Thousands of death investigations remain incomplete at B.C. Coroners Service, as family waits for answers

Jordan Brazier has been waiting almost a year for details about her younger brother's sudden death in custody — but she's heard few details from the B.C. Coroners Service, which is facing a backlog of incomplete investigations numbering in the thousands.

Brazier says a coroner phoned her in January to confirm that the death of John Taylor Brazier, 26, in a Port Coquitlam, B.C., pretrial centre was due to heart failure. But that's all she knows.

"It's awful. He's just been totally disregarded as a human being," said Brazier, 29, who lives in Carp, Ont., near Ottawa.

The B.C. Coroners Service says Brazier's death remains under investigation, one of an unprecedented number of new cases over the past two years.

B.C. coroners have seen an increase of almost a third in the number of deaths reported to the service since 2019, when it conducted 10,341 preliminary investigations — an average of 862 per month.

Between Jan. 1 and Sept. 31 of this year, a total of 10,299 deaths were reported to the service, an average of around 1,144 per month — an increase of almost 33 per cent.

Of the cases that coroners opted to fully investigate, 5,749 remain incomplete.

The B.C. Coroners Service is in charge of determining the facts in all sudden, unnatural or unexpected deaths, as well as all deaths involving children and certain institutions, and medically assisted deaths in the province. The service reports findings to prevent similar deaths.

Most COVID-diagnosed cases don't fall under the coroner's mandate.

'Sharp' uptick

In an email, Chief Coroner Lisa Lapointe confirmed a "sharp" increase in reported deaths has been driven by the opioid crisis and the summer "heat dome" event that caused record-breaking temperatures across B.C., which she said has "challenged existing resources."

Lapointe said the service has hired more staff and found more resources to meet the increased caseload. 

In response to questions about long waits for results, she said coroners are "acutely aware" of the grief and trauma that families cope with after a sudden death.

CBC asked about the delay of a final report into Brazier's death but was told the coroner couldn't share any more information as the case remains under investigation.

Strained death investigation system

Dr. Michael Multan, a resident physician at Vancouver General Hospital, has researched Canada's coroner systems, which vary by province, and has long called for an overhaul.

He says the system in B.C. needs more revamping. 

For example, Ontario's coroners are physicians and Alberta's medical examiners are trained forensic pathologists, but in B.C., coroners are not required to have medical training.

In B.C., "more and more deaths get investigated, but the system hasn't kept up with that," said Multan, who is studying to become a forensic pathologist at the University of B.C.

He suggests looking at Ontario's efforts to improve the system, following a 2008 inquiry which brought in changes to improve the accuracy of death determinations and to better triage caseloads and communicate with families.

Brazier's sudden death

That communication has been poor, according to Brazier's family, who says it has now waited 13 months for answers.

Brazier was found "unresponsive" in his cell at the North Fraser Pretrial Centre in Port Coquitlam on Sept. 11, 2020.

What at first appeared to be a drug overdose was later judged to be a heart failure, after toxicology reports revealed no drugs in the man's system.

Jordan Brazier says more investigation is required, as she fears her brother may have been killed in custody.

CBC News has learned that Brazier had been chased and shot at in Surrey, B.C., in May 2020, and RCMP had approached him to testify in an attempted murder investigation. His sister said he had been offered witness protection but turned it down.

Weapons charges in the case were stayed about three weeks after Brazier died in custody. 

Torment of silence

Brazier described the wait for details about her brother's death as agonizing.

"He was just a number in a cell and I guess he died and I guess that doesn't matter," she said.

"It's tormented my mother: How long did he lie there? Was he alone?"

Brazier received a box of her brother's belongings, which included a sweatshirt that appeared much too small for him, a plastic bag with his name spelled incorrectly on it and some unworn shoes. She wants to know what happened to her brother's journal, where he wrote rap lyrics and sketched.

Brazier said her "funny and complex" brother struggled with mental health and addiction. He was in custody for robbery at the time of his death. 

"We got along great. He had a bit of a rebellious streak. You probably wouldn't describe him as an angel," she said.

CBC News has made repeated requests to several ministries and the B.C. Coroners Service for more information about the increased caseload but has yet to receive a reply.