Regina Police 'breakdowns' in Nadine Machiskinic case not a 'one-off problem'

A six-month delay in a Regina mother's death investigation after she fell down a laundry chute is "not just a one-off problem", according to an email obtained through access to information.

There have been delays identified in other cases too.

Leading forensic pathologist, Dr. John Butt, said in his decades of experience these sorts of fundamental failures by police are rare and surprising.

"They dropped the ball," said Butt. "It's so basic it's just laughable really."

Earlier this year, the Regina Police Service admitted it forgot to send Nadine Machiskinic's toxicological samples away to the RCMP forensic lab for testing. It was an error that led to a six-month delay in her death investigation.

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The mother-of-four was fatally injured after plunging down a laundry chute in Regina's Delta Hotel. She died on January 10, 2015. 

On July 23, 2015, Saskatchewan's Chief Coroner Kent Stewart sent the RPS a list of toxicology tests his office was expecting but hadn't received. These tests help the coroner assess the types and amounts of drugs, alcohol, or other toxins in the body of someone who has died.

The list has been heavily redacted, so it's unclear how many delayed cases the coroner identified. But it is clear that one of them was Machiskinic's.

In its investigation earlier this year, CBC's iTeam discovered that, according to Machiskinic's autopsy report, four RPS officers attended her January 2015 autopsy and received samples for toxicological testing from the coroner. But they failed to send them to the RCMP for testing.

'Obviously this is not just a one-off problem'

It wasn't until the July 2015 email exchange in July 2015, six months after Machiskinic's death, that the problem was identified. That's when the coroner started asking about Machiskinic's test results.

"Inquiries have discovered that the tox specimens are sitting in the evidence fridge and have not been sent," wrote Kent Stewart, Saskatchewan's Chief Coroner. "I believe we have spoken about this issue before and I had hoped that it had been rectified."

Dean Yadlowski with the RPS's forensic identification unit, wrote, "I am so sorry for this. Obviously this is not just a one-off problem."

Yadlowski said he had discovered a couple of "breakdowns" in the system that lead to several delays.

"There are two types of breakdowns on our end," Yadlowski wrote. "Sometimes tox is not sent (for testing). Sometimes tox is sent but results are not forwarded to [the coroner's office]."

"They dropped the ball anyhow. It's so basic it's just laughable really. It really is. It's just crazy," said Butt. "It tells me, to be blunt about it, that there's a management problem."

The July email identified one case in which toxicology test results had been received by RPS in February but police had failed to forward the results to the coroner — resulting in an unnecessary five month delay.

The emails don't make it clear how many other problems were discovered by the coroner.

RPS acknowledges there were failures

The iTeam asked the Regina Police Service for an interview about the delays, why they happened and what was done about them.

RPS communications manager Elizabeth Popowich declined, explaining that it wouldn't be appropriate to comment given the fact that a coroner's inquest has been called in the case of Machiskinic.

Machiskinic's aunt, Delores Stevenson, says she has recently learned the inquest will take place March 27-31 2017. The coroner's office hasn't confirmed that date but says it has been in discussions with the family and an inquest will be held next year.

Popowich wrote "I am sure the inquest will examine the delay in submitting samples for toxicological testing, identify issues and make recommendations."

Despite declining an interview, she did offer some further details about the delays.

"We have examined past cases and found two (other than the Machiskinic case) in the past five years where the toxicology was not sent to the lab until we were reminded by the coroner."

Popowich said "in one of the cases, the toxicology was irrelevant to the criminal investigation but was still required for the coroner's death investigation."

"The other was an error. In neither case was evidence lost, compromised or contaminated." And RPS says it's making changes to ensure this doesn't happen again.

The iTeam asked what effect the delay in the second case had on the criminal investigation. That question went unanswered.

Popowich also acknowledged that police discovered three cases where they had received toxicology test results back from the RCMP lab but failed to forward the report to the coroner's office.

"All were rectified as soon as they were discovered."

CBC asked if police contacted the families of the deceased to let them know about the delays but that question went unanswered too. 

'This is causing us quite an inconvenience,' said RPS

In the case of Machiskinic, the internal emails show that once the problem was identified in July 2015 police sent the samples to the lab right away.

A few months later, in October, RPS learned they wouldn't receive the test results until mid-December 2015.

Because of media and family pressure, RPS wrote to the RCMP forensic lab which was conducting the test and asked for a quicker turn-around.

"Unfortunately this is causing us quite an inconvenience," wrote Darrell Danylyshen with RPS.

Danylyshen explained that the family had gone to the media "wondering why the autopsy report hasn't been completed and claiming police don't care about doing an investigation."

There 'has been a fair amount of covering given missing and murdered aboriginal women and this investigation adds to it.'- Darrell Danylyshen, Regina Police Service

He went on to explain that "the deceased in this matter is an Aboriginal female" and there "has been a fair amount of covering given missing and murdered aboriginal women and this investigation adds to it."

Dr. John Butt scoffs at the fact that police were concerned this was causing them "an inconvenience."

"Well no, that's not really the case is it?" said Butt. "The real answer is this is embarrassing."

Police knew Machiskinic delay was their fault but said nothing

While RPS, the coroner's office and the Ministry of Justice knew that the delay was the fault of the police service, no one shared that information with the family or the public. It remained hidden until an investigation by the Public Complaints Commission — launched by the family — uncovered the error and reported it to Stevenson, Machiskinic's aunt.

During the months of delay, the coroner's office told CBC's iTeam that coroners reports usually take four to six months. It explained that in the case of Machiskinic "the delay is an unfortunate and unusual occurrence."

However, they never did flag the RPS's role in the delay.

John Butt said in matters like this police should be more transparent with the family. After the family learned of the six month delay police told CBC they apologized to the family. 

Butt also pointed out that the coroner's office shares blame for the communications problems.

"The coroner is as much responsible for developing and administering the protocol for the toxicology or any other laboratory result that's ancillary to the autopsy report as anybody is," said Butt.

Coroner's office flags 16 other cases of possible delay province-wide

When the Machiskinic delay was identified in July 2015, Chief Forensic Pathologist, Shaun Ladham identified other cases with similar delays. 

On July 22, 2015 he wrote "I do have a few northern cases awaiting tox from last year (2014), but those do not have them back yet due to a failure to send out the specimens right away."

Then, in November Ladham wrote an email to the Chief Coroner and other officials.

The subject matter was "cases outstanding."

Ladham provided a list of 16 cases across Saskatchewan, 11 in the north and five in the south.

The note is heavily redacted. All the names of the deceased and their dates of death have been removed. 

If those 16 cases are related to suspicious deaths then one might want to know why they hadn't been fast-tracked.- Dr. John Butt, Forensic Pathologist

Ladham says these sixteen cases were people who had died up to the end of May but their final reports still hadn't been completed. That meant at least five to six months had gone by since their deaths and still their final coroner's report was not complete.

"That isn't satisfactory," said Butt. "But it's an issue again that needs to be orchestrated by the Chief Coroner."

"If those 16 cases are related to suspicious deaths then one might want to know why they hadn't been fast-tracked."

Ladham notes that he was aware that some toxicology reports appear to have been delayed but there are others where "I do not know the status with regard to the tox reports."

The Ministry of Justice says toxicology reports from the RCMP take seven to eight months on average.

Province conducted review of Coroner's office

In the wake of the many problems identified by CBC's iTeam in the case of Nadine Machiskinic, the Ministry of Justice launched a review of the coroner's office, which it recently completed.

The ministry says the purpose of the review was to improve the effectiveness, quality and efficiency of the coroner's investigative services.

It won't say if the issue of toxicological testing was among the issues reviewed or addressed. In fact the ministry says it will not make its review findings public.

However it does say that the government has hired new full-time coroners in Regina and Saskatoon.

The ministry and the coroner's office say because of the pending inquest into the death of Machiskinic they are unable to comment on this story.