Shelter staff training examined at coroner's inquest in Whitehorse

Warning: This story contains distressing details.

Witnesses who testified on the second week of a coroner's inquest into the deaths of four women at an emergency shelter in Whitehorse were questioned about whether shelter staff were properly trained to respond to medical situations, including overdoses or caring for intoxicated guests. 

Questions from lawyers came after footage from the video surveillance taken on the night Darla Skookum died was screened at the inquest.

The footage revealed that shelter staff members placed Skookum on a floor mattress, lying directly on her stomach with her face appearing to be buried in a pillow. She appeared to be motionless, and remained unchecked for more than 12 hours.

Skookum, 52, was found dead on April 16, 2023. She's the last Indigenous woman the inquest will hear about before the jury issue recommendations in the upcoming days.  

The inquest has also looked into the deaths of three other women at the Whitehorse Emergency Shelter (WES). Myranda Tizya-Charlie, 34, and Cassandra Warville, 35, were reported dead on January 19, 2022. Both were members of the Vuntut Gwitchin First Nation in Old Crow. Josephine Elizabeth Hager, 38, was reported dead on Feb.1, 2023. She was a member of Selkirk First Nation. 

What the inquest heard 

Testimony from some shelter guests and staff members depicted a harsh reality at the facility.

All spoke about staff who didn't have training to assess or manage guests at the shelter who were under the influence of drugs or alcohol, and who didn't have training about trauma-informed care.

Some staff members testified about the lack of mental health support, and how after incidents such as Skookum's death, there was no debrief afterward. They said that led to some employees leaving. 

Some staff members testified about the lack of mental health support or debriefs after incidents such as Skookum's deaths, which they said led to employees leaving. The presiding coroner and jury heard the shelter had to fill in shifts with casual workers who didn't have established, trusting relationships with guests. 

A publication ban was issued by presiding coroner Michael Egilson to protect some of the witness names.

On Wednesday, Skookum's adult son and her partner testified about being evicted earlier in the winter of 2023. They said they were using the shelter until they could find somewhere else to live.

Both testified they were drinking with Skookum on the night she died. 

"She didn't look well ... at all," her son said, adding that his mother was unconscious when staff transferred her from the lounge area to the women's overflow room — where guests can sleep for the night — in a wheelchair because she couldn't stand on her own.

Testimony revealed the shelter's policy on level of care says staff have to call for emergency medical services if intoxicated guests need assistance standing up, and that staff can't lift guests up by themselves.  

One RCMP officer who was called to the shelter the morning Skookum was found dead also testified. She stressed that paramedics must be called when people are unable to respond to questions, or move on their own. 

Shelter staff members working that night said while Skookum didn't respond verbally and was dozing off, they weren't concerned about her well-being before wheeling her off to bed.

The RCMP officer said that should never have happened. 

"I believe Darla was too drunk ... that she should have never been put to bed," the officer said. "If medical assistance had been sought, she'd still be alive."

It's normal daily practice, staff members testified, to put intoxicated guests to bed and to place them lying on their stomachs. They said at the time, there was no policy that told them how often to check on sleeping guests, and to this day, there's no policy on how to safely position them in bed. 

"We put people who are intoxicated to bed every day," one staff member said.

"There was nothing not normal ... Putting (Skookum) in recovery position wasn't an option." 

The inquest heard that since Skookum's death, Connective — the organization running the shelter in partnership with the Council of Yukon First Nations (CYFN) since October 2022 — has started doing three nightly checks where staff must ensure sleeping guests are still breathing. 

Two staff members, however, said that's "not nearly enough." 

"People can die in five minutes ... once every three hours is the bare minimum," one person testified. 

Cause of deaths

Skookum's body position at the time of her death was put under scrutiny at the inquest. 

Dr. Elizabeth McKinnon, a pathologist who performed or reviewed the autopsies of all four women, was called as an expert witness on Tuesday.

She said Skookum died of acute alcohol poisoning. She said while there was no evidence that Skookum experienced asphyxiation, her body position could have been a contributing factor. 

The paramedic assigned to the shelter the morning of Skookum's death spoke of the importance of positioning an intoxicated and unconscious person in the recovery position. That means placing them onto their side in order to protect the airway, he said. 

Other testimony revealed that the recovery position is taught at the basic level of first aid training — which all shelter staff members are required to have.  

McKinnon also testified that Hager, Warville and Tizya-Charlie all died from a mix of drugs and alcohol intoxication. 

Her testimony opened the conversation about the danger of mixing both.

Forensic toxicologist Dr. Aaron Shapiro testified street drugs are almost always cut with other substances which lead to different effects in different people, even if they are using from the same supply. 

The inquest is expected to continue next week. 

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.