The death of any individual is hard to deal with. It is even harder when that loss is tragic. But when an incident involves two young men whose lives were tragically cut short, questions need to be asked.

On January 8, 2006, Ricardo Wesley, 22, and James Goodwin, 20, died of smoke inhalation in a jail fire in Kashechewan, northern Ontario. At the time, the two were being held for public intoxication in a Nishnawbe-Aski Nation Police Service (NAPS) detachment facility.

Their fate in no way matched their crime. However, what is criminal was the dilapidated and ill-equipped condition of the facility that became their infernal interment.

Three years after the fatal incident, a coroner’s inquest in Toronto delivered its report and recommendations on May 21. While the two deaths were ruled accidental, the five-member jury did make 86 recommendations to help deter any similar incidences in the future.

“It’s more that what we hoped for,” said Nishnawbe Aski Nation (NAN) Deputy Grand Chief Alvin Fiddler, who attended the conclusion of the 11-week-long coroner’s inquest in Toronto. “The jury members were quite engaged during the course of the inquest in terms of the questions they were asking the witnesses. They understood the issues early on in the inquest and that was reflected in the quality and number of the recommendations that they made. For this we are very thankful.”

The report calls on Canada and Ontario to provide NAPS the funds needed to ensure that its policing standards, services and infrastructure are equivalent to those in non-First Nations communities.

It also recommends that the two governments provide adequate funding for annual fire inspections of all Nishnawbe-Aski Nation (NAN) police stations, as well as additional fire response training for officers.

The final recommendation calls for a public inquiry or Royal Commission to be conducted for the NAN communities, which would address parity of services, health and safety, and the quality of life.

Fiddler explained that many of the police facilities do not meet the National Building Code standards. “This is one of the key points in this report. It was the substandard conditions that led to this tragedy – and those conditions still exist in many of our communities.”

Out of the 35 NAPS run detachments in NAN, 19 of below standard. These facilities represent a variety of different types of buildings, said Fiddler.

“Some are former residences that have been converted into detachments. One of biggest concerns about the current policing agreement is that both levels of government (federal and provincial) do not allow for capital expenditures in terms of constructing a facility. They expect our communities to provide the buildings.

“In Kashechewan, it was an old post office/residence that was converted into a police facility with a few homemade cells and it wasn’t up to standard.”

During the inquest, jurors heard the Kashechewan police station had no working smoke detector, fire extinguisher and sprinkler when the fire ripped through the building. It is believed that the fire was started by one of the men inside the holding cell.

Police officers tried desperately to free the two men, but the building was quickly engulfed in flames. Officers could not unlock the cell doors and had to flee for their own safety, leaving the two men to die. It was pointed out that one officer was also injured while trying to open the cell doors.

Some of the other recommendations that were made, include:

• A fire safety plan should require an interconnected smoke alarm system that is regularly maintained and tested as well as the regular maintenance of fire extinguishers throughout all holding facilities.

• All police detention facilities should have sprinkler systems. An emergency evacuation plan should be posted and practical training provided for police officers, guards and matrons.

• Standard correctional locking mechanisms should be used on cell doors and a single key to access all cells should be located in a secure but available place.

• The use of foam mattresses in holding cells should be prohibited.

• Prisoners in holding cells should be physically checked every 15 minutes with more frequent checks when prisoners are heavily intoxicated or at risk.

Kashechewan First Nation is a remote fly-in community located the west coast of James Bay on the Albany River with a population of 1,600 people. The community gained national prominence in 2005 when the federal government ordered the evacuation of the reserve after E. coli was found in the water supply. The population has also been forced to leave another four times since 2005 because of spring flooding.