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 deaths of DEMUS
JAMES, THRONE KIRKNESS and KAYLEIGH OKEMOW

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

APPEARANCES:
Counsel to the Inquest: N. Roch

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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 DEATHS OF: DEMUS JAMES, THRONE KIRKNESS and
KAYLEIGH OKEMOW
An inquest into the deaths of Demus James, Throne Kirkness and
Kayleigh Okemow was held on July 30, 31 and August 1, 2013 and March
3, 2014 in God’s Lake, Manitoba and on 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

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INTRODUCTION AND CHRONOLOGY OF PROCEEDINGS
By letter dated June 21, 2011, the Chief Medical Examiner 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 sections 19(1) and (2)
of The Fatality Inquiries Act. These deaths occurred on March 14, 2011 in
God’s Lake, Manitoba.
On June 20, 2011 the Chief Medical Examiner for the Province of Manitoba
had directed that an inquest be held into the death of Errabella Angel
Harper (age 2 ½ months), pursuant to the same sections. Her death
occurred on January 16, 2011 in the community of St. Theresa Point First
Nation, Manitoba.
These deaths 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. N. 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 to March 17-19, 2014.
The joint Inquest 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.
While the two Inquests were held together, the experiences of the
communities of St. Theresa Point and God’s Lake, and their responses to
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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
(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

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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
Demus James (age 73), Kayleigh Okemow (age 3) and Throne
Kirkness (age 2) died on March 14, 2011 in a house fire on the First Nation
community of God’s Lake, Manitoba. There is no issue that the cause of
their deaths was the result of the fire. God’s Lake First Nation is 1037 km
north east of Winnipeg, and is accessible by air year round and by winter
road in the winter months. The population of God’s Lake First Nation is
approximately 2000 people.
5)

God’s Lake First Nation is policed by Band Constables as well as by
the Royal Canadian Mounted Police (RCMP) detachment in the nearby
neighbouring community of God’s Lake Narrows.
6)

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WITNESSES
Robert Chubb, Wallace Anderson, Hubert Watt and Ronald “Randy” White
(Evidence given on July 30 and 31, 2013)
These four gentlemen are all residents of God’s Lake First Nation
and responded to the fire at the James residence on March 14, 2011.
7)

Between 9:00 and 9:30 a.m., all observed from their various
locations that a fire was occurring and made their way quickly to the house.
The James house was located on an access road close to the main road.
The house had a front porch with a door, which lead to the front door of the
house, as well as a back door at the rear. They initially observed smoke
mainly coming from above the living room window.
8)

Upon his arrival Mr. White attempted to kick in the porch door to
gain access to the house. It took some time to gain entry as the door was
either locked or blocked. The back door was also not accessible.
9)

Mr Chubb also noted that the windows of the house were covered in
plastic. He, Mr. Anderson and Mr. Watt attempted to get inside the home,
but were unable to make any headway as it was too hot and very smoky.
They were unable to see or breathe. Mr. Watt described how the air burnt
his lungs.
10)

Mr. Chubb testified that he yelled to see if there was anyone inside
and did not receive an answer. He tried to go in a second time but was
again unsuccessful. Mr. Chubb also broke a bedroom window at the front
of the house, and removed the plastic covering but was only able to see
black smoke inside. Mr. White dragged a “quad” over to a window to look in
and described seeing red and orange flames in the living room.
11)

Mr. Watt ran to his residence next door to get wet towels and to ask
his wife to notify the Band office to call for the water truck to come.
12)

Mr. Watt was a Band Councillor at the time and was aware that the
community fire truck was not operable. He drove to the garage to get the
hoses for the water truck and then returned to the James residence; by that
time the water truck had arrived. The fire was put out using the water truck,
but according to Mr. Watt, it took some time because the water pressure
was low, like that of a garden hose. He further explained that the pressure
was low because the water plant had been “down” for a couple of days
13)

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prior and was not able to keep up with the demand from the community. He
said that while there has been improvement in the pressure since the time
of the fire, even at the time of his testimony there were still problems from
time to time.
There is conflicting evidence as to whether the fire hydrant was
used at this fire scene. It is unclear what effect the pressure at the water
plant had on the ability to suppress this fire.
14)

Mr. White testified that the fire got worse very quickly after they
arrived and took a long time to be completely out. In contrast, Mr. Chubb
said that once the water truck was hooked up to the fire hydrant it didn’t
take too long to put the fire out.
15)

Mr. Watt also confirmed as a council member that at the time of the
fire there was no firefighting plan in place for the community, and no fire
chief. He was not aware of whether there were trained firefighters in the
community at that time or not. He said that the community did have a fire
truck at the time of the fire but that it was not working and wasn’t
repairable. At the time of his testimony, he confirmed that the community
had a new fire truck that was stored in a garage at night during the winter
and at James Watt’s residence during the summer. James Watt is the new
fire chief, and there are new volunteers trained in how to use the fire truck,
hydrants and portable pumps.
16)

Mr. Watt testified that there is also now a communication plan in
place. In case of fire, people are to call the Band office, the radio station,
the fire chief and the garage. There are “CB” radios to notify the firefighters
when they are needed.
17)

Mr. Watt gave some details about the James residence. He said
that it was owned by the Band and was built in 1993 of hard board
construction and heated by baseboard heaters, as are 70 – 75 % of the
houses on the First Nation. Houses built during that era had battery
operated smoke detectors.
18)

He further advised that the James’ had reported problems to the
Band regarding their base board heaters and that this was a common
complaint from many residents. The complaints included incidents of the
heaters “sparking”. Mr. Watt said that a certified electrician is required to
service the baseboard heaters, and that they don’t have one in the
19)

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community. They are therefore required to bring one in and pay for their
flight, accommodation, wages, required parts and freight.
Constable Alexander Key (Evidence given December 15, 2014)
Constable Key is a member of the RCMP. God’s Lake Narrows,
Manitoba was his first posting beginning in January 2010 and ending in
February 2012.
20)

He was on duty on March 14, 2011 when the call came into the
detachment at approximately 10:55 a.m. that the James residence was on
fire. He confirmed that there is no 911 service in God’s Lake.
21)

He arrived at the James residence within three minutes and noted
upwards of forty vehicles parked near the house. Band Councillor Leona
Trout was present and assisted him in speaking with Esola James who
speaks only Cree. He initially learned four others lived in the house and
that their whereabouts were at that time unknown. The Constable then
learned that both Esola and Delmar, her grandson, had not slept at the
house the previous night.
22)

Prior to his arrival other community members had already tried to
enter the residence. He tried as well but was unable to. Fire suppression
started after his arrival. There were two water trucks present, but the water
pressure was very low, similar to a garden hose. His recollection was that a
fire hydrant nearby was not in use.
23)

Constable Key testified that the water did not have much impact on
the fire and that it essentially burned itself out.
24)

He indicated that at the time of the fire, there was no fire truck on
the First Nation, but that the neighbouring Métis community of God’s Lake
Narrows did have one. He said, however, that he had never seen it in use.
25)

Constable Key said that he was aware that some community
members were trained to fight wild fires, but he was not aware of anyone
trained or designated as a firefighter per se. He did note that none of the
community members present had fire equipment or were wearing fire gear
and that nobody appeared to be coordinating the firefighting efforts.
26)

Ultimately, three bodies, one adult and two children were located in
the residence when the fire was out. Their remains were turned over to him
27)

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after the Office of the Fire Commissioner (OFC) had completed their
investigation. Prayers were performed by elders at the scene before the
remains were transported to the RCMP detachment.
Constable Key conducted witness interviews of those at the scene
and assisted with follow up to the Fire Commissioner’s investigation.
28)

Constable Morgan Page (Evidence given on December 15, 2014)
Constable Page is an eight year veteran of the RCMP. She was
called in to work on the day of the fire to assist those on day shift. She first
contacted the OFC, arranged for their flights to the community and then
attended the James residence at 12:36 p.m.
29)

When she arrived she observed that police tape surrounded the
scene and that there was still smoke coming from the residence, but that
the fire was dying out. At 2:10 p.m. she was able to examine the house and
recorded a sketch of it in her notebook. She located the remains of Demus
James in the kitchen area. Constable Page said that the body was very
badly burned and was unrecognizable. She did not venture further into the
residence at that time. She was able to look through the burned out wall on
the other side of the structure and see the bodies of the two children
Kayleigh and Throne in the back bedroom. Although they were also very
badly burned she could see that they wore diapers.
30)

In terms of firefighting capabilities in the community, Constable
Page was aware that the neighbouring Métis community had a fire truck but
believed that it was not operable at the time of this fire.
31)

Beverly Trout (Evidence given on August 1, 2013)
Beverly Trout is the daughter of Esola and Demus James and the
grandmother of Throne Kirkness. Kayleigh Okemow was her brother’s
daughter, but Beverly and her partner stood in the place of parents to her.
32)

The weekend of the fire was to have been Ms. Trout’s wedding. She
had left Kayleigh in the care of her biological mother. Ms. Trout was
unaware that Kayleigh had been left at her parents’ house in the care of Mr.
James.
33)

Ms. Trout testified that her parents’ house was not in good
condition. She said that the baseboard heater in the living room was wet all
34)

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the time from the condensation on the window above it, and did not have a
cover. She felt the situation was dangerous and worried about it. The
baseboard heaters in the kitchen and bedrooms also did not work well. In
addition to another space heater near the front door, Ms. Trout said that her
parents often used the oven to heat the house, especially in the mornings.
She described how her father Demus would turn the baseboard
heaters on high while items like clothing were close by. Ms. Trout testified
that her father had suffered two slight strokes and had difficulty with his
balance and with walking. He was not strong enough to look after young
children.
35)

She said that despite this her father still felt that he was capable and
was stubborn and not always willing to listen to others.
36)

Ms. Trout reported that her mother Esola had phoned the Band
office many times to have the heaters repaired and problems with the
windows addressed to no avail. She felt that her mother’s complaints were
not taken seriously or were simply ignored.
37)

Ms. Trout testified that the back door of her parents’ house was not
in use and was covered in plastic in an effort to keep the house warmer.
38)

Ms. Trout’s mother Esola now lives with her. She has not been the
same person since the fire, suffering from depression and loneliness.
39)

As for herself, Ms. Trout said she is also a different person. She
now always worries about the well being of her children and never leaves
them unless they are with a good babysitter. Ms. Trout expressed the hope
that housing in her community will improve and that the leaders will listen to
the concerns of their people.
40)

Delmar James (Evidence given on July 30, 2013)
Delmar James is the son of Beverly Trout, the father of Throne
Kirkness and the grandson of Demus and Esola James. In March of 2011
he lived with his grandparents in God’s Lake First Nation. At the time of the
fire, his son Throne was visiting him and also staying in the home. On the
morning of the fire he was at his girlfriend’s residence, where he had spent
the night.
41)

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Delmar James testified about the condition of his grandparents’
home. He said that the baseboard heater under the living room window
was in “bad shape”. He said that the interior parts of the heater “crackled”
and sometimes a “shock” would come out of the heater. The window above
the heater had condensation on it and the curtains were often wet.
42)

Delmar said that although the living room heater was the worst, all
of the baseboard heaters in the house were in disrepair and that two didn’t
have covers on them. He testified that he would try to keep them turned
down low, but his grandfather liked the house warm and would always turn
them up when he got up in the morning.
43)

Delmar said that the front door of the house did not close properly
due to ice build up. He would chip the ice off but it was necessary to hold
the door closed by leaning a piece of wood up against it at night. The back
door was not used and was sealed off with plastic to keep the cold out.
44)

In terms of smoke detectors, Delmar said that there were two in the
house, one in the living room and one in the hallway by the bathroom. He
could not say whether they were in proper working order, but he did say
that the smoke detector in the living room was covered with toilet paper to
keep it from going off.
45)

In closing, Delmar James said that this fire has devastated his
family, and that he found it very difficult to attend court and testify. At the
time of his evidence he was planning to move back to the community and
hoped that there would be better housing available in the future.
46)

David Schafer (Evidence given on August 1, 2013 and December 18, 2014)
Mr. Schafer is employed with the Manitoba Office of the Fire
Commissioner (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, he
has been the operations coordinator with the OFC and has operated the
Manitoba Emergency Services College which is the training branch of the
OFC.
47)

Ken Giersch, an investigator from the OFC conducted an
investigation into the fire at the James residence, and concluded that the
48)

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fire was accidental in origin. He determined that the origin of the fire was in
the living room, with a possible cause being the baseboard heater on the
west wall. He was however not able to eliminate all other possible heat
sources in the area of origin due to the heavy damage caused by the fire.
The remainder of Mr. Schafer’s evidence as it relates to fire
prevention, fire protection and recommendations for God’s Lake will be
dealt with later in this report.
49)

James Watt Sr. (Evidence given on August 1, 2013)
Mr. Watt is a full time Band Constable in God’s Lake First Nation.
As of April 2013, he is also the volunteer fire chief. The community received
a fire truck in March 2013, and he and three others attended a two day
“crash course” on how to run the truck. He and eleven others also attended
a five day training session put on by Ivan Hart in May, 2013. During this
session they learned how to run the pumps on the truck and how to
extinguish a fire from outside a building. They were not taught in this
session how to rescue people from the inside. Other than this he has not
received any training specific to being a fire chief.
50)

Mr. Watt believes his responsibilities are to take care of the fire
truck and related equipment, and to respond to a fire call as quickly as
possible.
51)

Radios were also received along with the truck and distributed to
some of those that took Ivan Hart’s training. Unfortunately the actual
location of the radios was not presently known and those that have them
have not kept them charged and turned on. As a result when a fire occurs,
the alert is usually relayed by the radio station or by phone contact.
Everyone who is responding meets at the location of the fire and Mr. Watt
brings the truck. Mr. Watt said that usually half of those who have received
training respond.
52)

This group has responded to three house fires (one abandoned)
and three brush fires. With respect to the abandoned house they arrived
too late to be effective, and with respect to the rest, Mr. Watt reported that
there were no injuries. They have encountered some problems along the
way as already noted regarding the use of the radios. In addition on one
occasion Mr. Watt was not able to locate the key to unlock the garage to
53)

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get to the truck, so he had to break the door in. He now ensures that he
has the key to the garage with him at all times.
Mr. Watt confirmed that the community has no written fire protection
plan and that he, as fire chief does not provide any additional training to
others or participate in public education. As chief he would like to see
further training provided on how to rescue people from inside burning
buildings, as well as first aid and CPR training. He would like to have a fire
hall to store the truck and proper equipment for all volunteer firefighters. He
said that although they received four sets of gear along with the fire truck,
three of the four sets of gear are too small to fit anyone, so they must take
turns using the one remaining set of larger gear.
54)

Mr. Watt added that he would appreciate a paid day once every two
weeks away from his full time job as a Band Constable to focus on being a
fire chief.
55)

Stanley Duck (Evidence given on July 30, 2013)
Mr. Duck is a member of God’s Lake First Nation and has been a
councillor for eleven years. At the time of his testimony, he was the
councillor responsible for community services, which includes services like
water and sewer.
56)

Mr. Duck testified that there are 1495 Band members living on the
First Nation in 266 houses. He provided information about the differences
between the older homes in the community and the new ones now being
built.
57)

New homes are built using drywall as opposed to hard board (wood
construction) which was used in older homes, of which the James’ was
one. New homes are heated with furnaces as opposed to baseboard
heaters, and have hard wired smoke detectors. The older homes have only
battery operated smoke detectors. He was unsure as to how many of the
battery operated units would actually be in working order.
58)

Regarding baseboard heaters, he testified that most are installed
underneath a window which creates condensation on the window. The
moisture then results in rotten baseboards and sparking from the heaters
themselves. As a result of the rotting, the heating units also pull away from
the wall, which is hazardous.
59)

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With respect to the James residence, Mr. Duck advised that the
Band had received complaints about the windows in the residence as well
as the fact that the front door would not close properly. He was not aware
of complaints about the heaters themselves.
60)

Mr. Duck confirmed that many of the homes in the community still
have baseboard heaters and that there are often complaints about them.
He added that heating with baseboard heaters is more economical than
heating with a furnace.
61)

Mr. Duck estimated that the community currently needs between
500 and 600 homes to address their backlog. Between 60 – 70 % of
existing homes need to be remediated or replaced, and of those, 90%
should be torn down. The overcrowding of up to twenty people in a three
bedroom house causes health problems for those living there.
62)

According to Mr. Duck the Band’s capital budget for housing is
between $400,000 and $600,000 per year. They can therefore only build
four houses each year. Every year decisions have to be made as to how
the budget is allocated in terms of building new houses or using the budget
to repair existing homes. In the last three or four years no new homes have
been built.
63)

Harvey Weenusk (Evidence given on July 31, 2013)
Mr. Weenusk has been the technical services director with the
Keewatin Tribal Council (KTC) since 2009. From 2001 – 2009 he was the
housing and building inspector and advisor for the same organization. He
has had his Red Seal carpenter designation since 1992 and is a
journeyman carpenter.
64)

The KTC was created by the Federal Government in 1984. The
KTC’s role is to provide administrative and technical services to eleven
remote northern First Nation communities. God’s Lake First Nation falls
within their mandate.
65)

In 2013 the Tribal Council received two million dollars from the
Federal Government to provide these services. Mr. Weenusk indicated
however that in 2014 they will expect to receive only $500,000, due to
budget cuts.
66)

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In 2013 the federal funding was used to improve infrastructure,
housing, fire safety and to advocate on behalf of First Nation communities
to improve services in these areas. Because all houses on the First Nation
are owned by the Band, the KTC also assists with the submission of
proposals on behalf of its communities. By way of example Mr. Weenusk
cited the Canadian Mortgage and Housing Corporation’s National Housing
Program and the Residential Rehabilitation Assistance Program.
67)

This latter program is aimed at the repair of substandard homes to
bring them up to minimum standards. He noted that this program would not
replace faulty baseboard heaters with a new furnace, but would supply new
baseboard heaters.
68)

Mr. Weenusk also travels to communities within his jurisdiction to
conduct home inspections. Because of the housing backlog in First Nation
communities, his approach is to try to save an existing home if possible by
repairing it. He estimates that the housing backlog in God’s Lake is
between 300 and 380 houses, and estimates that the backlog will double
within the next ten to fifteen years. He noted that the average number of
people living in a house in God’s Lake is 6.2 as compared to the national
average of 2.4.
69)

In 2012 only eight new homes were built in all of the eleven
communities in the KTC region. Mr. Weenusk offered the view that the
funding earmarked for housing needs to increase.
70)

Regarding God’s Lake First Nation, Mr. Weenusk testified that a
KTC inspector had done few home inspections there within the last three
years. With the expected reduction in funding they will only be able to
conduct inspections when requested by the Chief and Council. He has not
been asked to specifically inspect baseboard heaters in God’s Lake.
71)

Mr. Weenusk testified that between 70 - 80 % of the houses on the
reserve are constructed of hard board panelling, and 20 – 30 % are
constructed of dry wall. He said that fire spreads approximately six times
faster in hard board compared to drywall.
72)

He further testified that all new houses have hard wired smoke
detectors, as compared to older homes that may only have a batterypowered detector.
73)

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Mr. Weenusk made several recommendations for the community of
God’s Lake First Nation in the area of fire safety.
74)

1. Only proper fuel should be used in any wood stoves. This is
because fuel like old wood panelling burns too hot and
destroys the integrity of chimneys.
2. Wood panelling should be either removed from homes or
covered with drywall that is more fire retardant.
3. Electrical outlets, particularly those on outside walls, should
be replaced regularly. This is because they tend to loosen due
to cold, causing sparks.
4. Replace windows with triple pane argon gas filled windows
to prevent condensation from the baseboard heaters.
5. Install balanced ventilation/exhaust systems that not only
remove air from the home but also bring in outside air. Mr
Weenusk said that the best way to accomplish this would be to
replace baseboard heaters with furnaces, but acknowledged
that this was not practical.
6. Install proper insulation that protects electrical wiring and
improves the functioning of the heating system.
7. Install hard-wired smoke detectors.
Mr. Weenusk estimated that the cost to accomplish this for each
house would be between $30,000 - $50,000. It would take four to six
people including an electrician and a carpenter between three to five weeks
to complete. In his estimation, to bring the houses in God’s Lake up to
minimum standards, it would cost approximately $12 million dollars.
75)

Mr. Weenusk would also like the KTC fire safety officer, Ivan Hart to
be involved in education in the community. In the past $7,000 of the budget
went towards fire prevention and fire safety programming but this will
change in the future due to budget cuts. They may only be able to visit
three communities in the coming year instead of all eleven as in the past.
76)

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Overall, he is concerned about his ability to deliver services on
behalf of the Keewatin Tribal Council to the First Nations within his
jurisdiction.
77)

Ivan Hart (Evidence given on July 31, 2013)
Mr. Hart has been employed by Keewatin Tribal Council (KTC) as
their fire safety officer since September of 2010. He is a certified firefighter
and has also been a fire chief in the past. He was also the director of the
Manitoba Association of Firefighters (MANFF) between 2000 and 2003.
78)

In his current job, Mr. Hart does training in the eleven First Nation
communities that fall under KTO in basic firefighting, CPR, first aid training
and public education. He is also available at the request of Chief and
Council to help with the set up of a fire department, including training,
purchase of equipment and the establishment of fire protection plans. He
receives assistance from the OFC to deliver these services.
79)

In terms of training, his practice has been to travel to a community
three or four times per year to deliver basic fire training akin to Level I.
80)

Mr. Hart will also assist First Nation communities with proposals for
funding, as he said that obtaining sufficient resources is often an issue
when setting up a fire department.
81)

Mr. Hart confirmed that God’s Lake First Nation was made aware of
the services he offers in 2010, and as of the time of giving his evidence he
had received no requests from them for assistance.
82)

Mr. Hart participated in a Fire Protection Survey in conjunction with
Tim Langevin of the OFC. Together they travelled to each of the KTC
communities to conduct the survey.
83)

With respect to God’s Lake specifically, Mr. Hart advised that the
community currently has a fire truck and firefighting equipment. They have
also received some defensive fire fighting training as to how to extinguish a
fire from the exterior. Twelve individuals were trained over a period of five
days. This is not yet the equivalent of Level I training, so more is still
required.
84)

On the day he was in God’s Lake to give his evidence, he also
inspected the community’s fire truck. He reported that it was currently not
85)

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operable because it had not received proper maintenance over the winter
months. He explained that the pump had not been drained, so two valves
had frozen and cracked. Mr. Hart ordered the parts for the truck that day,
and said that a mechanic in the community would be able to install them
when they arrived.
This was a “real time” example of the practical and expert
assistance that Mr. Hart can provide quickly and efficiently simply by being
invited to be present in the community.
86)

As a result of his inspection, Mr. Hart was able to say clearly that
the First Nation required not only a proper fire hall in which to store the fire
truck but, also training on how to maintain it. This process has now begun.
87)

Mr. Hart does inspections of Band owned buildings for KTC
communities. He is also able to do home inspections if requested, and has
done three such inspections in God’s Lake. During those inspections he
found deficiencies, including a lack of smoke detectors and fire
extinguishers, blocked exits and exposed electrical wiring. Each inspection
took approximately three hours. He said he could complete several in a
day. Mr. Hart would also like to train someone in the community to do these
basic inspections. He said that he could train someone in two days to know
what to look for, and has done so in another community.
88)

In addition to conducting home inspections, Mr. Hart testified that he
would also like to work with Chief and Council to establish a fire department
with Level I training as well as a fire prevention plan and a public education
program. He is able to provide a full day workshop on home safety; how to
use a fire extinguisher, how not to overload electrical outlets, kitchen safety
and smoking safety. He indicated that it is the responsibility of the First
Nation to supply smoke detectors and fire extinguishers from the fire
prevention budget.
89)

In his view God’s Lake should have a complement of twenty
firefighters and a Chief, all with Level I training. He recognized however
that this may not be financially feasible. He further suggested that the
community should also have a central communication system, either
dispatch or paging in place to reduce response time when a fire occurs. He
estimated the cost to put this in place as approximately $20,000 and
$2,000 in yearly maintenance.
90)

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Mr. Hart had recently made a proposal (Exhibit 7) to Aboriginal and
Northern Development Canada (AANDC) for funding in the amount of
$140,000 to be used to deliver a seven week Level I training course to one
person from each KTC community, who could then pass on their
knowledge and skills to other firefighters at no cost. His proposal had the
support of the OFC and he hoped to deliver the training in Thompson. The
response he received from AANDC was that there was no funding
available.
91)

He then made a second more modest proposal (Exhibit 8)
requesting $43,172 from AANDC to provide a two week “hands on” skills
training for community firefighters. He had hoped to do this is June, 2013.
The response from AANDC was the same in terms of a lack of available
funding. Mr. Hart testified that it is important to keep these skills up by
doing drills and remaining familiar with truck preparation and practice.
92)

In conclusion Mr. Hart said that KTC will continue to do what they
can with the diminished funds that they have available, in the hope that
they can reduce loss of lives and property. He commented that in his view,
Chiefs and Councils need to receive education and become informed about
fire safety issues, so that they can take the communities’ concerns
seriously. He estimates that fire budget funding from AANDC should
increase to between $100,000 and $200,000 to support what is required for
a fire department in a community like God’s Lake.
93)

Peter Watt (Evidence given on March 3, 2014)
Mr. Watt has in the past served two terms as Band Chief in God’s
Lake. These terms were 1990 – 1994 and 2010 – 2012. He was the Chief
at the time of the fire at the James residence. He has also been the
community’s Probation Officer since 1978, with the exception of when he
served as Chief.
94)

Mr. Watt provided a brief history with respect to his community. He
spoke of pre and post colonial times, and his people’s experience with
residential schools and the resulting loss of culture, language and self
sufficiency.
95)

In addition, he spoke of an attitude change from one of helping one
another when required, to an attitude of individualism, in which nobody
wants to help another unless paid. He described a change from a
96)

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community of people who were self reliant to a people who are dependent
on others for their survival; a culture of helplessness. Mr. Watt feels,
however, that in the last fifteen years his people have been making efforts
to regain what has been lost.
Mr. Watt said that while he was Chief they were able to build
between thirty and forty houses in God’s Lake, but confirmed that the
waiting list for a new house is indeed a long one. He said that the last
house was built in 2012. They have however been able to provide six
mobile homes in each of the last two years.
97)

He confirmed that regular home inspections do not occur, but that
he was aware that if requested KTC would provide a certified inspector to
do so.
98)

When asked what had changed since this particular fire, Mr. Watt
testified that there was now a fire chief, a fire truck and a converted
warehouse to keep it in. He also confirmed that the water pressure from the
water plant was still problematic and that there was still no fire protection
plan or education program in place. There is also no agreement with any
neighbouring community to share services.
99)

Mr. Watt said that he met with Ivan Hart after the fire, but conceded
that he did not follow up on their meeting.
100)

Chief Gilbert Andrews (Evidence given on December 17, 2014)
Mr. Andrews has been the Chief of God’s Lake First Nation since
April, 2012.
101)

He confirmed that while there is now a fire truck and a small fire
department in the community since the summer of 2011, there is still no fire
protection plan in place for the community, and no community education
plan regarding fire safety. He was of the view that Ivan Hart was supposed
to help them with this. He was aware that the firefighters have received
some training from Mr. Hart, but could not comment on specifics. Further,
Chief Andrews said that there was no communication/ notification system in
place and that the firefighters are notified by word of mouth when they are
needed. He confirmed that usually he or another councillor would receive
the first call when a fire occurred.
102)

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Chief Andrews testified that the fire budget for 2014/15 of $33,980
would be used for upkeep of the facility, truck and equipment as well as
regular costs like hydro. His understanding was that salaries or honoraria
could not come from the fire budget. He said that his community is not
currently working with KTC due to that organization’s budget cuts, and
further, that God’s Lake has not been involved with MANFF because they
are governed by a tribal council.
103)

In terms of home inspections, Chief Andrews confirmed that none
are being done. When they have been done in the past, the inspector has
identified the existing problems for the resident, but the resident was
expected to address them.
104)

In terms of the housing backlog which he identified as 200, he
advised that the plan for the coming year would be to build six CMHC
houses at a cost of $300,000 each.
105)

Going forward, Chief Andrews said that he believes education is
very important and that he would like to be able to pay the firefighters in his
community an honorarium to promote a sense of pride in the work being
done.
106)

Michael Angers (evidence given on December 18, 2014)
Mr. Angers is a chartered accountant and is assigned as comanager for the First Nation of God’s Lake. His role is to assist the First
Nation with financial management issues, with the ultimate goal being to
get out of a deficit position. He said that the First Nation presents a
financial plan as to how to utilize various budget amounts and then he
reviews their plans for approval.
107)

He said that in 2011, the fire budget of $22,360 was mingled with
the community service budget for a total of $418,000. Fire related
expenditures included fuel and oil, insurance, and repairs and
maintenance. Training, travel expenses and honoraria would also be
acceptable expenses from this budget. He said that equipment like a fire
truck would ordinarily come from the Band based capital budget of
$1,164,500 per year.
108)

There are some circumstances, however in which a First Nation can
apply to AANDC for monies from special designated pools of funding. This
109)

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would generally be for major capital projects or specific items. In the case
of God’s Lake, this is how the community received its current fire truck.
David Schafer (Evidence given on August 1, 2013 and December 18, 2014)
continued.
Mr. Schafer’s qualifications and experience were set out at
paragraph 47 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)
110)

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.
111)

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.
112)

For both the James residence in God’s Lake and the Harper
residence in St. Theresa Point 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.
113)

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
expectation would be that upon notification by the tenant the owner would
address the issue, including supplying a new battery.
114)

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
than the Code, 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.
115)

The Code does not require that this age of residence have a carbon
monoxide detector.
116)

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The National Fire Code also applies to heating systems, and
includes the type of baseboard heater found in the James residence. Again
Mr. Schafer testified that the onus is on the owner of the residence to
ensure that the heating system is maintained so as not to create a
hazardous condition.
117)

There is however 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.
118)

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. 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 properly, 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 homes.
119)

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, he said that some very small communities in Manitoba do
not have active fire departments at all, and put their available resources
into fire prevention measures.
120)

Mr. Schafer explained the three possible levels of firefighting service
that a community can provide.
121)

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.
122)

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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.
123)

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.
124)

In his evidence, Mr. Schafer 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.
125)

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 in offensive firefighting.
126)

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.
127)

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.
128)

Mr. Schaffer testified about the essential framework required for
setting up a fire department.
129)

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 identifying the level of service that the community is committed and
financially able to provide.
130)

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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. Specific funds should also
be identified for training as well as for repair and maintenance of
equipment.
131)

Mr. Schafer testified that a fire department also needs sufficient staff
to address the level of service that they have committed to. This varies
depending on the level of service to be provided.
132)

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.
133)

“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”.
134)

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.
135)

For instance, the community would be required to cover the cost of
travel to and from the community and accommodation for the instructor,
while the actual delivery of the training programming is provided at no cost
by the OFC. As the level of training received increases the ultimate goal
would be that the community department deliver its own training.
136)

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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.
137)

The OFC will also come to a community to provide other
presentations and workshops at no cost.
138)

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.
139)

During the winter road months the travelling fire safety trailer can
also attend to remote communities as a resource.
140)

Mr. Schafer answered questions specific to the God’s Lake First
Nation fire budget of $25,000. He said that this amount could be sufficient
for a northern community of this size to provide a public education program,
but that he would not consider it sufficient to provide either “defensive” or
“offensive” service. His evaluation acknowledges the financial challenges
that northern communities face in terms of travel, shipping costs and
general accessibility as compared with southern communities of similar
size. Moreover, he said that First Nation fire departments are funded
considerably less than similar municipal departments.
141)

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
their fire department and want to be involved.
142)

Good leadership requires dedication and strong organizational
skills, as well as a visible presence in the community that inspires others to
become involved.
143)

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.
144)

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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 is in part
intended 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.
145)

The MOU acknowledges that the loss of life and property in First
Nation communities is significantly elevated as compared to other
Canadian communities.
146)

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.
147)

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.
148)

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, the Manitoba
Association of Native Firefighters, the Southern Chiefs Organization and
Manitoba Keewatinowi Okimakanak. 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.
149)

Mr. Schafer’s recommendations, which I adopt with respect to the
communities of St. Theresa Point and God’s Lake, can be found at page 15
of his report (Exhibit 6) and are summarized as follows:
150)

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

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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.
151)

For the preparation of the report, the Province of Manitoba provided
a Program Officer, Mr. Langevin, 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.
152)

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.
153)

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.
154)

The report provides a general summary in these areas, but does not
contain specific statistics about individual communities.
155)

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,
156)

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infrastructure and equipment, staffing, training, financial resources,
inspections and public education.
Some notable results of the survey include the fact that 93% of
communities did not have a written fire protection plan.
157)

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.
158)

Only 15% of fire departments had written operating guidelines and
most communities did not have a 911 or local dispatch systems.
159)

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.
160)

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.
161)

There are 72% of First Nation communities that are within twenty
minutes response time of an adjacent community with a fire department.
162)

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.
163)

Nine short term recommendations: to be completed within six to
twelve months are found at page 18 of Exhibit 14. They are as follows;
164)

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
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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;
165)

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:
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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.
166)

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 God’s Lake First Nation:
167)

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.

Inquest Report – Demus James, Throne Kirkness and Kayleigh Okemow

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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.
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 God’s Lake 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 Keewatin Tribal Council fire
safety officer and the OFC of every fire occurrence in the community.
It is the recommendation of the Inquest that the Keewatin 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.

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3. Train individuals in the community of God’s Lake to perform basic
annual home inspections with a particular emphasis on safe home
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

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Exhibits for the Inquest Report of Judge Tracey Lord into the deaths
of Demus James, Throne Krikness and Kayleigh Okemow
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 – Demus James, Throne Kirkness and Kayleigh Okemow

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Inquest Report Demus James, Throne Kirkness and Kayleigh Okemow