--- author: TVO Today date: '2026-10-27' guest: '' layout: post.njk source: https://www.youtube.com/watch?v=7dD5rZHumcw speaker: TVO Today tags: - coroners-act - inquest - prison-reform - forensic-pathology - indigenous-health title: 安大略省拟改革监狱死亡死因研讯制度及法医病理学家的工作 summary: 安大略省探讨修改《验尸官法》，拟以年度审查替代非自然拘押死亡的强制死因研讯，律师与死者家属质疑此举削弱透明度与问责；节目后半段专访加拿大首位原住民法医病理学家科诺·威廉姆斯博士，探讨法医病理实践与北部医疗缺口。 insight: '' draft: true series: '' category: politics-society area: society-thinking project: [] people: - Jeyan Jeganathan - Yusuf Faqiri - Joel Dick - Solomon Faqiri - Kono Williams companies_orgs: - TVO - Ministry of the Solicitor General - Health Sciences North products_models: [] media_books: - The Rundown - Unascertained status: evergreen --- ### 安大略省拟改革监狱在押死亡调查机制 **>>**: 当有人在安大略省的监狱中死亡时，有几个重要问题必须得到解答，比如：这起死亡是否本可以预防？又需要做出哪些改变来防止类似事件再次发生？目前，获得这些答案的一种途径是死因研讯。但安大略省正在考虑改变要求进行此类研讯的情形。根据现行法律，当验尸官认定在押人员可能死于非自然原因时，死因研讯是强制性的。但该省正在探讨一项修正案，拟引入年度审查来取而代之。根据这项提案，顾问委员会将与验尸官合作，审查前一年的所有死亡事件并提出建议。政府表示这可以让流程更加高效。有些死因研讯需要数年才能举行，但倡导人士表示，这种改变可能会付出代价。那么这里的利害关系究竟是什么？我们将探讨该系统目前的运作方式，以及这是否是解决问题的正确途径。另外，当有人意外死亡时，查明真相往往取决于法医病理学家的工作。这正是科诺·威廉姆斯博士奉献一生的事业。我前往萨德伯里，与这位加拿大首位原住民法医病理学家、近期加拿大勋章获得者交谈，探讨是什么引领她走上这条道路，又是什么支撑她坚持下去。我是杰扬·杰加纳森。欢迎收看《简报》。安大略省修改《验尸官法》的提议目前还只是一项提案。该省征求了律师、家属和其他人士的反馈，许多人都认同现行系统存在问题。优素福·法基里、乔尔·迪克，非常高兴两位来到《简报》。非常感谢。优素福，你的家人因你的兄弟所罗门的死亡经历了死因研讯全过程；而乔尔，你是一名倡导人身伤害诉讼的律师，并在死因研讯中代表涉案家属。你们两位在此都事关重大，并且对修正案的具体内容很感兴趣。事实上，我们先从总安全官部发给TVO的一份关于上述计划的声明摘要开始谈起。声明中写道：“我们正在探讨对《验尸官法》进行修正，该修正案将要求所有在监狱中的非自然死亡必须接受强制性年度审查。政府还在考虑为家属参与审查过程提供机会，并提供一个选项，允许亲属在其亲属死亡事件中在年度审查过程之外申请死因研讯。”乔尔，我们先来剖析这一点。用强制性年度审查取代强制性死因研讯听证会，问题何在？
Original English **>>**: When someone dies in an Ontario jail, there are important questions that need to be answered, like, could the death have been prevented? And what needs to change to stop something like that from happening again? Right now, one way to get those answers is an inquest. But Ontario is considering changing when those inquests are required. Under the current law, an inquest is mandatory when a coroner determines someone who died in custody might not have died from natural causes. But the province is exploring an amendment that would introduce annual reviews instead. Under the proposal, an advisory committee would work with the coroner to look at all the deaths from the previous year and then offer recommendations. The government says it could make the process more efficient. Some inquests take years to happen, but advocates say the change could come at a cost. So what's at stake here? Well, we look at how the system works now and if this would be the right way to fix it. And when someone dies unexpectedly, finding out what happened often depends on the work of forensic pathologist. And that's what Doctor Conor Williams has dedicated her life to. I headed to Sudbury to talk to the country's first indigenous forensic pathologist and recent Order of Canada recipient on what led her down this path and what keeps her going. I'm Jeyan Jeganathan. Welcome to "The Rundown". So Ontario's proposal to amend the Coroners Act is still just a proposal. The province asked for feedback from lawyers, families and others, and a lot of them do agree the system is broken. Yusuf Faqiri, Joel Dick, great to have you both on "The Rundown". Thank you so much. Yusuf, your family has been through the inquest process with the death of your brother Solomon and Joel. You're a personal injury lawyer and represent families involved in the inquest. Both of you have stakes here and interest in sort of what the amendments look like. We're going to start our conversation actually, with an excerpt from a statement sent to TVO by the Ministry of the Solicitor General about the said plan. It reads, we are exploring an amendment to the Coroners Act that would require all non-natural deaths in jails to be subject to a mandatory annual review. The government is also considering opportunities for families to participate in the review process and provide an option for relatives to request an inquest into the death of their loved one. In addition to the annual review process. Joel, let's unpack this first. What's the issue with replacing mandatory inquest hearings with mandatory annual reviews?
**>>**: 问题的核心是透明度，问题的核心是问责。死因研讯程序针对的是具体的个案死亡。验尸官办公室拥有调查员，拥有专职律师，主持研讯的医生们也非常投入，你会以非常透彻的方式处理某一起特定死亡事件，有时是一组死亡事件。举例来说，我曾代表过一些家庭，依据《信息自由法》提出申请时，并没有找到闭路电视监控录像，但验尸官的调查人员却能找到。仅凭知道发生了什么，就能给家属带来莫大的释怀。没有了死因研讯，我们面对的是一个支离破碎的流程，家属往往根本不知道发生了什么。而且在我们的体制中，死因研讯是唯一既面向过去又面向未来的时刻。我做了很多民事诉讼，那是面向过去的；我们探讨的是什么样的适当赔偿能试图纠正已发生的错误。但死因研讯可以提出“究竟哪里出了问题”这个问题，以非常细致的方式审视它，同时还会探讨“我们在未来应该怎么做”。由公民组成的陪审团会提出建议要求。我认为这是一个极其有意义且重要的程序。我每次参与其中，每个人都非常严肃地对待自己的职责。陪审团有五名成员，他们会真正深入探究这些问题。我认为，如果从强制性对每起死亡进行细致入微的个案调查，转向年度审查，我们将失去一些极其宝贵的东西。
Original English **>>**: So the issue is transparency and the issue is accountability. The inquest process looks at a specific death. The coroner's office has investigators has dedicated lawyers, the doctors who run the inquests are very committed and you deal with a specific death or sometimes a group of deaths, but in a very thorough manner. So, for example, I've acted for families. We're on the Freedom of Information Act request. You know, no closed circuit TV has been located, but the coroner's investigators are able to find it. And that brings a lot of closure for families. Just knowing what happened. We have a fragmented process without the inquests. Families don't often know what happened. But also there's a real sense the inquest is the one time in our system that is both backward and forward looking. So I do a lot of civil litigation that's backward looking. We ask what are the appropriate damages to try to make right the wrong that has happened. But inquest can ask the question what went wrong? And look at it in a very detailed way, but also ask what should we do in the future? You have jurors of citizens who make requests. I find it an incredibly meaningful and important process. Every time I've been involved, everyone takes their role very seriously. You've got five members on the jury who really dig into these issues, and I think we would lose something if we moved from that specific, granular investigation of each death on a mandatory basis to an annual review.
**>>**: 好的，优素福，我想听听你的看法。你是否支持用强制性年度审查来替代强制性死因研讯？
Original English **>>**: All right, Yousef, let me get your take here. Do you support a mandatory annual review instead of a compulsory inquest?
**>>**: 不，我不支持强制性审查。我支持强制性死因研讯。在此我想补充几点乔尔刚才说的话。当谈到惩教系统内的问责工具时，死因研讯是唯一的流程，对吧？因此，除了公开和透明之外，它是一次查明事实的使命。而且我认为，从家属的角度来看同样重要的是，死因研讯所起到的作用是，它允许家属在亲人在政府看护下被杀害或死亡时参与到这个过程中来。这就是关键核心所在，因为如果我们审视安大略省政府内部的惩教系统，那里根本不存在问责机制。死因研讯所做的是揭露这个系统，展示那些身陷高墙之内的有心理健康问题的人究竟遭遇了什么。从家属的角度来看这太重要了。家属得以查明自己的亲人到底经历了什么。就我家庭的个案而言，我们花了近十年的时间。从公众的角度来看，它向加拿大人和安大略人揭示了系统内部的真实情况，因为该系统在许多方面都是脱离透明度运作的，而公众得以了解我们惩教系统内部发生的事情。
Original English **>>**: No, I do not support a mandatory review. I support a compulsory inquest. And just add a couple of things that Joel added. It is. It is the only process when it comes within corrections of accountability tools. Right? So besides just it being public and transparent, it's a fact finding mission. And I think just as important from a family's perspective, what inquests do, it allows families to get involved in the process, in the process when their loved one gets killed or dies within government care. And and this is what's important to the crux of it, because our correctional system, if we look at corrections within the Ontario government, there is no accountability mechanism. What inquest does is that it exposes the system, shows what happens to people with mental health challenges that essentially are behind these walls. And this is so important from a family perspective. Families get to find out what happened to their loved one. In my case of my family, it took us almost a decade. From a public perspective, it shows Canadians and Ontarians what happens in the system because the system in many ways operates away from transparency, and the public gets to know what happens to what happens inside our correctional system.
**>>**: 优素福，我想对不熟悉你弟弟所罗门·法基里案的观众和听众补充说明一下：2016年12月，他在中东部惩教中心临时关押期间，遭监狱警员殴打后死亡。你自己也把这当成了自己的使命，你同时也是该运动的发起人。我想谈谈家属参与的机会，这是部门声明中提到的。为什么家属成为审查过程的一部分如此重要？
Original English **>>**: Yousef, I just want to mention, for our viewers and listeners who are not familiar with your brother, Solomon Fakir's case, he died after a beating by jail officers while temporarily housed at the Central East Correctional Centre in December 2016. And you yourself have kind of taken it as a mission. You're the founder of the movement as well. I want to talk a little bit about sort of the chance for family to participate. That's what the ministry has mentioned there. Why is it important that they are part of that review process?
**>>**: 因为家属能够补充细节背景。家属能够为他们的亲人赋予具体语境，说明那究竟是个什么样的人。以苏利为例，是的，他有心理健康问题。但那场死因研讯让我家人在他去世以来的这几年里，第一次真正得以参与其中，因为在此之前，政府甚至从未提及苏莱曼的名字。我弟弟死亡最悲惨的地方在于，他身上有50处瘀伤，手脚被绑，被喷了胡椒喷雾，被喷了两次胡椒喷雾。而且这也表明，惩教系统在照顾有心理健康问题的人方面是严重不足的。例如，那所监狱的隔离区负责人根本没有接受过心理健康培训。当我们讨论这项强制性死因研讯审查时，另一件非常重要的事是，我的家人没有被咨询过，我知道很多其他家庭也没有被咨询过。因此，政府跑出来说“噢，我们会咨询家属”，这真是太讽刺了。我们根本没有被咨询过。这本身就非常成问题。这又回到了我们对话的核心——透明度。我们的死因研讯程序是全世界最全面的程序之一。在很多层面上，将其推开将会给家属造成另一场不公，我认为对整个系统也是如此。
Original English **>>**: Because families are able to add nuances. Families are able to put, you know, the they're able to put context on what, you know, on their loved one, who they was. In the case of Suli, yes, he had a mental health challenges. But what that inquest allowed my family was to, for the first time in the. In the years since he passed away, we were able to essentially participate, you know, get involved because up until that point, the government did not even mention Suleiman's name. And what's so tragic about my brother's death is that there was 50 bruises, legs and hands tied, pepper sprayed, pepper sprayed twice. And it also showed that the system corrections is inadequate on taking care of people with mental health challenges. For example, the person who was head of segregation in that jail do not have mental health training. The other thing that's very important in when we're talking about these mandatory inquest review, my family has not been consulted, and I know many other families have not been consulted. So I think it's very rich from the government to come and say that, oh, we're going to consult families. We have not been consulted. And that in itself is very problematic. It goes back to the crux of our conversation transparency. Our inquest process is one of the most comprehensive processes in the world. And to to push this away in many ways, will, will create another injustice for families. And I believe for the system at large.
**>>**: 乔尔，我想请你谈谈。优素福刚才提到了家属所能带来的必要性和细节语境。
Original English **>>**: Joel, I'll get you in there. Yusef's talking about that. The need and the nuance of that family adds.
**>>**: 是的，你看，这很难。优素福显然有着非常切身的体会。你必须记住那些被监禁的人。政府说吃饭他们才能吃饭，政府说睡觉他们才能睡觉，政府说运动他们才能运动。因此，如果在我们的体制中有任何部分亟需透明度和问责，那就是我们如何对待那些在生活起居甚至生命本身都完全依赖政府的人。对吧？吃饭、睡觉、何时能去室外、何时不能去，我们体制中确实需要这种问责制和透明度。
Original English **>>**: Yeah, it's look, it's hard. Yusuf AFC has a very personal connection. You have to remember people who are incarcerated. They eat. When the government says to eat, they sleep when the government says to sleep, they exercise. When the government says to exercise. And so if there is any part of our system that demands transparency and accountability, it's how we treat people who are completely dependent on the government, even for their very lives. Right? Eat, sleep. When you go outside, when you don't, we really need that kind of accountability and transparency in our system.
### 效率改革与监狱过度拥挤的隐忧 **>>**: 好的。我想再读一段部门声明的摘录。开头说：“这种方法将支持对拘押死亡进行更及时、覆盖全系统的审查，并有助于确保更高效地提出建议。明确地说，我们仍在就潜在的修改方案与利益相关者和公众成员（包括原住民代表），以及亲人死于自然原因的家属进行磋商。”乔尔，先从你开始。一个更及时、更高效的计划，并且他们表示正在争取利益相关者的认同。在谈到比如优素福亲身经历的那种耗费数年的案件时，这听起来相当合情合理。
Original English **>>**: All right. I want to read another excerpt from the statement from the ministry. And it starts saying this approach would support a timelier, system wide review of In-custody deaths and help ensure recommendations are delivered more efficiently. To be clear, we continue to consult with stakeholders and members of the public, including First Nations representatives, as well as with families whose loved ones have died of natural causes on potential changes. Joel, I'll start with you. A timelier, more efficient plan. They're saying a buy in from stakeholders. This sounds quite reasonable when we talk about, you know, use of particular case several years.
**>>**: 更及时是好事，更高效也是好事。我认为问题在于，这需要对政府持信任态度，假设其具备善意，但这在这里可能并不适用。《多伦多星报》最近报道称，总安全官和住房厅长已经从建筑规范中删除了最低睡眠空间要求。这是在周五下午悄悄完成的。两位厅长都没有接受《多伦多星报》关于为何做出此决定的采访，所以我们不知道为何这么做，但过去曾有明确规定。建筑规范曾要求每名囚犯必须有一定数量的睡眠空间，现在这一条被删除了，我们完全可以猜到为什么这样做。正如《多伦多星报》的报道指出的那样，我怀疑，这是为了让我们把此前应对过度拥挤的权宜之计——在原本为两人设计的牢房里塞进三个人，即设置三层床——变成永久化的措施。但关于三层床我们知道些什么？这一点我们毫无疑问是清楚的：它会导致更多的暴力和打斗，因为环境过度拥挤，这可能导致更多的死亡。它会导致更糟糕的心理健康状况，因为环境拥挤，人们缺乏自己的私人空间。心理健康问题会导致药物滥用以及我们设施中的诸多其他问题，进而导致死亡。我们知道这是吸食非法违禁品所致，而且最近在枫树赫斯特，我们遭遇了一场在建筑内蔓延的传染病，导致了两人死亡。所以，是的，死因研讯确实需要进行得更快。我们的系统积压太严重了。及时性是好事。但当你把这两项改变放在一起看时——我认为这两项绝不能孤立看待，我们必须结合起来看——如果我们在计划推行三层床并让设施进一步过度拥挤的同时，又在撤走这盏聚光灯，这在我看来是极其、极其令人不安的。
Original English **>>**: Timelier is good, more efficient is good. I think the problem is that requires giving the government the benefit of the doubt, a sort of assumption of good faith that might not be appropriate here. The star reported recently that the Solicitor General and the Minister of Housing have removed the minimum sleeping requirement from the building code. It was done on a Friday afternoon. Neither minister would speak to the star about why it was done so we don't know why it was done, but there used to be a mandate. The building code demanded every inmate have a certain amount of space for sleeping that's now been deleted, and we can guess why it's been done. And, you know, the star reporting points this out. I suspect. So we can take what has been a temporary solution to overcrowding, putting three people in a cell designed for two, triple bunking and making it permanent. But what do we know about triple bunking? And we know this without a doubt. It leads to more violence and more fights because people are overcrowded. That can lead to more deaths. It leads to worse mental health outcomes because people are overcrowded. They lack their own space. Mental health challenges lead to substance abuse and a number of other problems in our facilities that can lead to deaths. We know that from using illicit substances, and recently in Maplehurst, we had an infectious disease go through the building that led to two deaths. And so, yes, inquests need to come quicker. Our system is too backlogged. Timeliness is good. But when you look at these two changes, which I don't think should be looked at in isolation, I think we have to look at them together. If we are planning on triple bunking and overcrowding our facilities more. At the same time that we're getting rid of this spotlight. That to me is deeply, deeply troubling.
**>>**: 我想提出一点质疑，因为我们看到该省有一项大约30亿加元的扩建计划。当谈到收容能力时，我们指的是数年内增加2500张床位，增聘700名惩教人员、支持人员和护士，来应对人员短缺和空间问题，难道这没有……
Original English **>>**: I should I want to push back a little bit because we have seen with the province there is about a $3 billion expansion. When we talk about capacity, we're talking 2500, 2500 beds over several years, 700 more correctional officers, support workers and nurses to sort of deal with staff shortages and space does that not.
**>>**: 人员短缺问题已经有所应对。我的担忧——公众同样可以查阅《星报》的报道——是我们已经看到在昆西（我认为是那里）发布的招标，计划在这些为两人设计的牢房中安装永久性的第三层床铺。所以，是的，确实宣布了一些建设计划。再次说明，我认为我们应该减少对等待指控判决人员的监禁。省监狱中的绝大多数人尚未被定罪。但眼下，我们确实存在问题。而且，政府不愿回答他们为何将其从建筑规范中删除的问题。但我们知道他们已经取消了最低睡眠空间要求。对我来说，这是令人不安的。
Original English **>>**: So staff shortages have been dealt with at my concern. And again, people can look at the star reporting. We see already tenders in Quincy. I believe it is looking at putting permanent third bunks in these cells designed for two people. So yes, there has been some building announced. You know, again, I would argue that we need to incarcerate fewer people awaiting their charges. The vast majority of people in provincial jails are have not yet been found guilty. But right now, we have a problem. And, you know, the government won't answer questions about why they deleted it from the building code. But we know they've taken away the minimum sleeping requirement. To me, that's troubling.
**>>**: 优素福，如果死因调查的主要目标是快速识别危险隐患并挽救生命，那么强制性年度审查难道不比陪审团程序更快、反应更迅速吗？
Original English **>>**: Yousef, if the primary goal of an inquiry is to quickly identify hazards and save lives, isn't a mandatory annual review, arguably faster and more responsive than a jury process?
**>>**: 搞审查与效率毫无关系。这是在拿人命开玩笑，当家属收到的亲人遗体是被装在尸袋里的时候。对家属而言，他们有权知道自己的亲人经历了什么。所以你不能把一堆死因研讯、一堆审查混在一起，把多条人命打包，然后用那种方式去审查，因为那样根本行不通。同时，当我们谈论效率时，极其重要的一点是，我们谈论的是活生生的人命。这种审查实质上做的是剥离了透明度这一环节。它掩盖了惩教系统正处于危机之中的事实。它掩盖了狱警不仅未受培训的事实。事实是有如此多受心理健康问题困扰的人被关在这些监狱里，像你所说的那样投入30亿加元或者雇佣2500名惩教人员并不能解决问题。他们应该被安置在具备文化适应能力的心理健康机构中接受帮助。因此，政府声称我们在提高效率，我们所卷入的这可是人命关天的事。与此同时，总安全官未作任何声明——正如乔尔对建筑规范的评论那样，它们全都是相互关联的，因为这个系统是在脱离问责制的情况下运作的。而验尸官死因研讯的作用在于，即使它不能建立一个问责机制，它至少打开了透明的窗口，让人们意识到：“等一下，这里出问题了。”另一件事，我想乔尔也提到了，那就是省立监狱里的大多数人法律上是无罪的，他们处于审前羁押状态。因此，将这些验尸官死因研讯改为强制性年度审查，其后果不仅是对家属造成问题，公众也将无法获知真相：我们缺乏心理健康培训，许多监狱只有一名精神科医生，某些狱警的行为无需承担责任。因此，在涉及验尸官死因研讯时，我们需要明白的是，这些研讯从根本上不仅具有透明度，它还在促使惩教部门把事情做对。他们目前并没有做对。我们已经有了数百起案例：克里斯蒂娜、杰扬、贾斯汀·圣托马斯·卡西迪、所罗门·法基里、乔丹，这些人都有心理健康问题，却在这个系统的管辖范围内失去了生命。这本身就是问题所在。因此，建监狱和增加2500名惩教人员根本解决不了任何问题。这能起到的作用只是应对某些特定问题，但有心理健康困扰的人不应该被单独关押，他们应该住进医院。这才是我们需要讨论的。
Original English **>>**: Doing a review, it has nothing to do with efficiency. Playing with people's lives when they buried their loved ones in body bags. You know, for families, they have a right to know what happens to their loved ones. So you cannot have a bunch of inquests, you know, a bunch of reviews, you know, taking multiple lives and then reviewing it that way. And because that doesn't work. And at the same time, what's very important when we're talking about efficiency, these are people's lives that we're talking about. And what, what this, what this review essentially does is that it takes away the transparency part. It takes away that corrections is in a crisis. It takes away from the fact that the guards, not only are they not trained. The fact is that people there's so many people that have mental health challenges that are being in these jails to put $3 billion, as you said, or hiring 2500 correctional staff, that doesn't solve the problem. They should be in mental health institutions with cultural competencies that help them. And so for the government to go say that we're making it efficient, these are lives that we're playing that, you know, that were involved in. And at the same time, for the Solicitor General to not make a statement, when, you know, to Joe's comment about the building code, they're all interconnected because the system operates away from accountability and coroner's inquest. What it does is that even though it doesn't create an accountability mechanism, it opens the transparency part where it says like, wait a minute, there's something wrong here. And the other thing, I think Joe mentioned this as well, is that most people that are in provincial jails are legally innocent. They are on remand. And so to have these coroner's inquests on mandatory on this mandatory review, what it does is that it creates not just a problem for the families, but the public doesn't get to know the fact that we don't have mental health training, that there's one psychiatrist for a lot of these jails that some of the guards, you know, are not held accountable for their actions. And so what we need to know, what we need to do when, when it comes to coroner's inquest is that these inquests, what what it essentially essentially does is that not only is it transparent, it also challenges corrections to get it right. They're not getting it right. We've had hundreds of cases. Christina Jeyan, Justin St. Thomas Cassidy, Solomon Faqiri Jordan shared individuals that had mental health challenges that thought lost their lives within the purview of the system. And that's the problem in itself. So building jails and having 2500 correctional officers, that's that does not solve anything. What it does is that, okay, it deals with certain issues, but people with mental health challenges, they shouldn't be in segregation, they should be in hospitals. And that's what we need to talk about.
**>>**: 乔尔，当我们展望未来的死因研讯时，一个合理的方案应该是什么样的？
Original English **>>**: Joel, what does the right plan look like when we talk about looking at inquests moving forward?
**>>**: 是的。那我们谈谈……
Original English **>>**: Yeah. So let's talk.
**>>**: 首先谈谈建议。我参与过多次因安大略省监狱内用药过量死亡而引发的死因研讯，多年来平民陪审团提出的建议确实发挥了作用。十年前的情况是，纳洛酮要么根本不在设施内，要么即便在设施内，也被锁在护士的推车上，距离任何人太远而无法派上用场。我们现在的局面是，纳洛酮至少在每个单元都有配备。它放在观察岗（即惩教人员坐的地方）或惩教人员的桌上。因此它是触手可及的，这毫无疑问挽救了生命。这都是因为验尸官死因研讯带来的改变。政府已经承诺雇佣更多警员，我认为这是件好事。死因研讯中反复出现的一个问题就是人员不足，人员短缺导致缺乏人手，从而引发悲剧性的后果。所以增加人员是件好事。还有及时性，我们确实需要让这些研讯开展得更快。因此我认为需要给验尸官办公室提供更多资金，以便他们能够聘请所需的调查员。但坦率地说，我们只需要把工作做得更好，这样我们就不必举办……我想去年强制性研讯的数字是45起。这个数字太大了。这意味着我们必须把工作做得更好，从而不再需要这么多次研讯。
Original English **>>**: About recommendations. To start with, I've been a part of a number of inquests that have arisen from overdose deaths in in Ontario's jails and the recommendations over the years from civilian juries have really helped. We went from a situation ten years ago where Narcan either wasn't in the facility, or if it was in the facility, it would be knocked locked on a nurse's cart far too far away from anyone to be of any use. We're now in a situation where Narcan is, at least in every unit. It's at the bubble, which is where the correctional officer sits, or the correctional officers desk. And so it's accessible, and that certainly has saved lives. And that's been because of the coroner's inquest. You know, the government has committed to hire more officers. I think that's a great thing. One of the things that consistently comes out of inquests is a lack of staffing, staffing shortages that lead to tragic outcomes because people aren't available. And so that is a good thing. Timeliness. We do need to have these inquests quicker. And so I think more funding for the coroner's office so that they can hire the investigators they need. But frankly, we just need to do a better job so we don't have to hold. I mean, I think last year the number was 45 mandatory inquests. That's too big of a number. And that is we need to do a better job. So we don't need as many inquests.
**>>**: 优素福，最后的话留给你。如果总安全官迈克尔·克兹纳现在就坐在你对面，关于这个程序该怎么做，你会对他说什么？
Original English **>>**: Yusuf, I'm giving you the last word here. If you had the solicitor, you know, General Michael Kerzner sitting across from you right now in terms of what needs to be done with this process, what would you say to him.
**>>**: 落实死因研讯的建议，哪怕是一部分。不要只给我们发些套话声明。而且，在一点上我想反驳一下乔尔：我们不需要雇佣更多的惩教警员，我们需要雇佣更多具备心理健康专业资质的人员，比如接受过相关培训的社工和精神科医生。因此，总安全官需要倾听公众的声音。但与此同时，我认为重要的是让政策制定者、专家们参与进来，例如伊万·辛格们、霍华德·萨珀斯们，这些真正拥有相关经验、能够为政府提供如何改革体制建议的人。但是，当一个系统抗拒改变且缺乏政治意愿时，就会形成一场完美风暴。而这场完美风暴将继续导致各个家庭收到的亲人遗体装在尸袋中，却没有任何透明度和问责机制。改变验尸官死因研讯程序在本质上将制造出更多的悲剧。这是极其悲惨的，也是至关重要的。这就是所罗门·法基里失去生命的原因，也是如果验尸官死因研讯不再按现行方式进行，很多人将继续失去生命的原因。
Original English **>>**: Implement inquest recommendations or some of it. Don't just send us boilerplate statements. And no, and I want to just push back one thing with Joel. We don't need to hire more correctional officers. We need to hire more individuals that have mental health, you know, that have mental health, you know, like social workers and psychiatrists that have those training. So the solicitor general needs to have the ears of the public. But at the same time, what I think it's important have the policy makers, the experts, the Ivan Zingers, for example, the Howard Sapers, the individuals that that essentially have these experiences that can basically advise government to know how to change the system. But when a system is resistant to change and there's no political will, you have a perfect storm. And this perfect storm will continue to create families, having their loved ones given to them in body bags, without a without a transparency and accountability mechanism process. And the coroner's inquest process being changed will essentially create more tragedies. And this is what this is what's tragic and this is what's important. This is why Solomon Faqiri lost his life, and this is why we're going to have many people continue to lose their lives. When coroner's inquests are not done the way that it is now.
**>>**: 我们先聊到这里。非常感谢两位，优素福·法基里、乔尔·迪克。正如大家所知，目前这还只是一份提议方案，但这是我们将持续报道的故事。非常感谢两位的参与。
Original English **>>**: We're going to leave it there. I want to thank you both, Yusuf Faqiri, Joel Dick, as we know, this is just a proposed plan at the moment, but this is a story that we will continue to cover. I want to thank you both so much.
**>>**: 感谢邀请我。
Original English **>>**: Thank you for having me.
### 专访原住民法医病理学家科诺·威廉姆斯博士 **>>**: 当有人意外死亡时，法医病理学家在弄清真相方面发挥着至关重要的作用。我前往萨德伯里，聆听北方健康科学中心东北地区法医病理室主任科诺·威廉姆斯博士讲述为何将此作为终生事业。科诺·威廉姆斯博士，很高兴见到你。你最近好吗？
Original English **>>**: When someone dies unexpectedly, forensic pathologists can play a critical role in understanding what happened. I headed to Sudbury to hear why Doctor Kono Williams, medical director of the Northeastern Regional Forensic Pathology Unit at Health Sciences North, has made it her life's work. Doctor Kono Williams, great to meet you. How are you doing?
**>>**: 很好。我也很高兴见到你。
Original English **>>**: Good. It's good to meet you, too.
**>>**: 你是一名法医病理学家，我相信很多观众和听众可能会觉得自己知道法医是做什么的，但我猜那是因为他们看过电视剧并形成了某种观念。但请帮我们了解一下，究竟什么是法医病理学？
Original English **>>**: You are a forensic pathologist, and I'm sure there's lots of viewers and listeners who probably think I know what they do, but I imagine that's because they're watching television shows and have an idea there. But help us understand what exactly is forensic pathology?
**>>**: 每次被问到这个问题，我总会想：它像《犯罪现场调查》（CSI）那样吗？它有点像，但又不像。法医病理学家是在法律背景下解释损伤和自然疾病。这是它的正式定义。但我更喜欢补充说，我的工作是寻找真相。我需要探寻某人死亡的核心原因，这需要面对大量的真相。这就是法医病理学的核心和灵魂。
Original English **>>**: Every time I get asked that question, I was like, is it like CSI? And it is, and it's not. So forensic pathologists, they interpret injury, natural disease in the context of the law. So that's kind of the formal definition of it. But I like to add that we're like, my job is truth. I need to get to the heart of why somebody died. And that involves a lot of truth. So that's sort of like the heart and soul of forensic pathology.
**>>**: 在所有的医学专业中，你本可以追求其他的，为什么偏偏选择这一门？
Original English **>>**: Of all the specialities of medicine. You could have pursued. Why this?
**>>**: 是啊。我父亲以前常说：“我的天哪，你怎么读到33年级了？”是的，家里能出一个医生，他起初超级兴奋，结果我跑来干了这个。这得益于很多非常优秀的导师，也有很多机缘巧合。我就是爱上了它。这是一项挑战，就像一道必须解开的谜题。它能为我在安大略北部服务的人们提供切实的服务，我认为能给逝者家属带去答案是很有意义的。
Original English **>>**: Yeah. My dad always said, my goodness, like you're. Why are you in grade 33? And yeah, like he was super excited at having a doctor in the family. And then I go ahead and do this. It was a lot of really good mentors, a lot of sort of opportunity, serendipity. And I just fell in love with it. It's a challenge. It's like a puzzle you have to work out. It serves a really good service to the people that I serve here in northern Ontario. And I think it's good to bring answers to the families.
**>>**: 我想排队去当法医病理学家的人肯定不多。请帮我了解一下，目前的病理学家群体规模很小吗？
Original English **>>**: I have to imagine there's not a lot of people lining up to be a forensic pathologist. Help me understand that. Is it a small sort of cohort of of pathologists out there?
**>>**: 是的，我们的队伍实际上非常小。法医病理学在加拿大实际上非常年轻，甚至还不到20年。所以这是一个新兴专业。我们的人数不多，培训周期很长，因此培养出我们这样一个人需要很长时间。
Original English **>>**: Yeah, we're actually quite small. And forensic pathology in Canada is actually very young. It's, you know, not even 20 years old yet. So it's a new speciality. You know, there aren't that many of us. The training is long, so it takes a long time to sort of incubate one of us.
**>>**: 我们具体在说多长时间？
Original English **>>**: What are we talking about? How long?
**>>**: 四年本科，四年医学院，五年住院医培训，一年专科进修。也就是中学毕业后还要接受14年的高等教育。哇，但这完全值得。
Original English **>>**: Four years of undergrad. Four years of med school, five years of residency. One year of fellowships. It's 14 years of post-secondary education. Wow. Totally worth it.
**>>**: 你的工作——你提到了医学与法律一个非常有趣的交集，它涉及为不同的利益相关者解释复杂的医学证据。我们指的是家属、调查人员、法庭以及公众成员。请帮我理解一下，准确地向需要不同信息的受众传达这些调查结果存在哪些挑战？
Original English **>>**: Your job. You mentioned a really interesting overlap of medicine and law, and it involves translating complex medical evidence for various stakeholders. We're talking families, we're talking investigators, we're talking courts and members of the public. So help me understand here the challenges of communicating these findings accurately with different audiences that sort of need different kinds of information.
**>>**: 这就是医学艺术发挥作用的地方。这就是我所做工作的艺术性所在，这需要大量的练习。以人们能够理解的方式传达复杂的医学信息实际上相当困难。我拿家人做过练习；跟孩子们沟通也很棒，因为你可以问他们：“嘿，我们今天来认识一下心脏吧。”如果他们能复述给你听并且听懂了，你就知道自己做得不错。但这极其重要，特别是在法庭上和面对家属时，提供可以理解的信息，让他们能带回去思考并明白：“好的，我知道我的家人是怎么去世的了。”这不仅至关重要，也是一门真正的艺术。
Original English **>>**: So that's where the art of medicine comes in. So this is the art of what I do. It takes a lot of practice. So communicating that complex medical information in a way that people can understand is, is actually quite, quite difficult. And, you know, I practised on family members. I practised on, you know, children are great because you can ask them, you know, hey, let's learn about the heart today. And if they can repeat it back to you and they understand that, you know, you've done a good job, but it is critically important, especially in court and to families, to communicate information that is understandable and that they can, you know, go away with, think about and think, okay, yes, I understand how my family member died. That is that is both critically important and a real art.
**>>**: 能否举一个潜在案件的例子？显然涉及某些案件时需要保密，但能谈谈你所做工作的一些复杂性吗？
Original English **>>**: Can you give me an example of a potential case? Obviously, confidentiality in terms of some of the cases, but some of the complexities of what you do?
**>>**: 好的。比如当我们遇到隐蔽性凶杀案时，在无人知晓的情况下送进来，看起来就像“噢，这只是一起普通案例”，而最后的责任就落在了我们身上。因此责任是极其重大的。当我看着一个人并意识到“噢，这里有隐情，这个人受到了他人的伤害”，在整整10到20秒的时间里，只有我和那个行凶的人知晓真相。做出这个决定总是非常艰难。做出定性，因为我知道接下来的后果：这会登上六点档新闻，会引发警方数十万加元的调查，而且会有人因为我的一句话而入狱。所以这种责任其实相当沉重。培训周期之所以这么长是有原因的。因此，拥有做出这一决定的信心和技能是至关重要的，这是一份沉甸甸的责任。但这也让人非常谦逊，能够提供这项服务是一项巨大的荣幸。
Original English **>>**: Yeah. I mean, you know, when we have something like a concealed homicide, for example, you know, when nobody knows and, you know, it comes in as just, oh, well, it's a regular case and we're kind of like the buck stops with us. So, you know, the responsibility is enormous. And so when I look at a person and I think, oh, you know, there's something going on here, like this person was hurt by somebody else for a good ten or 20s. It's just me and the other person who did it that know. And making that decision is always really difficult. And so calling it because I know what's going to happen that's going to, you know, hit the 6:00 news. That's like hundreds of thousands of dollars of police investigation. So, and somebody's going to jail for what I say. So that responsibility is actually quite heavy. And there's a reason why the training is so long. And so to be able to have the confidence and the skill to make that decision is, is enormous. And it's, you know, a big responsibility. But it's also very humbling. And it's, it's a huge honour to be able to provide that service.
**>>**: 你们必须相当准确。
Original English **>>**: You have to be fairly accurate.
**>>**: 非常准确。是的，必须如此。病理学家的错误率实际上不到百分之一的几分之一，因为他们必须做到这一点。所有病理学家都是如此，我们是最终的诊断者。所以我热爱我工作的这一面。它充满挑战，令人兴奋，但责任极其巨大。
Original English **>>**: Very accurate. Yeah. You are. Yeah. Pathologist error rates are actually like less than a fraction of a percent because they have to be. And that goes for all pathologists. Like we have. We're the final diagnostician. So I love that aspect of my job. It's challenging. It's exciting. But the responsibility is huge.
### 北部地区法医服务的独特挑战与原住民社群 **>>**: 是的。你刚才稍稍触及了身处北方以及那里的某种使命感。请帮我了解一下在安大略省北部从事法医病理学实践的独特挑战。
Original English **>>**: Yeah. You touched on a little bit about sort of being in the north and sort of the calling there. Help me understand the unique challenges of practising forensic pathology here in northern Ontario.
**>>**: 是的。我指导设在萨德伯里的东北地区法医病理室。我们覆盖的地理区域非常广阔，从帕里桑德一直延伸到詹姆斯湾沿岸。所以面积非常巨大。地理是一大挑战，天气是另一个挑战。因此，在我的工作中，提供本地化服务至关重要，确保我们能够为需要的人或逝者及其家属提供服务，然后将逝者送回家，以便尽可能不打断他们的哀悼过程。安大略省北部还有规模庞大的原住民人口。这也带来了它自身的复杂性和挑战。这也是我决定来到这里的部分原因。
Original English **>>**: Yeah. So I direct the Northeastern Regional Forensic Pathology Unit, which is based out of here in Sudbury. We cover a huge geographical area, like from Parry Sound, all the way up to the James Bay coast. So it's enormous. So geography is one. Weather is the other one. And so, you know, having local service is, is really important in my work, making sure that, you know, we can get somebody the service that they need or the deceased person as well as their families and then getting them home so that we don't interrupt that grieving process as much as possible. There's also a very large indigenous population in northern Ontario. And so that comes with its own complexities and its own challenges. And that's part of the reason why I decided to come here.
**>>**: 让我们深入聊聊这一点，因为这很有层次感。你是加拿大首位原住民法医病理学家。当涉及失踪和被谋杀原住民妇女及女童的案件时，法医病理学揭示了体制中的哪些缺口？
Original English **>>**: Well, let's talk about that because that's layered. You are the first indigenous forensic pathologist in Canada when it comes to cases involving missing and murdered indigenous women and girls. What gaps in the system does forensic pathology expose?
**>>**: 是的。从历史上看，死亡调查就像几乎所有其他政府机构一样，对原住民并不友善。存在着很多不信任、很多误解和大量的沟通不畅。尤其是寄宿学校的影响使这一切进一步加剧，当有人去世时，情况已经非常艰难，尤其是在失踪和被谋杀的原住民这一背景下。因此，当面对政府、医疗和法律系统的代表——我算是集这三者于一身——前来对他们的亲人进行某种处理时，沟通环节就变得尤为重要。我认为这也是我留在这里的部分原因。我工作的一部分就是充当那座桥梁，改善沟通，并有望改善这种关系。
Original English **>>**: Oh, yeah. So, I mean, historically, death investigation, like just about any other government institution, hasn't been kind to indigenous people. There's a lot of mistrust. There was a lot of misunderstanding, a lot of miscommunication. And so, you know, with the effects of the residential schools, particularly all that compounds, and then when somebody dies, it's already a really difficult situation, especially in the context of missing and murdered indigenous people. So, you know, when you have a government and, you know, representatives from the government and healthcare and legal system, I kind of represent all three coming in to do something to their loved one. You know, that communication piece becomes really important. And I think that's part of my reason for being here. And part of what I do is to be that bridge and to improve the communication and hopefully improve the relationships.
**>>**: 我想这一定也很不容易。
Original English **>>**: I have to imagine that must be difficult though, as well.
**>>**: 当你成为唯一的存在（样本量为一）时，是的，确实挺不容易的。责任非常重大，但我父亲曾上过寄宿学校，我母亲上过印第安走读学校。我是我们家族中第一代没有直接受到其影响的人。所以对我来说，我觉得很坚定。我父亲当时会问：“你在干什么？”但考虑到我的工作，以及我目前拥有的技能和专业知识，我认为时机是对的。能够拥有这样的机会，拥有所有那些导师和支持让我走到今天能够从事这项工作，我真的很感激。但这确实是一副重担。
Original English **>>**: Well, when you were an N of one, yeah, it was actually pretty. It's a lot of it's a lot of responsibility, but you know, my dad went to residential school, my mom went to Indian Day school. Like I'm the first generation of my family that wasn't directly affected. And so for me, I'm like, yes. My dad was like, what are you doing? But given what I do and the skills and the expertise that I have at this time, I think it was the right time. And it's I'm really just grateful to have the opportunity and have all those mentors and all that support to get me here to be able to do this work. But it is a lot.
**>>**: 作为一名病理学家，你如何从这一切中抽离片刻来调节自己？
Original English **>>**: How do you, as a pathologist, sort of take a moment from all of that?
**>>**: 这行并不适合所有人。从事这项工作并与逝者打交道需要特定性格的人。我拥有一片100英亩的土地和一个农舍。我回家尽情享受。我的整个后院都充满了生机。这是一种有趣的对照。不过是的，我走到大自然和土地上去，就像我父亲说的那样：回馈土地，它就会回馈你更多。我就是这么做的。
Original English **>>**: You know, this isn't for everybody. It takes a certain type of person to be able to do this work and work with the dead, but I have 100 acres in a farmhouse. I go home and enjoy it. My whole like, backyard is full of life. So it's an interesting juxtaposition. But yeah, I go out in the land and do, like my dad said, just give it back and it'll give you more. That's what I do.
**>>**: 你最近被授予了加拿大勋章，成为首位获得这项平民荣誉的第一民族法医病理学家。这对你意味着什么？
Original English **>>**: You were recently bestowed with an Order of Canada, the first First Nations forensic pathologist, to receive this civilian honour. Yeah. What does that mean for you?
**>>**: 这非常令人意外，我完全没想到，这是肯定的。仔细想想，我接下来要用它做些什么？这是一项极大的荣誉。在两个层面上：对原住民而言，50年前这可能是不可能发生的事；对法医病理学而言，它让这个专业受到了关注。我一直认为这项荣誉并不单属于我，它属于所有支持过我的人、所有的同事和原住民同胞。它属于他们。我只希望能不辜负这份荣誉。
Original English **>>**: It was a big surprise. I wasn't expecting it, that's for sure. And sort of thinking about it, you know what? What am I going to do now with it? It's it is a great honour. And, you know, on two fronts for indigenous people, like 50 years ago, this probably wouldn't have happened for forensic pathology. I was like putting that on the map. Like, you know, this is this is I always think about it as not the honour doesn't belong to me. It belongs to everybody who supported me. All my colleagues, you know, indigenous people. It belongs it belongs to them. And I'm just hoping that, you know, I can live up to it.
**>>**: 结合你今天告诉我们的一切，如果你能让福特省长政府倾听你的声音，你希望他们优先考虑哪一件事？
Original English **>>**: Given everything that you told us today, if you had the ear of Premier Ford's government, what's one thing you would like them to prioritise?
**>>**: 安大略北部需要帮助，我认为这对整个医疗保健系统以及广大民众而言都是如此。我们很幸运在这里设有一个病理室，在苏圣玛丽还有另一个病理室覆盖了安大略东北部。我们极度需要在安大略西北部设立法医病理服务，那是一个巨大的空白。考虑到原住民的死亡，以及偏远乡村、只能乘飞机抵达的社区的需求，我们绝对需要在安大略西北部提供服务。
Original English **>>**: We need help in northern Ontario, and I think that goes for all of healthcare and for people in general. We have the unit here. We're very fortunate. We have another unit in Sault Ste. Marie that has northeastern Ontario covered. We desperately need service, forensic pathology service in northwestern Ontario. That's a huge gap. And considering, you know, particularly the deaths of indigenous people and the needs of rural, remote Fly-In communities, we definitely need service in northwestern Ontario.
**>>**: 你所说的服务具体是什么形式？
Original English **>>**: When you say service, what does that actually look like?
**>>**: 在桑德贝设立一个法医病理室，在基诺拉再设立一个，那就太好了。确保服务能够保持在本地化运作，并且尊重逝者家属。
Original English **>>**: Forensic pathology unit in Thunder Bay and other one in Kenora would be great. And to ensure that the service sort of remains local and that's respectful for the families.
**>>**: 对于全省各地可能想从事法医病理学职业的年轻人，不管他们父母怎么说，你对他们有什么建议？因为正如你所说，这是一项与死亡打交道的职业，你肩上似乎承担着很多压力与责任。
Original English **>>**: For young people across this province who might want to pursue a career in forensic pathology, regardless of what their parents say, what advice do you have for them? Because, as you say, this is it's you're dealing with death. You there's it seems like there's a lot on your shoulders and responsibility as well.
**>>**: 是的，这是一条漫长的路。不要放弃，在学校努力学习。但这不仅限于法医病理学，法医学本身是一个庞大的领域，有很多机会从事不同类型的工作，与我们共事并参与其中。我肯定会说，是的，不要放弃。正如我所说，在学校好好表现，这很重要。但要明白，我们非常欢迎他们来加入我们。我们将需要帮助，我们的人手不足，我们需要他们。
Original English **>>**: Yeah, yeah, it's a long haul. Don't give up, you know, do well in school. But it's not just you don't only have to do forensic pathology. Forensics itself is a huge world. There's lots of opportunity to do different kinds of jobs and to work with us and to be part of this. I would definitely say, yeah, don't give up. You know, definitely, like I said, do well in school. That's important. But know that they're welcome to help us out. We're going to need the help. There aren't enough of us and we need them.
**>>**: 问你一个问题。我看到你脖子上的项链，那是一颗心形。我可以问问这个有什么特殊的含义吗？
Original English **>>**: Give me a question. I see your necklace there. It's a heart. Yes. Can I ask you a little bit about that? What is is there a special meaning to that?
**>>**: 有的。上面有一枚我和我丈夫的戒指。我不喜欢手指上戴东西，尤其是和人一起工作的时候。但这颗心，是我在完成专科进修后，很久没有养狗了，当时我养了一只非常可爱的小博美犬。它患有无法手术的心脏缺陷，很小就去世了。所以这就是它。我家里还有六只狗。
Original English **>>**: There is, yeah, one. So there is a ring on that with my husband. I don't like things on my fingers, especially when I'm working with people. But the heart I after I finished fellowship, I hadn't had a dog in forever. And I got a little, a little cute little Pomeranian. And he had a, an inoperable heart defect. And so he died really young. So that's him. I have six more dogs at home.
**>>**: 所以我有很大的地方。
Original English **>>**: So I've got lots of land.
**>>**: 我们有大片的土地。我算着每英亩养一只狗，但我丈夫说绝对不行。不过是的，我一直随身带着它。它真是一只非常棒的小狗，所以它一直陪伴着我。
Original English **>>**: We got we got plenty of land. I figured one dog per acre and hubby's like, absolutely not. But yeah, I carry him with me. He was just he was an amazing little dog. So he's with me all the time.
**>>**: 我想即便是对法医病理学家来说，面对死亡对任何人都是艰难的。即便你接受了14年的培训，悲伤依然是一件沉重的事。
Original English **>>**: So I have to imagine, even for a forensic pathologist, death is is hard for everybody. Yeah. It's even though you've got 14 years of training, it's grief is still a hard thing.
**>>**: 是的，对每个人来说都不同。拥有这样的经历，经历自己家庭中的死亡以及社区中的离世等，确实让我对正在面对这些的家庭有了更多的共情与同情心。我希望没人需要用到我的服务，但当他们需要时，我会为他们守候在那里。
Original English **>>**: Yeah, yeah. I mean, it's different for everybody. And, you know, having having that experience is, you know, an experiencing, you know, death in my own family and, you know, in the communities and such. It does give me that much more empathy and compassion for families who are dealing with this. Like, I hope nobody has to need my services. But when they do, you know, I'm there for them.
**>>**: 博士，非常荣幸能与你交谈。非常感谢，由衷感激。
Original English **>>**: Doctor, it was a pleasure. Thank you so much. I really appreciate it.
**>>**: 非常感谢。
Original English **>>**: Appreciate it.
**>>**: 如果你想了解更多关于所罗门·法基里案的信息，请收听TVO的播客《无法确诊》（Unascertained），该节目记录了他的家人寻找真相的历程。非常感谢收看《简报》，我们明天见。
Original English **>>**: If you're looking to find out more about Solomon Fakir's case, check out the TVO podcast Unascertained, which follows his family's search for answers. Thank you so much for tuning in to The Rundown. I'll see you tomorrow.