• Home
• Our Work
• Backgrounders
• Expanding on Lessons from a Rural Inquest

Expanding on Lessons from a Rural Inquest: Addressing Questions and Providing Support for Action

In this resource, panelists from the Learning Network Special Event: Lessons from a Rural Inquest share responses to additional questions from participants to provide further clarity about the Inquest including recommendations, advocacy, and implications for the gender-based violence sector.

January, 2023

Access the PDF here

On September 22, 2015, Carol Culleton, Anastasia Kuzyk, and Nathalie Warmerdam were murdered in a triple femicide in rural eastern Ontario. In June 2022, a coroner's inquest examined the circumstances of their deaths to consider how future femicides could be prevented. The jury produced 86 recommendations for system changes for possible implementation by the provincial government and other public bodies.

On November 17, 2022, the Learning Network hosted a Special Event to explore the key moments in the proceedings of the Inquest, through the lens of several individuals who played key roles in the Inquest, with a focus on the recommendations and advocacy for their implementation. Panelists included: Pamela Cross, Erin Lee, Kirsten Mercer, and Prabhu Rajan.

Due to the high number of questions from the audience during the Special Event, we invited panelists to share their responses to additional questions to provide further clarity about the Inquest including recommendations, advocacy, and implications for the gender-based violence sector.

The opinions expressed here are those of the author and do not necessarily reflect the views of the Government of Ontario or the Centre for Research & Education on Violence Against Women & Children. While all reasonable care has been taken in the preparation of this publication, no liability is assumed for any errors or omissions.

Questions from Participants

1. Is the transcript of the testimony given at the Inquest available to the public?
2. What are some concrete examples of recommendations from the Renfrew Inquest that have already been implemented?
3. Where is the responsibility to form the Implementation Committee? 
4. Does the Ontario Domestic Violence Death Review Committee (ODVDRC) plan on completing annual reports since the Renfrew Inquest?
5. How have the Inquest recommendations been shared nationally with provincial and territorial Coroners and Medical Examiners?
6. Are the recommendations only for the provincial government or can advocacy also be at the federal government level?
7. Is there a particular policy maker we should be targeting to act on an implementation plan?
8. Do any jurisdictions in Canada label/categorize death certificates with “femicide”?
9. What about funding stability? How do we get movement from the government to fund services sustainably and not based on per capita ratios? 
10. How can I find out about high-risk teams in communities? 
11. What is the "See it, Name it, Change it" program?

Responses from Panelists

1. Is the transcript of the testimony given at the Inquest available to the public?

When individuals are requesting transcripts of an inquest, they should put their request in writing to occ.inquests@ontario.ca. The Ontario Office of the Chief Coroner will then communicate with a court reporting office on their behalf to determine the cost to the requestor to receive an official transcript of the recording. It is up to the requestor to pay for the service, but the Office will facilitate the request on their behalf.

2. What are some concrete examples of recommendations from the Renfrew Inquest that have already been implemented?

This question illustrates the importance of Recommendation #5: to establish an implementation committee consisting of members from within government and from the community, which would be able to track progress on consideration of the recommendations and share that information with the public.

There are a number of recommendations that will take time to implement, but there are also action items that could happen right away to build on the work of this Inquest and move towards meaningful action to implement these recommendations.

Some examples of possible “early wins” are listed here:

For Ontario:

• Recommendation #1: Declare intimate partner violence (IPV) to be an epidemic in Ontario
• Recommendation #4: Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system.
• Recommendation #5: Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. The committee should include senior members of relevant ministries central to IPV and an equal number of community IPV experts. It should be chaired by an independent IPV expert who could speak freely on progress made on implementation.

For the Chief Firearms Officer:

• Recommendation #73: Amend PAL (firearms licence) application and renewal forms to require identification as a surety.
• For the Office of the Chief Coroner:
• Recommendation #74. Ensure that the Ontario Domestic Violence Death Review Committee (DVDRC) reviews its mandate with a view to enhancing its impact on IPV and provide the DVDRC with improved supports.
• Recommendation #75. Ensure DVDRC annual reports are published online in a timely manner.
• Recommendation #76. Ensure that DVDRC reports and responses to recommendations are publicly available and will continue to be available without charge.

For Canada:

• Recommendation #79. Explore adding the term “Femicide” and its definition to the Criminal Code to be used where appropriate in the context of relevant crimes.
• Recommendation #80. Consider amendments to the Dangerous Offender provisions of the Criminal Code, or the inclusion of a new classification of Offender under the Criminal Code, that better reflects the realities of IPV charges and takes into account risk factors for serious violence and lethality in an IPV context.

In terms of what has already been done, while there are lots of activities happening on the ground in communities to put the Inquest recommendations into practice (like better coordination around high-risk cases and improved coordination with the Crown Prosecutors in Renfrew County), there hasn’t yet been a lot of action from the institutions to whom the recommendations were directed.

The Coroner’s Office has already begun to implement some changes to the DVDRC (Rec # 74) and the Information and Privacy Commission has engaged with frontline service providers and experts on its work to develop a plain language tool to empower IPV professionals to make informed decisions about privacy, confidentiality, and public safety (Rec #78).  The federal government has begun implementation of the National Action Plan on GBV (Ref #83)- though there is still much to do.

One agency received a small amount of provincial funding through the Rural Enhancement Fund (MCCSS) to support implementation of the recommendation in their context.

To continue moving things forward, elected leaders need to know how engaged folks are across the province with this issue.

At this point, the parties to whom recommendations were directed (the province, the chief firearms officer, the chief coroner, the office of the information and privacy commissioner and the federal government) have made no public statements about their intentions with respect to the recommendations. They have six months from the date they received them to provide the Chief Coroner with a report on the steps they have taken, so there should be a sense of where things are at early in 2023. A number of recommendations could be informally implemented at the community level, so there may be work going on there as well.

3. Where is the responsibility to form the Implementation Committee? 

It is still unknown which Ministry would be responsible for the Implementation Committee, if they decide to convene one.  There has been a suggestion that the Implementation Committee might reside with either the Attorney General or the Minister for Women’s Social and Economic Opportunities.

If the government wanted to take a “whole of government” approach to implementation, then the Implementation Committee could live with the central agencies of the Premier’s Office/Cabinet Office.  Despite outreach efforts, the Premier’s Office has not been engaged at all on the government’s response to the Inquest.

4. Does the Ontario Domestic Violence Death Review Committee (ODVDRC) plan on completing annual reports since the Renfrew Inquest?

Yes, the most recent DVDRC annual report is currently in the approval process.

5. How have the recommendations been shared nationally with provincial and territorial Coroners and Medical Examiners?

The Inquest verdict and recommendations have not been formally shared with other jurisdictions. This information is accessible on the Inquest page of the Office of the Chief Coroner of Ontario website.

6. Are the recommendations only for the provincial government or can advocacy also be at the federal government level?

While 68 of the 86 recommendations are directed at the province of Ontario, there are also recommendations made to the Chief Firearms Officer, the Coroner’s Office, the Information and Privacy Commissioner, and the federal government.

7. Is there a particular policy maker we should be targeting to act on an implementation plan?

Key decision makers at the Province of Ontario include:

At the Federal level, consider contacting:

It is always helpful to also engage with your local MP and MPP, as well as your municipal government representative. 

8. Do any jurisdictions in Canada label/categorize death certificates with “femicide”?

We are unaware of any jurisdiction that uses the term “femicide” to categorize a death.

9. What about funding stability? How do we get movement from the government to fund services sustainably and not based on per capita ratios? 

It is important to capitalize on what we already know. For instance, the impacts of Covid-19 and increased violence directly connected to increased isolation. We need funding that reflects the distinct experiences relevant to rural realities including longer response times, limited housing options, and limited mental health and GBV resources.

10. How can I find out about high-risk teams in communities? 

You can find out about your community’s high-risk team/committee by contacting your community’s Violence Against Women Coordinating Committee (VAWCC). If you don’t know how to find your VAWCC, you can find a list of them on the Building a Bigger Wave website: http://www.buildingabiggerwave.org/

11. What is the "See it, Name it, Change it" campaign?

A group of individuals from the counties of Lanark, Lennox and Addington, and Leeds and Grenville have been working together in response to the increase in violence and murders in rural eastern Ontario.  They formulated action plans based on four forums hosted in April 2016, and small groups have been working on a variety of initiatives to increase positive outcomes and safety for victims of violence. “ See It, Name It, Change It” is one of the larger initiatives. 

“See it, Name it, Change it” is a simple concept much like the one we have all learned about fire safety; stop, drop, and roll. It consists of a multimedia campaign that can be used as an opening to a conversation, a message to offer help and resources,  a tool to educate about violence in relationships, and a means to encourage healthy alternatives for the community and all its members. 

There is curriculum, billboards, tear aways for local businesses with contact information, and social media campaigns you can use to share the campaign. Find more at https://lcih.org/see-it-name-it-change-it/

Let’s do something to empower each other and share responsibility to see it, name it, and change it!

Call To Action

Join advocates in ensuring that the recommendations are implemented! To help you do so, Luke’s Place has created an inquest recommendation advocacy toolkit that you can access here.

It contains:

• Templates for letters to politicians and for writing an op ed for your local newspaper
• Suggestions for how to approach politicians to engage them with the inquest recommendation
• A tipsheet to help you work with your municipality to include IPV in its community safety and well-being plan (following recommendation # 10)
• Information about Lanark County's decision to declare IPV an epidemic

Luke’s Place adds new resources to the toolkit on a regular basis so make sure to keep checking in!