Introduction

Why are we doing this review?

Two devastating fires that took place in 2016 in Pikangikum First Nation and Oneida Nation of the Thames led to calls for the Office of the Chief Coroner for Ontario to review fire deaths that have occurred in First Nations communities. These tragic deaths were not isolated.  In response to multiple fire related deaths in many First Nation communities, First Nation Chiefs and community members were calling for an inquest to explore potential systemic issues contributing to ongoing fire related deaths.  A meeting was held in December 2017 between members of the Office of the Chief Coroner (OCC), Department of Indigenous Services Canada’s Ontario Region (ISC), and Indigenous community representatives to discuss a strategy that would establish a framework to effectively gain an understanding of these tragedies. It was decided that the OCC, along with the Office of the Fire Marshal (OFM) and the Ontario Forensic Pathology Service (OFPS), would assemble the Ontario Chief Coroner’s Table on Understanding Fire Deaths in First Nations to lead and facilitate analyzing these tragedies.

Who was involved?

A core group from the OCC and the OFM formed the main governance team and set the strategic direction for the review. In the spring of 2018, the review’s Working Group was established by bringing together technical experts from the OCC, OFM, OFPS, Ontario Native Firefighters Society, Ontario Provincial Police, Nishnawbe Aski Nation – Infrastructure & Housing, Ministry of the Attorney General – Indigenous Justice Division, and ISC. In 2019, an Advisory Group consisting of Elders and Knowledge Keepers from six communities impacted by multiple fatal fires was formed. The Advisory Group guided the Working Group to ensure that the review was carried out respectfully and in a manner that reflected the voices and perspectives of First Nations communities.

Background on the OCC and OFM

In Ontario, death investigation services are provided by the OCC and the OFPS. According to legislature, all non-natural deaths require investigation. Death investigations and inquests are conducted to gather information about the circumstances surrounding a death. The purpose is to answer five questions: who died, when and where a person died, the medical cause of death and the manner of death. Investigations and inquests can also lead to recommendations to protect the public and, where possible, prevent further deaths. As part of the death investigation, all persons who pass away in a fire undergo a post mortem examination. Where possible, toxicological testing is completed to determine carbon monoxide levels as well as any other substances present.

OFM investigations of fatal and non-fatal fires in First Nations communities in Ontario are conducted in support of investigations that may be led by other agencies like the Office of the Chief Coroner and police services. In some circumstances, the OFM may be invited by Chief and Council.

An OFM investigation may determine the cause, origin and circumstance of a fire or explosion. Every OFM fire investigation is scientifically based, and the methodology utilized is applied consistently to ensure the reliability and validity of the finding(s). Information from OFM fire investigations may be used to inform public education, inspection and emergency response/suppression programming to reduce the risk of fire deaths, injury, and loss of property.

The OFM recommends that municipal fire protection services be based on the three lines of defence:

Line 1: Public fire safety education

Line 2: Fire safety standards and enforcement

Line 3: Emergency response (suppression)

As of July 1, 2024 all municipalities must complete a Community Risk Assessment as set out in O. Reg. 378/18, a regulation under the Fire Protection and Prevention Act, 1997. The Community Risk Assessment is to be used to inform decisions about the provision of fire protection services. In setting levels of service municipalities are strongly encouraged to consider the OFM three lines of defence.

To assist municipalities with the implementation of the Regulation, the OFM has developed a technical guideline and worksheets for municipalities. These documents are available on the OFM website.

What is the aim?

The aim of the Ontario Chief Coroner’s Table on Understanding Fire Deaths in First Nations (OCC-UFDFN) was to collect data and information to effectively inform the understanding of fire deaths in First Nations communities.  The findings will be shared with, primarily, First Nations communities and, secondarily, other interested parties, to identify both community and system level factors and gaps that contribute directly or indirectly to fire deaths in First Nations communities in Ontario. The sharing of the findings is also to provide information to assist in program and policy development, enhance fire safety, and contribute to fire prevention in First Nations communities. The OCC-UFDFN also established a mechanism to share information from fire death investigations through the development of a First Nations Fire Template (FNFT). The FNFT is a tool that can allow for the collection and sharing of information from fire death investigations and can assist in the evaluation and comparison of fire fatalities.

What did we look at?

The OCC-UFDFN examined fire deaths in First Nations communities in Ontario over a ten-year period, spanning from 2008 to 2017. This included reviewing 56 deaths in 29 fires that occurred in 20 First Nations communities across Ontario. This review did not include non-fatal fires in First Nations communities.

The OCC-UFDFN did not make recommendations or develop policies and strategies. The data and information in this review will inform and support First Nations communities and others to recommend and develop policies and strategies to prevent fire fatalities.

What did we do and how did we do it?

Cases for the review were selected based on a scan of the OCC’s data management system (Coroner’s Information System). All cases in First Nation communities involving a structural fire fatality were selected. These cases were cross referenced with the OFM’s data management system (Fire Investigative Report System) to ensure that all relevant cases were included in the review.

The “First Nations Fire Template” (FNFT) was developed to gather data to analyze  fire deaths in First Nations communities in Ontario. It includes the following:

• Information about the deceased person – the individual’s demographic information
• Community Information – the community’s demographics and resources
• Fire Marshal Information - the fire’s cause, origin and circumstances
• Coroner Information - the individual’s relevant medical history and manner of death
• Forensic Pathology and Forensic Anthropology Information - the individual’s post mortem findings, including the cause of death

Data was then gathered from case files at the OCC (Coroner Death Investigation Reports, Post Mortem Reports, Toxicology Reports, Forensic Anthropology Reports, Police Reports), OFM (Fire Investigative Report System), and through ISC (First Nation Profiles^{footnote 1[1]}, Registered Indian Population^{footnote 2[2]}, Asset Conditioning Report System), Statistics Canada (Census^{footnote 3[3]footnote 4[4]footnote 5[5]} ), Nishnawbe Aski Nation, Sioux Lookout Area Aboriginal Management Board, and data shared by the communities.

The geographical location of the communities was considered, with respect to the presence of year-round access and closeness to resources and services. Communities that have Municipal-Type Service Agreements (MTSA) in place were used as an indicator for closeness to other municipalities or services. Indigenous and Northern Affairs Canada’s website includes First Nation Profiles which is a collection of information that describes First Nations communities. This includes geographical zones.  The geographical zones and the presence of MTSAs were used to form three groups for this review:

• communities with year-round road access to a service centre and an MTSA in place,
• communities with year-round road access to a service centre and no MTSA in place,
• and communities with no year-round road access to a service centre.

A priority of the review was to maintain the deceased individual’s privacy and attempt to reduce further trauma to those impacted by the fire fatalities. For these reasons, the data is this report was anonymized.

A literature review was conducted to determine previously identified risk factors in fire fatalities, as well as factors that may be specific to Indigenous Peoples and First Nations communities.

Anonymized information was then combined and reviewed to describe the fires, structures and individuals impacted as well as potential relationships between these factors. The findings were compared to information from the Ontario Fire Marshal for fatal residential fires in non-First Nations communities in Ontario during the same time period when possible.

What do we know about fire fatalities – A review of the literature

Residential fires and fire fatalities

Risk factors for fire and fire fatalities are not the same, and factors that affect individuals’ ability to survive a fire do not necessarily affect the likelihood of a fire occurring.footnote 6[6] Rural homes are often isolated and removed from fire response services and have shown a higher concentration of residential fires resulting in higher fire mortality rates.^{footnote 6[6]footnote 7[7]footnote 8[8]} Allareddy et al.^{footnote 6[6]} found that rural homes were more likely to use supplemental heating sources than urban households.

Though there are differences in provincial/territorial fire coding, a Canada-wide study reveals the leading cause of residential fires to be cooking followed by heating equipment and arson/set fires.^{footnote 9[9]} These results were very similar to those reported for residential fires in the United States.^{footnote 9[9]} The same study found that most fire deaths in Canadian homes where a cause was identified were from smoking followed by arson/set fire and cooking.^{footnote 9[9]} The association of fatal fires with smoking material and cooking is also observed in other jurisdictions outside of Canada including in the study by Jonsson et al.^{footnote 8[8]} in Sweden. Based on data available from five Canadian jurisdictions, the study by the Canadian Centre for Justice Statistics^{footnote 10[10]} found the source of ignition in residential fires to be cooking equipment (i.e. ovens and fryers) followed closely by smoker’s equipment/open flames, heating equipment, and electrical distribution equipment.

When examining all fire fatalities in Ontario, the major known fire cause was smoking followed by arson/set fire and electrical distribution equipment.^{footnote 9[9]} The leading probable cause of fire deaths was asphyxia (carbon monoxide and hydrogen cyanide poisoning) followed by complications from burns or scalds.^{footnote 9[9]} In 2014, sources of ignition in Ontario residential fires were found to depict a similar pattern with cooking equipment leading, followed by smoker’s equipment/open flames, heating equipment, and electrical distribution equipment.^{footnote 10[10]} There was a slight variation observed when examining the ten-year span of 2008-2017 as the source of ignition in residential fires was reported to be lit smokers’ material followed by arson and cooking equipment.^{footnote 11[11]} Fire play and electrical failure were the top two causes of fire deaths in the pediatric population in Ontario, followed by unattended candles, stove fires, and cigarette fires. However, a cause was not identified in 28% of fires.^{footnote 12[12]}

Fatal fires tend to occur more commonly during the night.^{8, 9, 13-15} Chen et al.^{footnote 12[12]} looked at pediatric fire deaths and found nighttime fires were most commonly due to electrical failures or unattended candles. Daytime fires were primarily caused by unsupervised fire play and stove fires.^{footnote 12[12]} A review of fire fatalities in children and youth from 2005-2014 by the British Columbia (BC) Coroners Service^{footnote 7[7]} found that residential fatal fires happen more frequently in colder months.

The absence of a life safety system (smoke alarm or sprinkler system) appears to increase the risk of fatality in fires.^{footnote 8[8]footnote 13[13]footnote 15[15]} In homes that do have smoke alarms, it is the functionality of the smoke alarm that is a risk factor.^{footnote 12[12]footnote 13[13]footnote 16[16]}

Previous studies have shown that behavioural, demographic and socio-economic factors contribute to fire deaths. These include age (children or elderly), sex (males), smoking, alcohol use (younger adults) living alone, disability, low-income, and sub-standard housing.^{footnote 6[6]footnote 7[7]footnote 8[8] footnote 13[13]footnote 14[14]footnote 15[15]footnote 16[16]footnote 17[17]footnote 18[18]}

Studies have reported factors believed to increase childhood risk for fire injury and death, include maternal education, socioeconomic status, single-parent households, housing regulations, substandard and overcrowded housing conditions, behaviour (fire escape and fire-play), smoke alarm functionality, exposure to smoking environments, degree of adult supervision and children protection service involvement.^{footnote 7[7]footnote 12[12]footnote 16[16]} Caregivers in low-income families are more likely to disable working smoke alarms due to annoyance with false alarms from cooking or cigarette smoke in overcrowded living spaces.^{footnote 12[12]}

In fire fatalities the individual’s cause of death is usually smoke inhalation and/or thermal burns.^{footnote 8[8]footnote 10[10]}

The literature indicates that the ability to escape is affected by an individual’s physical and mental capacities (children less likely to be able to self-rescue), any attempts made to put out the fire, the route of escape (trapped by spreading fire or smoke), distance to nearest exit, and familiarity with surroundings.^{footnote 7[7]footnote 10[10]}

Fire and fire fatalities in Indigenous communities

The research into fire related deaths of Indigenous people shows the rate of fire-related mortality is higher than in non-Indigenous populations. In 2007, the Canadian Mortgage and Housing Corporation^{footnote 19[19]} found the First Nations per capita fire incident rate and the death rate to be 2.4 and 10.4 times higher than the non-First Nations people in Canada. Research from BC between 2006 and 2011 found a rate of 36.5 deaths per 1,000 fires in First Nations community residential structure fires compared to 15.1 deaths per 1,000 fires for non-First Nations people in BC.^{footnote 7[7]} The BC Coroners Service^{footnote 13[13]} found from 2007-2011 Indigenous people were four times more likely to die in residential structure fires than non-Indigenous people and were also on average 20 years younger than non-Indigenous people. Forty percent had died on Federal Reserve land.^{footnote 13[13]} Gilbert et al.^{footnote 20[20]} found age-specific death rates were higher in every age category for Indigenous people who were registered as Indian under the Indian Act in BC. Indigenous people in other countries also experience higher rates of fire fatalities in comparison to non-Indigenous people.  For example, in New Zealand the fire fatality rate for Maori aged 15-64 was reported to be 5 times the rate for non-Maori of the same age.^{footnote 17[17]}

Cigarettes and heat sources (e.g. wood fires, electrical heating units) were common causes of residential fatal fires in Indigenous communities in BC.^{footnote 20[20]} Other issues related to fire deaths include: lack of mechanism to enforce compliance with building and fire codes, substandard housing, overcrowding, prevalent use of wood stoves (which may not always be installed and maintained as prescribed), youth experimenting with fire, absence of functioning life safety systems (including smoke detectors, fire extinguisher and sprinkler systems) and inadequate or inaccessible fire response services.^{footnote 19[19]footnote 21[21]footnote 22[22]footnote 23[23]} Gilbert et al.^{footnote 20[20]} also identified risk factors for fatal fires that had not been recognized in non-Indigenous populations including: abandoned and traditional housing and use of propane lanterns due a lack of access to electricity.

Previous and current federal government attempts to examine fires in First Nations communities include: First Nations Fire Protection Strategy 2010–2015^{footnote 24[24]}; Joint First Nations Fire Protection Strategy 2016-2021^{footnote 25[25]}; and, From the Ashes^{footnote 23[23]}. The important role of knowledge and awareness through public education programs and fire prevention in First Nations communities has been acknowledged. Fire inspection regimes are not uniform and vary from community to community.^{footnote 21[21]footnote 25[25]} Concerns with funding of fire services to meet communities’ needs have also been identified.^{footnote 23[23]}

The literature reveals a long history of under-resourcing Indigenous communities. The final report of the Truth and Reconciliation Commission of Canada,^{footnote 26[26]} demonstrated that for much of their history, Canadian residential schools operated outside the jurisdiction of existing fire regulations:

“Residential schools were often poorly built and isolated from help in case of fire. Many of the boarding schools were of wood-frame construction. The wood and coal-burning stoves used to heat the buildings could throw off sparks that could result in a blaze. Heat was transmitted from room to room by stovepipes that were themselves a potential source of fire. Most of the schools were far from any source of electricity, and, for years, most of them were lit by gas lamps.”^{footnote 26[26]}

“Over time, most schools acquired electrical generators, but poor wiring was often the cause of school fires.”^{footnote 26[26]}

There are accounts of inadequate power and water to provide satisfactory fire safety, inadequate firefighting equipment and means of escape; poor structure maintenance and overcrowding conditions; use of dangerous and forbidden practices (locking of fire escapes).^{footnote 26[26]} Many of these conditions were noted by Indian Affairs officials but little action resulted.^{footnote 26[26]} “In the interest of cost containment, the Canadian government placed the lives of students and staff at risk for six decades”.^{footnote 26[26]} It wasn’t until after the 1940s that a decrease in deaths of children who were forced to attend residential schools was noted and attributed in part to new buildings being built that provided higher degrees of fire protection.^{footnote 26[26]}