Whitehorse shelter had no clear policy for handling overdoses, inquest hears

Staff members who were working at the Whitehorse emergency shelter the night two women died there in 2022 told an inquest jury on Tuesday that at the time, there was no clear policy or training for staff to deal with overdoses or monitor intoxicated guests.

The inquest jury also heard that if there had been paramedics stationed at the shelter that night, the women might have survived.

"My state of mind that night was ... overwhelmed ... that's why I said three staff were not enough," Brian Bunning said, who was the shelter's supervisor at the time of the women's deaths. 

The testimony came on the second day of a coroner's inquest being held in Whitehorse, looking into the deaths of four Indigenous women at the shelter, in 2022 and 2023. The first part of the inquest is focused on Myranda Tizya-Charlie, 34, and Cassandra Warville, 35, who were reported dead on January 19, 2022. Both were members of the Vuntut Gwitchin First Nation, in Old Crow. 

Chief coroner Heather Jones said later that year that the two women's deaths "were found to be the result of toxic illicit drugs," and she ordered an inquest at that time. 

All three shelter staff who were working there the night Tizya-Charlie and Warville died testified on Tuesday. They were questioned about their training, as well as the shelter's policies. 

All said the only training they received was basic CPR and how to administer naloxone — medicine that rapidly reverses an opioid overdose.

Bunning described the night the women died as chaotic and understaffed. He claimed that on that very same night, he sent an email to his manager about the unacceptability of staffing numbers. 

He testified that as a result, he was "running all over the building." He said he found the two women unconscious in a shower room more than three hours after he had unlocked that room for them. 

He told the inquest jury that there was no clear policy at the time about how many people could go into those rooms together, nor was there any policy about how often staff should check on people.

Bunning also said that the shelter was inadequately staffed. Not everyone, he said, was following the same procedures. 

"Some were intimidated by guests and were not functioning in their role," Bunning said, stressing the importance to provide "unconditional love" and a non-judgmental space at the shelter. 

Meanwhile, former staff Binnet Joyal Jose testified that he was never made aware that Warville and Tizya-Charlie were in one of the shower rooms. 

Yukon government changed shelter policies following deaths 

The inquest revealed that after the deaths, the Yukon government, which was running the shelter at the time, sent an internal email introducing new procedures about the shelter's main floor shower rooms. It included allowing only one guest at a time, announcing over the radio who was using the showers and doing checks every 20 minutes. 

Censors were also installed in shower rooms, sending an alarm to staff after detecting no movement for five minutes. Staffing was also raised to a minimum of four people per night shift. 

The inquest also heard on Tuesday that paramedics were sometimes stationed at the shelter, but not on the night Tizya-Charlie and Warville died.

Timothy Milsom-leBreux, a paramedic who responded to the 911 call after the women were discovered unconscious, told the inquest that having paramedics on site may have prevented the deaths.

He said Tizya-Charlie had a weak pulse when he arrived at the shelter and was going to be treated for overdose. But by the time they had prepare what was needed to administer naloxone, he continued, she had no pulse and was treated for cardiac arrest instead. 

Milsom-leBreux explained that naloxone isn't useful once the heart has stopped. 

The inquest before presiding coroner Michael Egilson is expected to take three weeks.

Besides Warville and Tizya-Charlie, it will also focus in the coming days on the deaths of two other women at the shelter. Josephine Elizabeth Hager, 38, and Darla Skookum, 52, who both died in separate incidents in early 2023.  

The Yukon government says additional counselling supports will be available during the inquest.

In-person and virtual rapid access counselling appointments can be made by calling 867-456-3838, or toll-free at 1-866-456-3838. In-person counselling will be available in Whitehorse, as well as in Carmacks from April 17-19 and April 22-23, and Pelly Crossing from April 10-12.