[84]

After the fire on January 16, 2011, Mr. Mason, in his advisory role
with ILTC, drafted a letter to Chief and Council of St. Theresa Point with
several recommendations. He recommended that obtaining an operational
fire truck should be a priority, and that volunteer firefighters receive training.
Further, he recommended that the community put in a notification system
with portable radios for firefighters. He had discussions with the First Nation
regarding quotes and negotiations to implement these recommendations
for the required purchases, and ultimately left it with the First Nation to take
action.
[85]

Mr. Mason was also involved in responding to the Fire Protection
Survey (Exhibit 12), not only respecting St. Theresa Point, but all four of the
Island Lake communities. The survey identified a number of areas of
concern with respect to the community of St. Theresa Point. Mr. Mason
said that the funding provided for fire protection may not be adequate. He
also pointed out however, that the funding received may not always be
used in the best possible way. By way of example, he indicated that the
amount of money required to purchase a specific item like a fire truck may
be dependent on the winter road season. It may be necessary to pay more
to get such an item into the community on short notice while the winter road
is passable rather than wait for the next opportunity to do so the following
year.
[86]

Inquest Report – Errabella Angel Harper

 P a g e   19

When Mr. Mason returns to work from his leave he will assist with
the fire protection plan for St. Theresa Point.
[87]

At the end of his evidence Mr. Mason made several
recommendations.
[88]

Regarding equipment for the fire department he suggested that
because the community is so spread out, they would benefit from having
two fire trucks, and a second station in the south end for the second truck.
As there are no fire hydrants in the south end, the truck would have to hook
up to the water truck for a source of water.
[89]

In terms of training, Mr. Mason’s view was that the firefighters
should all have Level I training provided by the OFC in Brandon. He further
indicated that he was aware that MANFF had provided some informal
training to the firefighters. This training however was not a certificate
program equivalent to Level I. He had concerns about the cost of this
training relative to its actual quality. Further, he felt that in addition to the
Level I training, the fire chief should also have officer training.
[90]

He also recommended that those that drive the fire trucks have
Class IV licences, rather than what he referred to as the “crash course” that
they had received.
[91]

Mr. Mason recommended that regular home inspections be
conducted in St. Theresa Point to ensure that smoke detectors are in
proper working order. He indicated that many residents remove the
batteries or disable the breaker of hard-wired detectors.
[92]

He also recommended that a review be done in homes with new
tenants to ensure that they have an understanding of how their heating
system works and fire safety issues. He also felt that the community could
benefit from public education sessions about fire safety, with the same type
of sessions in the school for children. Mr Mason was aware of the available
resources from the OFC and indicated a desire to continue regular
meetings with them about available education.
[93]

Finally, Mr. Mason recommended that the Fire Protection Survey be
completed on a regular basis, and that the community be called upon to
justify the use of funding to make sure that resources are being used
appropriately and effectively.
[94]

Inquest Report – Errabella Angel Harper

 P a g e   20

Mr. Mason concluded his testimony by commenting that the current
fire department in St. Theresa Point is a great improvement over what
existed in 2011. The tragic events of January 2011, in his view, kick started
the community’s awareness and interest in making needed improvements.
[95]

Chief David McDougall (Evidence given on March 18, 2014 and December
16, 2014)
Mr. McDougall was the Chief in St. Theresa Point in January 2011
at the time of the death of Errabella Angel Harper. He left office on March
6, 2012 and was re-elected on March 7, 2014. He had been back in office
ten days at the time he first testified. At the time he left office in 2012, he
said the new fire department and fire hall were in the process of being set
up, but that in 2011 at the time of this fire there was no active fire
department.
[96]

Further, he said that wood stoves were not being monitored or
inspected, and there was no other program to inspect for other hazards.
With respect to the Leslie Harper residence, Chief McDougall testified that
it had long been occupied by an elderly couple (presumably Ms. Harper’s
parents). When they received a new trailer from the Band, the house
became occupied by various family members. He stated that because Ms.
Harper had married someone from the community of Wasagamack, she
was officially attached to that First Nation and not to St. Theresa Point. He
said that in terms of assistance, she had “fallen through the cracks”, and
could not say why she had received no financial support from St. Theresa
Point after the fire.
[97]

In terms of future inspection and monitoring of wood stoves in the
community, Chief McDougall said he could not commit to do this. He
indicated that there were people capable of doing the inspection and
monitoring in the community but that they did not have sufficient resources
to make it feasible. He further confirmed that there is no ongoing inspection
program with respect to other hazards within community homes.
[98]

Chief McDougall testified that in his view, the pressure of the water
supply in the community was inadequate for firefighting and that they did
not have the proper fittings to use the fire hydrants.
[99]

While Chief McDougall testified that he was committed to creating a
fire protection plan he confirmed that no such written plan existed. He did,
[100]

Inquest Report – Errabella Angel Harper

 P a g e   21

however, say that the band has proposed operating guidelines for the fire
department which will become part of a band resolution.
He advised that he is open to collaboration with and assistance from
the OFC, but only if the community has resources to do so.
[101]

Chief McDougall confirmed that the Band had no fire prevention
education plan in place and that they have to do more in this regard.
[102]

Chief McDougall testified that the community needed 300 new
houses to “catch up” and then twenty to thirty new houses each year to
replace houses that are no longer habitable, and to address the growth in
population in St. Theresa Point. Although not top quality, he advised that
each housing unit would cost $170,000.00. It is very expensive to build a
house in St. Theresa Point due to issues accessing water, hydro and the
necessity to build a concrete foundation. He said that a committee exists to
determine who will receive a new Band constructed house, and that many
factors are considered.
[103]

On the issue of maintaining houses on the reserve, Chief McDougall
discussed the impact of historical practices. Traditionally their ancestors did
not live in permanent dwelling structures. A family would ordinarily only stay
in a log cabin structure for a year or so. There was no future orientation as
it related to housing maintenance. Chief McDougall in describing the
current mindset offered the view that “learned helplessness” had set in. He
confirmed that skills and training are also required in this area.
[104]

Chief McDougall was aware of the First Nations Fire Protection
Survey. He believed that Mr. Knott had completed it with support from Ivan
Mason of ILTC. In terms of a fire protection plan for the community, Chief
McDougall said it was still in draft form and was being worked on by a
committee. It still needed to be reviewed by Chief and Council. He
indicated that the review would occur by the end of January or February of
2015.
[105]

For the 2014/15 fiscal year, Chief McDougall testified that the fire
protection budget would be $77,960.00, plus funds in the amount of
$70,000 from Band based capital. He testified that in 2014 the fire budget
was used to repair the leased fire truck (the community owned truck was
out of the community being repaired, so it was necessary to lease a second
truck). In terms of maintenance of fire trucks, Chief McDougall testified that
[106]

Inquest Report – Errabella Angel Harper

 P a g e   22

they do not have a certified mechanic living in the community, so they
either have to fly one in or send the truck out for maintenance. The budget
was further used for the purchase of firefighting gear, hoses and other
equipment, the maintenance of fire hydrants and the fire station, including
hydro and phone service. Budget monies were also used to establish a 24hour emergency phone service with a dedicated phone number and paid
dispatchers.
In retrospect, he was not able to say what the fire budget would
have been used for in 2011 at the time of the fire at Ms. Harper’s
residence, because they did not have a fire hall or fire truck to maintain or a
fire department to outfit.
[107]

Chief McDougall said that he is committed to expanding and
strengthening the fire department in St Theresa Point. In terms of
community education, he did not have information about what was being
done, but confirmed that he was open to working with the OFC to deliver
educational programming. Further he committed to improving media
delivery on this topic through radio, TV and their website. He was aware
that Ivan Mason of ILTC was also available to assist the Band but did not
know if he had been contacted.
[108]

Although Chief McDougall agreed that it should be part of a fire
prevention plan, he opined that having smoke detectors in all residences in
the community would be impractical in older homes relying on wood stoves
for heat, and where there were no fume hoods on stoves.
[109]

Respecting wood stoves, he advised that some residences still rely
on them for heat, and advised that they are removed from the houses in the
summer months to create additional living space and reinstalled for the
winter months. He confirmed that there are no inspections done and no
regulations enforced. He advised that in general there is some resistance
from residents to allowing people into their homes as they are embarrassed
by their living circumstances.
[110]

In terms of establishing a home inspection program, Chief
McDougall testified that if inspected, most homes in St. Theresa Point
would not only not pass an inspection, but would be condemned. In short,
the whole community would have to relocate. He reiterated that 341 new
homes are presently required and that remediation of existing homes would
be very costly.
[111]

Inquest Report – Errabella Angel Harper

 P a g e   23

Chief McDougall said that while he is happy with the improvements
that have been made in St. Theresa Point since this fire, they have not
been able to do everything that they would like to do. He indicated that the
Band intended to be more diligent going forward with a rental regime and
acknowledged that there are certain responsibilities that the Band has that
they have not been fulfilling. Chief McDougall concluded his evidence by
saying that he feels like the community is on a positive trajectory and that
they must make a better future for their children and grandchildren.
[112]

Jacques Marion (Evidence given on December 18, 2014)
Mr. Marion is an accountant specializing in intervention services for
the Government of Canada and First Nations. He was involved with St.
Theresa Point First Nation as co–manager from February 2009 until
November 2012 when he was released from service by the First Nation.
Mr. Marion provided information about the fire protection budget and
expenditures for the 2010/11 and 2011/12 fiscal years.
[113]

In the fiscal year 2010/11 the fire protection budget provided by
Aboriginal Affairs and Northern Development Canada (AANDC) was
$69,400.00. That figure increase in the 2011/12 fiscal year to $70,600.00.
In both years the Band’s expenditures relating to fire protection exceeded
this budget line. He confirmed that all expenditures made were appropriate
and related to the maintenance of equipment, training, transportation and
shipping.
[114]

Mr. Marion testified that in the 2010/11 fiscal year $14,328.00 was
spent on wages and training, $2,536.00 was spent on fuel and oil, and
$17,444.00 was spent on equipment.
[115]

In the 2011/12 fiscal year $35,715.00 was spent on training,
$3,052.00 was spent on fuel and oil and $22,801.00 on equipment.
[116]

Additional costs in both years were covered by the operations and
maintenance budget. He cited the maintenance of buildings and water lines
as examples.
[117]

Mr. Marion clarified that the MANFF training referred to by Ivan
Mason was not paid for out of the fire protection budget in the 2011/12
fiscal year. If that expenditure was made by the First Nation it came from
another source of funds.
[118]

Inquest Report – Errabella Angel Harper

 P a g e   24

As for wages, Mr. Marion explained that the funding provided for fire
protection was not sufficient to cover permanent wages for firefighters. He
did indicate however that stipends or honoraria for specific tasks are
permissible expenditures from this budget line. This fact was contrary to the
understanding of the First Nation.
[119]

Mr. Marion testified that the purchase of a second fire truck could
not be accommodated from the fire protection budget line, and would have
to come from Band based capital funding. He pointed out that the purchase
of a fire truck would be the same level of expenditure as one house. He did
add however that AANDC has in the past purchased essential service
vehicles for a First Nation without charge, but he was unsure of the process
for doing so.
[120]

David Schafer (Evidence given on August 1, 2013 and December 18, 2014)
continued.
Mr. Schafer’s qualifications and experience were set out at
paragraph 40 of this report. Mr. Schafer prepared a report entitled,
Responses and Proposed Recommendations to the Inquest into the Fire
Deaths at St. Theresa Point First Nation and God’s Lake First Nation. (It
has been marked twice in these proceedings as Exhibits 6 and 10).
[121]

He gave testimony about the Regulations that are applicable to both
house fires that are the subject of this Inquest. While there was initially
some confusion as to whether Provincial Codes applied to First Nation
communities, Mr. Schafer clarified that it is the National Fire Code (the
Code) that is applicable to both residences. The Code requires that there
be a functioning smoke detector in every single storey dwelling in between
the sleeping areas and the rest of the living space.
[122]

For both the Harper residence in St. Theresa Point, and the James
residence in God’s Lake a battery-operated smoke detector would have
met this requirement because they are older homes. Newly constructed
homes require hard-wired smoke detectors according to the National
Building Code.
[123]

Mr. Schafer testified that it is the responsibility of the home owner,
their agent or representative (in this case the First Nation) to ensure
compliance with the Code. If a smoke detector is not working the
[124]

Inquest Report – Errabella Angel Harper

 P a g e   25

expectation would be that upon notification by the tenant the owner would
address the issue, including supplying a new battery.
The Code does not require that houses of this age have carbon
monoxide detectors.
[125]

With respect to wood stoves, the Code deals specifically with
chimneys and flue pipes. Section 2.6 requires their annual inspection,
cleaning, replacement and repair.
[126]

On a First Nation, the Band Council could pass a resolution or a bylaw that would provide for a higher, more stringent level of fire protection if
they chose to. Mr. Schafer also believes that a Band could pass a
resolution or by-law allowing for a lower level of protection; however he was
not aware of this ever having been done.
[127]

There is no requirement in the Code that single family dwellings be
inspected. He also pointed out that this does not preclude a municipality or
First Nation from passing a by-law or resolution requiring mandatory home
inspections. By way of example, he noted that the First Nation community
of God’s River requires this on a regular basis.
[128]

Mr. Schafer testified that he understood the reservations and
concerns voiced by both Chiefs of the communities about implementing
home inspections and the consequences that may result from them. He
clarified that the kind of inspection he intended was of a very basic kind,
meant to ensure smoke detectors were in place and operating, and that
any fire hazards such as blocked exits were addressed. He acknowledged
that this type of inspection program required both a commitment from
leaders and “buy in” from community members to allow inspectors into their
private homes.
[129]

In his report, Mr. Schafer also addressed the provision of adequate
firefighting equipment and personnel in communities like St. Theresa Point
and God’s Lake. He said that First Nation communities face many of the
same issues as provincial municipalities of similar size with similar levels of
funding. In fact, some very small communities in Manitoba do not have
active fire departments at all, and put their available resources into fire
prevention measures.
[130]

Mr. Schafer set out the three possible levels of firefighting service
that a community can provide.
[131]

Inquest Report – Errabella Angel Harper

 P a g e   26

The lowest level of service is “defensive” firefighting. At this level the
department does not have the equipment and training necessary to
offensively attack a fire by entering the building to suppress it and rescue
trapped persons. In this model, fire suppression is restricted to fighting fires
from outside the building and ensuring that fires do not spread to other
structures. Mr. Schafer said that many communities elect to provide only
this level of service for financial reasons.
[132]

The next level of service is “offensive” firefighting, in which
firefighters are trained to actually enter a building in order to make rescues.
This model is more expensive to support in terms of personnel, training and
equipment.
[133]

The final and highest level of firefighting is “all hazards” service.
This incorporates all the objectives of the previous two levels but also
provides the capability of taking on technical rescues, and hazardous
material responses.
[134]

In his evidence, Mr. Schafer also addressed the minimum
requirements to establish a community fire department. He emphasized
that a basic requirement for all three levels of firefighting is an adequate
water supply, with a pressure of 3000 litres per minute. Whether this is
sourced from hydrants, or fire and water trucks, or natural sources, an
adequate level of pressure is important.
[135]

All three levels of service also require a communication system
such as a dedicated paging system capable of notifying firefighters of an
incident. Further, radio communication for the firefighters to talk to each
other during an incident is also required for offensive firefighting.
[136]

Mr. Schafer testified that having a fire truck is ideal for all levels of
firefighting and is certainly required for “offensive” and “all hazards” service.
He noted that portable pumps and other water sources like water trucks
can also be used effectively in defensive firefighting if there is an
accessible water source nearby.
[137]

All three levels of firefighting service require protective equipment or
“turnout gear”. This gear should be individualized for each firefighter; it
should not be shared. In “offensive” and “all hazards” service, breathing
apparatus, which is very expensive, is also required for at least some of the
team.
[138]

Inquest Report – Errabella Angel Harper

 P a g e   27

When setting up a fire department, Mr. Schafer testified that a
number of essentials require consideration.
[139]

To start, the community needs to establish their authority to actually
operate the fire department. In the case of a First Nation that would be by
Band by-law or resolution giving the fire department the authority to operate
and identify the level of service that the community is committed to and
financially able to provide.
[140]

The community should establish the general categories of support
in a budget document. The budget should set out operating funds for the
purchase of equipment. It should also identify funds for wages, as most
volunteer fire department members are paid for the time they are required
to spend responding to calls and taking training. Funds should be identified
for training as well as for repair and maintenance of equipment.
[141]

Mr. Schafer testified that a fire department also needs sufficient staff
to address the level of service that they have committed to which varies
depending on the level of service to be provided.
[142]

To provide “defensive” firefighting, a minimum of four firefighters is
required to respond to a call for service, with the ideal number being six or
more. Each firefighter should have a Manitoba Level I firefighting certificate.
This certificate entails approximately 120 – 140 hours of time to complete
22 blocks of training. Mr. Schafer testified, however, that even completing
50% of the course would allow a “defensive” service to operate safely. This
training could be delivered right in the community.
[143]

“Offensive” service requires a minimum of six firefighters to respond
to a call, with the preferable number being between eight and twelve.
Complete Level I certificate training would be required for all firefighters in
this scenario. As indicated, some of this training could be done right in the
community, while part of it would require travel to a larger centre and the
use of a facility to complete. The costs of this level of training can be
significant, including instructor travel/accommodations, candidate
travel/accommodations and the wages/travel/accommodation of having an
evaluator attend for the certification process would also be required. In Mr.
Schafer’s estimation the cost for “offensive” training is double for that of
“defensive”.
[144]

Inquest Report – Errabella Angel Harper

 P a g e   28

Mr. Schafer touched upon some of the services and resources that
the OFC will provide at no cost to a community to assist them with their fire
departments and fire safety programming.
[145]

For instance, while the community would be required to cover the
cost of travel to and from the community and accommodation for the
instructor, the actual delivery of the training programming is provided at no
cost. With increased training the ultimate goal would be for the community
departments to deliver their own training.
[146]

The OFC also has a fire and lay safety educator program, which
allows for an individual to learn the skills required to deliver fire education in
their home community. Again, the community would be required to pay for
travel and accommodations for the individual to attend, but there is no cost
for the course itself. Free public education materials such as pamphlets,
posters and videos are also available upon request.
[147]

The OFC will also come to a community to provide other
presentations and workshops at no cost.
[148]

An online newsletter regarding fire prevention is also distributed to
all Manitoba fire services and partners, and public service announcements
are available for radio stations to use during fire prevention week.
[149]

During the winter road months the travelling fire safety trailer can
also attend to remote communities as a resource.
[150]

Mr. Schafer stressed that preparing a fire protection plan is not just
about having a written document. It is also about program development,
which may take a long time to perfect. This requires strong community
leadership at the municipal or band level, as well as strong leadership from
the fire chief to create an environment in which the community is proud of
the fire department and want to be involved.
[151]

Good leadership requires dedication and strong organizational
skills, as well as a visible presence in the community that inspires others to
become involved.
[152]

Mr. Schafer feels that it is the role of the Tribal Council fire safety
officer to assist Chief and Council of a First Nation to accomplish these big
picture goals and confirmed that the OFC is also committed to being
involved.
[153]

Inquest Report – Errabella Angel Harper

 P a g e   29

At Tab 10 of Mr. Schafer’s report is a Memorandum of
Understanding (MOU) that was entered into after the fatal house fires in St.
Theresa Point and God’s Lake, dated June 29, 2011. The MOU was to
address a Fire Prevention and Protection Assessment Program for First
Nation Communities, and was entered into by the Government of Manitoba
and the Assembly of Manitoba Chiefs.
[154]

The MOU acknowledges that the loss of life and property in First
Nation communities is significantly elevated as compared to other
Canadian communities.
[155]

The signatories to the MOU agreed to collaborate on a program to
determine the current state of fire protection in each First Nation community
in Manitoba in order to make a subsequent determination of precisely what
steps and resources are required to establish an acceptable level of fire
protection for each community. They further agreed to use a Fire Protection
Hazard Analysis and Risk Assessment tool developed by the OFC to do so.
This involves the “First Nations Fire Protection Survey” referred to by
previous witnesses.
[156]

Mr. Tim Langevin, who is an experienced member of a municipal
fire service was hired by the OFC to carry out the goals of the MOU. He
attended to 61 of 63 First Nation communities and conducted an
assessment of each community using the survey, and prepared a final
report.
[157]

There has also been a working group established which includes
representatives of the Province of Manitoba, Assembly of Manitoba Chiefs,
Aboriginal Affairs and Northern Development Canada, Manitoba
Association of Firefighters, Southern Chiefs Organization and Manitoba
Keewatinowi Okimakinak. The group continues to meet quarterly and now
includes the Tribal Council fire safety officers as well. The OFC provides
financial support for attendance at these quarterly meetings.
[158]

Mr. Schafer’s recommendations which I adopt with respect to both
communities involved in this Inquest, St. Theresa Point and God’s Lake,
can be found at page 15 of his report (Exhibit 6)and are summarized as
follows
[159]

That where possible, provincial and federal fire protection programs be
aligned to reduce duplication of effort, and improve service delivery. As
an example, endeavoring to coordinate training programs and public

Inquest Report – Errabella Angel Harper

 P a g e   30
education initiatives offered in provincial northern affairs and First Nation
communities to benefit both communities.
That the Manitoba OFC endeavor to develop a closer working
relationship with federal representatives as well as Tribal Councils in an
effort to assist First Nations Communities to prepare formal fire
protection plans, having a strong emphasis in the area of home fire
safety and residential fire inspection programs.
That the Manitoba OFC endeavor to work with federal representatives to
ensure that a consistent level of training and fire prevention services are
provided to First Nation communities and Manitoba Municipal Fire
services.
That the level of support provided by the Manitoba OFC to First Nation
communities in Manitoba be delivered at a level consistent with that
provided to the rest of Manitoba Municipal Fire services.

Exhibit 14 is the Report on the First Nation Community Fire
Prevention and Fire Protection Assessment, 2012. This report should be
read in conjunction with the MOU of June 29, 2011 that called for it. The
report is comprehensive and addresses the concerns and challenges that
have been identified.
[160]

For the preparation of the report, the Province of Manitoba provided
a Program Officer who was hired in December, 2012 to visit each First
Nation community to conduct a fire protection hazard analysis and risk
assessment using a survey tool developed by the OFC.
[161]

Communities were visited between January and September 2012.
When possible the Program Officer was accompanied by the community’s
fire safety officer of the respective Tribal Council.
[162]

The assessment tool used was a seventy question survey regarding
each community’s status on a variety of fire prevention and protection
criteria in the areas of governance, emergency response, fire protection
programs, demographics and community access.
[163]

The report provides a general summary in these areas, but does not
contain specific statistics about individual communities.
[164]

The report concludes that overall there is a shortfall in fire protection
services in Manitoba First Nation communities when compared to most non
First Nation communities. This gap applies to all areas including planning,
[165]

Inquest Report – Errabella Angel Harper

 P a g e   31

infrastructure and equipment, staffing, training, financial resources,
inspections and public education.
Some notable results include the fact that 93% of communities did
not have a written fire protection plan.
[166]

In 89% of the communities they did not have a written by-law or
Band council resolution respecting fire protection and 80% of the
communities did not have a fire protection officer.
[167]

Only 15% of fire departments had written operating guidelines and
most communities did not have a 911 or local dispatch system.
[168]

In 28% of the communities they had no fire truck, 39% had no fire
hall, and there was a low percentage of communities overall that had
adequate equipment or gear.
[169]

There were 11% of the communities who had a fire and life safety
education program in place, and 18% of the communities had fire
prevention inspection programs.
[170]

There are 72% of First Nation communities within twenty minutes
response time of an adjacent community with a fire department.
[171]

The Report makes both short term and long term recommendations
for improving the status of fire prevention and protection in First Nation
communities in Manitoba. I adopt these recommendations.
[172]

Nine short term recommendations: to be completed within six to
twelve months are found at page 18 of Exhibit 14. They are as follows;
[173]

1) That the roles and responsibilities of First Nation Communities, Tribal
Councils, MANFF, AANDC, and other relevant stakeholders with
respect to fire protection are clearly identified, documented, and
communicated.
2) That support for the role of Tribal Councils and their FSOs is
increased, including ensuring that they are adequately funded to
provide fire support services to their member communities.
3) That more detailed documentation of the rationale or formula for the
amount of fire protection funding provided to First Nations
Inquest Report – Errabella Angel Harper

 P a g e   32

communities, Tribal Councils, and MANFF is made available to all
parties.
4) That all First Nation communities work with their respective Tribal
Council or MANFF to prepare a formal fire protection plan. The fire
protection plan should provide for:
a. A public education program
b. A fire prevention program
c. An incident management system
d. Fire department operating guidelines
e. A training plan
f. A records management system.
5) That fire safety inspections are made a priority, and that
responsibilities for conducting inspections are clearly set out. This
should include public, commercial, and residential building/home
inspections.
6) That First Nation community leaders take steps to ensure that proper
resources are allocated towards fire protection services.
7) That a review of the system for reporting of fires and fire losses on
Manitoba First Nation communities is initiated.
8) That all First Nation communities pursue formal written mutual aid or
fire protection agreements with adjacent communities where the
opportunity presents itself.
9) That AANDC publish a status update on its “First Nations Fire
Protection Strategy, 2010-2015”.
There are two long term recommendations which will take longer
than twelve months to accomplish. They are as follows:
[174]

1) That 911 service or local dispatch service is established in all First
Nation communities, with 911 service being the ultimate goal.
2) That a model similar to that used by Manitoba Aboriginal and
Northern Affairs (ANA) for funding fire protection in ANA communities
should be implemented. The model should:
Inquest Report – Errabella Angel Harper

 P a g e   33

a. Divide communities into service groups based on capacity and
capabilities. For example,
i. Fire prevention and public education only
ii. Fire prevention and public education + defensive fire
mandate
iii. Fire prevention and public education + offensive mandate.
b. Specify the method by which communities will be sorted into
groups, and what the requirements are to move from one group
to another.
c. For each service level, set out minimum requirements for
staffing, training, infrastructure and equipment.
d. Specify funds to be spent each year on ongoing staffing,
training and equipment maintenance.
The ultimate goal of the recommendations adopted from the reports
of Mr. Schafer, the First Nation Community Fire Prevention and Fire
Protection Assessment and the additional recommendations of the Inquest
that follow, is the creation of a comprehensive strategy involving all levels
of government, Tribal Councils and community Chief and Councils to
address fire prevention and firefighting capacity at the community level for
all First Nations in Manitoba. The strategy should provide for equal
emphasis on fire safety education/prevention and fire protection services.
[175]

In addition to the adopted recommendations of Mr. Schafer and the
adopted recommendations of the First Nation Community Fire Prevention
and Fire Protection Assessment It is the recommendation of the Inquest
that community Chief and Council in St. Theresa Point First Nation:
[176]

1. Prepare a written fire protection plan which formalizes the level of
service to be provided to the community, and which addresses the
community’s commitment to public education, fire prevention
programming and an annual home inspection program.
2. Commit to provide the required ongoing training for community
firefighters, with a minimum of Level 1 training and officer training for
the position of fire chief.
Inquest Report – Errabella Angel Harper

 P a g e   34

3. Create a voluntary position of community fire safety coordinator and
provide funding support for this individual to receive the Fire and Life
Safety Educator training course offered by the OFC.
4. Provide support to this position in accessing available public
education materials from the OFC and in the set up of a culturally
sensitive public education program in the community.
5. Give consideration to an honorarium for the volunteer fire chief,
firefighters and community fire safety coordinator.
6. Support the education training and retention of a certified electrician,
carpenters and other trades people in the community to perform
home fire safety inspections and conduct required repairs.
It is the recommendation of the Inquest that the St. Theresa Point fire
chief:
1. Prepare written operating guidelines for the community fire
department.
2. Prepare a long term training plan for all staff, as well as a schedule of
required maintenance for all equipment, vehicles and buildings.
3. Provide written incident reports to the Island Lake Tribal Council fire
safety officer and the OFC of every fire occurrence in the community.
It is the recommendation of the Inquest that the Island Lake Tribal
Council:
1. Continue to retain the position of fire safety officer.
2. Commit to increased consultation and support with the community
safety coordinator, fire chief and Chief and Council in the areas of
public education programming, fire safety home inspections, fire
department staff training and equipment maintenance.
3. Train individuals in the community of God’s Lake to perform basic
annual home inspections with a particular emphasis on safe home
Inquest Report – Errabella Angel Harper

 P a g e   35

heating in the winter months and proper maintenance of smoke
alarms.
It is the recommendation of the Inquest that the Province of Manitoba
Office of the Fire Commissioner:
1. Develop a close working relationship with federal representatives as
well as Tribal Councils to develop and implement comprehensive fire
protection plans for all First Nation communities.
2. Continue to provide educational resources and firefighting training in
a manner that best addresses the geographical constraints and
challenges faced by first nation communities in Manitoba.
Dated at the City of Winnipeg, in Manitoba, this 30th day of October,
2015.
“Original signed by Judge Tracey Lord”
__________________________
Judge Tracey Lord

Inquest Report – Errabella Angel Harper

 P a g e   36

EXHIBITS for the Inquest Report of Judge Tracey Lord into the death
of Errabella Angel Harper
Exhibit
Number
1

Exhibit Description

2

Folder of documents Section 1: A to C

3

Letter from the CME calling the inquest dated June 21, 2011 (4 pages)

4

Folder of Documents Section 11: D to G

5

Resume of David Schafer, Fire Commissioner of Manitoba, Manitoba
Office of the Fire Commissioner (3 Pages)

6

Responses and Proposed Recommendations to the Inquest into the Fire
Deaths at St. Theresa Point First Nation and God’s Lake First Nation
prepared by the Office of the Fire Commission – July 10, 2013.

7

July 31, 2013 – T. Mroz – Seven Week Training Proposal submitted by
Keewatin Tribal Counsel

8

Two Week Training Proposal submitted by Keewatin Tribal Counsel

9

August 1, 2013 – T. Mroz - David K. Schafer credentials

10

Responses and proposed recommendations to the inquest into the Fire
Deaths at St. Theresa Point First Nation and God’s Lake First Nation.

11

March 17, 2014 – T. Mroz – Letter dated June 20, 2011 from A.
Balachandra

12

December 16, 2014 – T. Penner - First Nations Fire Protection Survey

13

St. Theresa Point Fist Nation Notice of Appointment Band Council
Resolution.

14

Assembly of Manitoba Chiefs and the Manitoba Office of the Fire
Commissioner Report on the First Nation Community Fire Prevention and
Fire Protection Assessment 2012

15

December 18, 2014 – A. Pilcher – Letter from Collins Barrow HMA LLP
(Michael P. Angers) Re: God’s Lake First Nations – Fire Protection and
Housing Funding.

July 7, 2013 – T. Mroz – letter of CME calling the inquest dated June 20,
2011

Inquest Report – Errabella Angel Harper

 I37

Inquest Report Errabella Angel Harper