Beyond Blame: Kate’s Story

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Part I:  #1 | #2 | #3 | #4 | #5 | #6 | #7 | #8 | #9 | #10 | #11 | #12 | #13 | #14 | #15 | #16 |#17 | #18 | #19 | #20 | #21 | #22 | #23 | #24 | #25 | #26 | #27 | #28 | #29 | #30 | #31 | #32

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Late in the evening of September 3rd, 2014, my niece Harriet received a phone call no one expects or wants ever to receive: a sergeant from the Ontario Provincial Police was delivering the news that her mother, my sister Kathryn (Kate to many), had been found deceased in her home in Casselman, Ontario. It was shocking and hard to take in: Kathryn was 54 years old and in good health despite a lifelong history of food and environmental allergies—she had always managed them.

We would soon find out that Kathryn had placed a 911 call from her home two days earlier, that she had struggled to make herself understood by the dispatcher, and that no emergency responders had come to the house. We would also learn—after making an official complaint to the OPP—that from the moment Kathryn placed her 911 call, at 4:43 pm on Labour Day, a mind-boggling series of errors and miscommunications were made all the way down the emergency response chain.

As a result of our official complaint, two investigations were launched—an independent investigation of the uniformed officers by the Office of the Independent Police Review Director (OIPRD) and an internal investigation of the civilian 911 operators by the OPP. Not satisfied with an internal investigation of Ontario’s emergency response system (the full results of which were not shared with us), our family lobbied for an inquest, which we finally received (in conjunction with another case) on appeal to the Chief Coroner in February 2017. (The inquest is scheduled to take place in October 2018.)

As a result of the OIPRD investigation, the OPP charged two constables under the Police Services Act. My sisters and my niece and I attended the hearings, which were drawn out over nearly a year. One constable was found guilty of two counts of neglect of duty. This decision was the subject of several media articles, which presented the case as though all the responsibility for Kathryn’s death rests upon the shoulders of this one OPP constable. This is so far from the truth that we want to set the record straight.

I’m telling Kathryn’s story in serialized installments here on this website. (You can find them below.) It’s the story of the search for justice for Kathryn and for changes to the 911 system, and much more. My intention is to present her story in its larger context and in a compassionate, forgiving light that I hope might also help others who feel they have been wronged and are seeking justice and inner peace. I’m calling it:

Beyond Blame: Kathryn’s Story

Part I

Installment #1: A brain tumour

My story of my sister Kathryn begins with a brain tumour. And it wasn’t hers.

In June of 2014, our mother began to notice that she was dropping things more often, that she was having trouble with her new computer keyboard, and that she was occasionally forgetting to turn off a light at night and, once, scarily, a burner on the stove. She was also not as steady on her feet. All this was very unlike our 85-year-old mother, who had an excellent memory, still walked at a good clip around the neighbourhood, and attended the fitness classes offered in her condo. (I first saw her sporting cool leggings in her early 80s.) Of course, she didn’t mention this to any of us. Nor did she tell us, until after the fact, about the day she felt numbness in her left arm and hand. She thought she might be having a TIA—a transient ischemic attack—or “mini stroke.” (After 25 years of volunteering at Toronto’s Aphasia Centre she was well versed in the symptoms of stroke.) Living on her own since our father’s death seven years before, and being a practical person who wouldn’t want to put anyone else out, she drove herself to her doctor to get checked out. The doctor arranged for her to have tests at the local hospital later that day. Mom then drove herself home. Thankfully she made it safely both ways, though I believe another dent was added to the car from one of the inconveniently placed concrete columns in her parking garage.

While my oldest sister Nancy accompanied Mom to the hospital for the tests, the rest of us awaited the results at home: Lynne in Toronto, Kathryn in Casselman, and I in the Madawaska Valley. In the grand scheme of things, a mini-stroke didn’t seem such a bad prospect. With this diagnosis already in all of our heads, including Mom’s, none of us was prepared for what really was going on in Mom’s head…. A tumour was growing in the right side of her brain.

Installment #2: “It’s my life”

Mom was admitted to hospital so she would be fast-tracked for an MRI that would give us more information on the tumour. Even before the results came, she was adamantly against treatment. She’d had radiation for breast cancer the year before and didn’t want to go through it again.

“I’ve had a good life,” she said.

“I think I probably have two months,” she added.

She made this statement so matter-of-factly I wondered if somewhere inside she “knew.” And hoped fervently she didn’t. It was too much to take in that our vibrant mother might be about to die: she had just had her passport renewed and had no end of travel plans, including a trip to the Yukon the next month that was going to have to be cancelled.

It didn’t look good: the MRI revealed an aggressively growing tumour already 3.7 centimetres in size. The oncologist estimated that without treatment Mom would have three months. She sent her to see a neurosurgeon.

The neurosurgeon was blunt: there was no cure. But he could give her radiation, which would extend her life by a couple of years. And he was offering it, he added, only because she was strong and healthy, and more like a 75-year old than a “moribund 85-year-old.”

Mom was still saying “no radiation,” but when she saw the look on her daughters’ faces, she asked us, “What do you want?”

To agree with the no-treatment option seemed tantamount to saying we wanted her to die. And moribund she definitely was not. So, at our gentle urging, she relented.

The only way to plan the course of radiation, said the neurosurgeon, was to do a biopsy to find out what kind of tumour it was. Mom, Lynne and Nancy trekked back down to the hospital for the pre-op appointment. And were horrified to learn what the biopsy would entail: a four- or five-centimetre incision in her skull (which would create a big flap of skin), screws in her skull to close up the wound, a possible brain bleed, and several days of recovery in the neuro-trauma unit. All this and the tumour wouldn’t even be removed; it was in too dangerous a place.

Mom flat-out refused.

“No biopsy, no radiation,” said the blunt surgeon. “It’s a package deal.”

“Fine,” replied our equally blunt mother. “I’ll enjoy the rest of the time I have.”

As sad—and shocked—as we were, we were now in complete support of her decision. As she told us many times: “It’s my life and my decision.”

Installment #3: A steroid-manic mama

After she made the decision not to have treatment, Mom was given steroids to release the pressure on the brain, medication to help her sleep, and a referral to palliative care in her home, with support from Ontario’s Community Care Access Centre. She and my father had always said “no nursing homes,” and we were all determined for her to live at home for as long as possible.

There was no way she could stay on her own. There was her increasing weakness, her risk of falls, and her failing short-term memory. Then there was that left hand of hers that had a mind of its own. She didn’t have much feeling in it, and it would flail about, knock things over, even pick things up without her realizing. She would find herself carrying around a clothes hanger or a bottle of vitamins, or holding the hand in weird positions.

Nevertheless, the morning after she was discharged from the hospital, she came into the guest room where I was just waking up and announced, “I’m fine. Go home. Good-bye.” (“Can I at least have breakfast?” I asked.)

It took her falling out of bed—that night on her own after I’d gone home (on a full stomach)—before she accepted, and we truly realized, that she needed someone with her 24/7.

We hired my friend Sandy, who had caregiving experience, to come to live with her Mondays to Fridays, and my sisters and I set up a roster of weekend stays. To fill in the time before Sandy was able start, Lynne and Kathryn each spent the better part of a week with Mom.

We had no idea how long we could care for her this way: in the back of all our minds were the doctor’s predictions of seizures, paralysis, increased weakness, incontinence. We dreaded the day these things would begin to happen.

Mom remained indomitably cheerful (at least in our presence). She basked in the company of her four daughters and her six grandchildren, and all the relatives and friends who phoned or came to visit—grateful beyond measure that the tumour had not affected her speech. And she became uncharacteristically effusive, even hugging me one day as I was leaving, and she had never been a physically demonstrative person.

In fact, she became more everything: more blunt, more bossy, more grateful, more restless. We were afraid these changes were the effects of the tumour, but Dr. Leung, the palliative care doctor who came to her home every two weeks, attributed them to “steroid-induced mania.” We thought we could live with steroid mania, since it kept Mom so upbeat.

The downside (for her caregivers) was that she woke up every morning at four a.m. raring to go.

Installment #4: Giggling is the best medicine

The four a.m. wake-up times were a caregiving challenge, to say the least. We set up a baby monitor in Mom’s room, and at any sound, the caregiver would get up instantly to make sure Mom—already in her ensuite bathroom (she wasn’t going to wait to be assisted)—wasn’t losing her balance or getting tangled up in her clothes.

She wanted to carry on as normally as possible, and her schedule, even with her decreasing strength and energy levels, was enough to exhaust any guest or caregiver. There were the exercise classes held in the condo (she sat in a chair now) and the condo’s needlework group (she no longer had the fine motor skills to knit but enjoyed the chat). There was her favourite activity, shopping, and walks in the park (she would agree only to use a cane, not a walker, and clutched her companion’s arm with her other hand). There were also walks to the mall across the street to replenish her supply of Pinot Grigio (she became very excited about her evening glass of wine that summer). There were hair appointments and condo-offered pedicures (a newly discovered luxury), and even more visitors and phone calls than usual. All this on top of home visits from occupational therapists and personal support workers and Dr. Leung and his assistant.

Despite our exhaustion, and our anxiety about her condition and worry about what was to come, those times we each came to be with Mom were enjoyable. Even fun. And often funny.

“We are a laughing family,” Mom would tell any visitor, looking with effusive steroid-manic gratitude at whichever daughter was staying with her that weekend.

Giggling is in the female Missen genes. We’ve always been able to laugh at ourselves and at anything that strikes us as absurd. And thankfully Mom’s tumour didn’t affect her sense of humour, even in the most unlikely circumstances. Such as the evening she and Lynne were watching TV, and she began to slide lower and lower on the couch, lacking the strength to stay upright. As Lynne tried to help her back up, Mom slid right to the floor. The near impossibility of getting an older, frail person up from the floor could well have been—and maybe should have been—cause for alarm, even panic. Mom and Lynne (who by then was nearly on the floor too) simply gave in to helpless giggles.

Laughing got us through that summer.

Installment #5: Mother-daughter head butting

There were some weeks when Sandy the Monday-to-Friday caregiver had other obligations, and we rearranged the schedule, with Kathryn and me often filling in (since we were both self-employed)

I was initially worried about how it would go between Mom and Kathryn: they were known to butt heads (silently but potently) over their different lifestyles and preferences.

The biggest source of their suppressed conflict was food. Kathryn had been born with severe and extensive food and environmental allergies, with reactions ranging from eczema to asthma. She (and I, though to a lesser degree) had allergies to everything from wheat and eggs to cow dairy products and peanuts—pretty much the staples of the 1960s North American diet. It was the days before the prevalence of non-wheat, non-cow-dairy alternatives, and our mother had quite a time trying to find or prepare things we could tolerate.

While my allergies lessened over the years, Kathryn’s became more severe. Several times she wound up in Emergency after having an asthma attack from unknowingly ingesting peanuts. By the time she was in her 40s and 50s, she was managing her allergies through a strict diet and herbal remedies. Any time she came to Toronto she brought her “entire kitchen” (as Mom somewhat complainingly put it) in big coolers—glass containers of curries or stir-fries she had already prepared, hummus and goat cheese and rice crackers, and mounds of vegetables like collard greens and bok choy. None of it food eaten by our mother, who had a very conventional diet that, since our father’s death, included lots of frozen prepared meals. A salad for Mom was romaine lettuce tossed with caesar dressing, not anything containing dandelion greens or arugula. And she was not going to be persuaded to eat kale, no matter how good it might be for her.

It was also true that after so many years struggling to feed the two of us during our childhood, Mom had no desire to cater to Kathryn’s adult dietary needs. “Bring your food,” she would tell Kathryn before a family gathering. This perceived unyieldingness was a secret source of hurt for her daughter, who also felt sensitive that she, and the food she ate, were always being singled out.

Kathryn had her own unyielding side. She didn’t like the air conditioning on in Mom’s condo or car. She didn’t want to watch TV (an evening ritual for Mom, who always took her dinner into the TV room). She also turned up her nose at Mom’s beloved discount stores. Before Kathryn’s first scheduled visit that summer, Mom sent Nancy to Walmart on a chocolate-bar restocking mission, and had Lynne drive her around town, buying supplies as though she were preparing for Armageddon. Why were they doing this? asked Lynne. Because, explained our mother, Kathryn wouldn’t go into places like No Frills or Walmart.

Ohhhh, this did not bode well for Kathryn’s stints as caregiver.

Installment #6: Sisterly head butting

Mom wasn’t the only one who butted heads with Kathryn.

We were only 21 months apart, and as the two middle (and allergic) sisters we’d been good pals as children. And were again in our early 20s when I moved in to the three-storey rowhouse she shared with two friends in Toronto’s Kensington Market area. We became famous for our “Missenterpretive dancing,” acting out the lyrics to songs like “Be My Baby” and “Da Do Ron” in the living room.

It was after she got married that our relationship became uneasy: she seemed to feel some resentment toward me (during years when she was, I found out much later, deeply unhappy in herself). In later decades she became nothing but open and welcoming to me, but by then I had found it hard to deal with her unyielding side and her need to be “right.” Especially on our annual sisters’ weekends (which we extended to include Mom after Dad died). Kathryn always seemed to be the odd man out: unable, or unwilling, to go along with whatever the rest of us wanted to do—innocuous things like watching a rom com or belting out Elton John songs in the car. (She must have wondered how she’d ended up in such an incompatible family, with such terrible taste in movies and music!)

Of course the two of us were always thrown together… When I hosted a family gathering, it would invariably work out that Kathryn arrived earlier or stayed on a day or two longer than the others. When I visited Ottawa (where she lived before she moved to Casselman) it was natural to stay over at her place.

Not that it was all bad. I certainly appreciated staying with her in Ottawa. And she loved canoeing too: she she visited me, we paddled from my dock over to the marsh, where she could indulge her passion for photographing plants. We also both loved Champagne, especially Bollinger, and we had a penchant for witty repartee that would get us giggling. Those were the best times, when we were giggly “Bolly Dollies” together.

It was a tightrope walk though: I never knew when she was going to push my buttons and she never knew when I was going to say something insensitive that hurt her feelings.

If there was a silver lining in all those times she was the last to leave my place, it was the opportunity to make up for our clashes. It only happened a few times, a few precious times when our good-bye became a long embrace, and I would hear myself say, “You know under everything I love you.” She would say she knew and she loved me too. And at the articulation of such rarely (in our family) spoken sentiments, tears would spill, leaving a damp patch in the shoulder of each other’s sweater.

I also knew, even as I bucked at it, that there was a reason we were thrown together so much: what you resist is often the thing that has the most to teach you. Kathryn, I knew, just might be holding up a mirror to my own inflexibility and intolerance. Darn it all, anyway!

Installment #7: A caring caregiver

At the end of Kathryn’s first week with Mom that summer, I came down on the Friday to do the weekend care and to overlap with Sandy, who was to start the following week. Kathryn was going to stay one more night. Secretly I hoped she wouldn’t linger too long on Saturday. I also worried about what atmosphere I would be walking into in the condo.

To my relief there was no obvious, or even less obvious, tension. On the contrary. The next morning I walked in to Mom’s bedroom to find her seated in a chair and Kathryn on her knees, holding out a pant leg for Mom’s foot. I was surprised: it was early days yet, and although Mom had trouble with things like buttons she could still dress herself, and I thought she should do so as long as she could. (Though, I asked myself later, to what end? Why not simply make things easier for her, as my sister was doing?) I watched as Kathryn tugged socks onto Mom’s feet. My biggest surprise was how patient and gentle she was being.

Undoing it all, for me, was the proprietorial tone she adopted when relaying the results of the occupational therapist’s and doctors’ visits (though it didn’t seem to bother Mom).

After Kathryn left to drive back to Casselman, Mom confessed that she had been worried about Kathryn’s stay too, but that she had been nothing but kind and attentive the whole week. “She was great,” she said, with steroid-induced effusiveness. “We had a lovely week. She’s a nice person!”

Even as it both horrified and amused me that Mom was only now learning this about a daughter she’d known for 54 years, it also made me realize just how much the surface irritations and differences had defined their relationship. Now their intense one-on-one time seemed to be giving them the chance to really get to know—and enjoy—each other.

One of those hidden blessings of a “bad” situation.

Installment #8: Twins

Toward the end of August, I came for another near-week-long stay with Mom. One morning I overheard her tell someone on the phone that we were going to look through old photo albums. She hadn’t mentioned this to me, but it made perfect sense that she would want to relive old times. I hauled out several ancient albums, with their black-and-white photos affixed to stiff black pages.

We sat on the couch in the TV room (Mom staying upright today) and flipped through the pages and the years, from her birth in Pittsburgh in 1928 and on through her growing-up years in Hamilton as an only child. There were a good number of photos I’d never seen before, and I realized the album was one that had belonged to my grandmother, not one of our well-thumbed family albums.

I flipped a page to see Mom smiling at the camera in a party dress at age eight or nine. She had chin-length white-blonde hair, with one lock pulled up into a small pigtail at the side. I was sure I had a seen this photo before—and taken not in the 1930s but in the 1960s. I turned to Mom. “Oh my God. You look exactly like Kathryn!”

In another photo Mom, aged 10, posed with a bicycle, which reminded me of a photo of Kathryn standing in an identical position beside her new bicycle. Even the bikes—“coasters” with angled double cross-bars designed for girls and fenders on the wheels—didn’t look that different.

As adults, there had always been a resemblance between Mom and Kathryn, no surprise for a mother and daughter. Kathryn, though, had been plump for years, while Mom was tiny—the only “big” part of her a round tummy she seemed to have inherited from her mother. However, another side effect of the steroid was weight gain, and arriving for one of my visits, I was taken aback by Mom’s “moon” face, which gave her an even more startling resemblance to Kathryn. Now, on the couch weeks later, with photos from decades before in my lap, it struck me that the physical similarity between them had come full circle.

And maybe the similarities weren’t just physical.

Installment #9: “Don’t pray for me”

Soon after she got her diagnosis, Mom (in a not so sanguine moment) had asked, “Why me? Why this?” Then, in a tone layered with irony and exaggeration: “Why did God do this to me?”

I knew she was imitating those who think that when a terrible event or illness befalls them, it’s a punishment from God. Mom didn’t believe in such a vindictive God. Nor in a God who intervenes in people’s lives at all. She had, in fact, come to the point where she didn’t believe in God at all.

It was a surprise, to say the least. She had been a church-goer her whole life: she grew up in the United Church and then married, and became, an Anglican, and she and Dad took the four of us to church every Sunday. In the 1960s she started a theology group within the East York/Leaside University Women’s Club. For 50 years, she and the dozen other participants took turns presenting a monthly paper on an aspect of God or religion of their choosing. In short, our mother steeped herself in church and religious study, and I naturally assumed that made her “religious.”

It wasn’t until after Dad died (and she returned to the United Church) that she became much more outspoken about her beliefs—and her growing disbeliefs. There is, she would say, no theistic God—no external entity who created and rules the universe, and who intervenes in the lives of his human creations. And the Biblical stories of Jesus, she told us emphatically, are just that—stories—and not meant to be taken literally. For Mom, Jesus was an enlightened man, not the “son” of God.

Listening to her talk about how misguided she found Christianity, I realized my own ideas had evolved in a similar way: I no longer believe in a theistic God either. To my understanding, the Divine force that animates the universe, and every creature and object within it, is Love. Drawing from various spiritual traditions, I see the Earth as the feminine aspect of the Divine, look to the natural world for nurturing, and appreciate the wisdom and gifts of all the Earth’s creatures. Mom didn’t follow Earth-based spirituality, though I knew Kathryn (who, like Mom, still went to church) did.

Despite my acceptance of Mom’s disbelief in a theistic God, it was still a shock when, her diagnosis confirmed, she admonished my sisters and me not to pray for her. “If there’s no God,” she said, with indisputable logic, “there’s no one to pray to.”

I prayed anyway. Even if it was to the God—the Divine essence—in Mom. I didn’t pray for her to be healed: that was none of my business. Maybe her time had come (as much as I didn’t want it to). I prayed that the rest of her days, however many there were to be, would be as pain-free and joy-filled as possible. That her decline would not be prolonged. And that her soul would pass easily into the next realm she was no longer sure existed.

Installment #10: Another surprising churchgoer

Given Mom’s rejection of the essential tenets of Christianity, I found it surprising she still went to church (even the relatively liberal United Church). It was an oddity she shared with Kathryn, the only other remaining churchgoer in our family.

Of the four of us, Kathryn had been the rebellious one, bucking against our parents’ strict rules and conservative attitudes. Curiously, her rebellions didn’t extend to weekly church attendance. On the contrary, as a teenager she became the most devout of us all. If there was any religious rebellion, it was against the bare-bones style of worship in our “low” Anglican church. During university, she sang in the choir of a “high” (Anglo-Catholic) church, loving the ceremony and ritual, the bells and incense, the liturgy set to music.

After her marriage (to an Anglican priest) ended in the 1990s, she joined an Anglo-Catholic church in Ottawa and sang in its very accomplished choir. Around the same time, she began to embrace other spiritual traditions and practices, including rituals honouring the Goddess. Like me, she was attentive to the wisdom and nurturing of the Earth. And she gathered with friends to celebrate the solstices. She also followed the step-by-step journey to personal transformation and wholeness laid out by the Pathwork community in Ottawa.

Aspects of her journey outside the Church might well have been considered “heretical,” and her embracing the feminine aspect of the Divine, as manifested in the Goddess and the Earth, was definitely antithetical to the Christian doctrine of the Trinity, that God exists in three persons: Father, Son and Holy Spirit (with nary a female family member among them).

So it did seem odd that, like Mom, Kathryn continued to go to church. For years the rest of us assumed it was solely for the music: singing was her passion.

Not that her involvement was confined to the choir: she took care of the church gardens, produced the monthly newsletter, photographed parish events, and looked out for older members of the congregation.

I might have explained it as enjoyment of community—which was Mom’s reason for her own continuing church attendence­—except that, as we were surprised to find out, Kathryn took communion. (It would have been easy for her to discreetly abstain: the choir sang hidden away in the loft behind the congregation.) Participating in such a central ritual seemed to indicate an acceptance of essential Christian doctrine, and I wasn’t sure how she reconciled that with her other (to my mind more expansive) spiritual beliefs.

Unlike Mom and Kathryn, who seemed to revel in theological debates, Kathryn and I didn’t talk much about our respective spiritual journeys, though we were definitely aware of similarities in our approaches, including the conviction that we are here to grow and heal. And I felt those similarities extended to our view of the afterlife. My sense was that my sister and I had a shared, if unspoken, understanding that after our earthly body dies the soul, our essence, make its way to the Light—to the Divine source of our being—and continues its journey to learn and grow and love in the spiritual realm.

Installment #11: A new Trinity

It was a hot afternoon, and Mom and I were plodding along Lawrence Avenue to the bank, her one hand clutching my forearm, the other holding her cane. We were both concentrating on her keeping her balance. And having a conversation about the Trinity. (Naturally!) It would have been Mom who brought it up, to poo-poo the idea of a multi-personed (or even single-personed), male-centric theistic God.

We came to a red light, and Mom announced that she had a new Trinity. Standing at the corner, as if she were a diminutive itinerant preacher, she proclaimed: “God is Love. Jesus was filled with Love. And you can be too.”

I loved this Trinity! And was surprised I’d never heard it quoted before. It sounded like the wisdom of an evolved spiritual teacher. As the light turned green, I turned to Mom. “Who said that?”

She was indignant. “I did.”

If I was worrying about how Mom’s doubts might affect her transition to the spiritual plane after she died (and I’m not sure I was), that would have been the moment I stopped. Whatever she believed or didn’t believe didn’t matter. She “got” it: why we’re here.

And not only did she “get” it, she’d been living it for as long as I’d known her: giving of herself as a volunteer in the community and always being willing to help out a neighbour, or anyone, in need.

And now she was living the equally important other-side-of-the-giving-coin: receiving.

“I’m learning how to ask for help,” she wrote in an email to her cousin in mid-July. (Though “demand” might have been the more accurate word….)

But if she was blunt and bossy, her gratitude more than made up for it. At the end of each day, and especially the day you were leaving at the end of your stay, she thanked you, with her now characteristic steroid-induced effusiveness and heart-wrenching sincerity, for all you had done for her.

So, no, I wasn’t worried about Mom dying. And, anyway, I was too busy helping her live. She was, even more than usual, making the most out of every moment. And wearing out her happy-to-be-worn-out caregivers.

Installment #12: A Mother’s nurturing

I sat on the dock, checking things off my list of gear for Algonquin. It was Labour Day Monday, and I seemed to have been packing ever since Friday, when I’d got back from my week in Toronto. Mom still wasn’t sleeping much, in spite of the sleeping pill she took every night (and so neither was I). And her gross and fine motor skills were becoming more impaired. She definitely needed help now with dressing and cutting up her food. And she could no longer get out of a sitting position by herself unless it was from a chair with arms so she could, as she put it, “launch” herself. Tylenol was easing her headaches.

Despite her increased debilitation, she still had her caregivers on a mind-boggling schedule that began anywhere between four and six o’clock in the morning. The only concession she made to the tumour growing in her brain was to rest a little longer between outings and visitors.

Needless to say, I had arrived home depleted. It wasn’t just from the physical and emotional energy I (happily) expended in helping her. I live in the bushlands of central Ontario, where a walk in the woods with my energetic akita/Australian shepherd Maddy or an evening paddle on the river out my door rejuvenates me daily. It’s been decades since I’ve lived in a city, and even though Toronto is surprisingly  green amid the concrete, I still feel out of my natural—and nurturing—environment when I’m there. The closest I could come to experiencing it at Mom’s was in the park across the street from her condo. That week we had taken walks together (Mom at last consenting to use the walker), and I also went on my own while she was at her exercise class or needlework group, where I knew she would be well looked after for an hour.

That week, instead of striding along at my usual pace, I found myself pausing on the path to watch a raven in a tree (it seemed too big for a crow, but a raven in Toronto?) or to peer up at the sky at a hawk circling in the thermals. I would catch myself gazing at a solitary pine tree growing in the field beside the path. It wasn’t like me to stand around on a walk. Without consciously intending to, I was drinking in all the revitalizing reminders of home.

Now at home, even basking in the sun on the dock wasn’t enough. To truly replenish my emotional, physical and mental energy, I needed to be in a canoe in the Algonquin Park interior, where I could receive nurturing from my Earth Mother so I could go back to help my earthly mother.

Installment #13: Rejuvenating on Jubilee

The day after Labour Day, I loaded gear and dog into the car, put the canoe on top, and made the three-hour drive to the other side of the park.

Algonquin Provincial Park is my home away from home: I’ve been doing canoe trips in the interior since the late 1980s, and (since the late 1990s) most on my own. Having just seen for myself how (relatively) well Mom was doing, and been reassured by Dr. Leung’s assessments, it felt safe to go out of communication range for a few days.

I stopped at the park office to get my permit, and bumped over the ruts in the 25-kilometre dirt road that leads to the put-in. The plan was to paddle and portage several lakes in to one of my favourites, Jubilee, rather than do an actual trip. Maddy and I would do day trips from one campsite instead.

We made good time, arriving on Jubilee by mid-afternoon. In another hour I had camp set up. After an early supper, I took a book down to the shore. As soon as I leaned back in the legless camping seat, my 53-pound dog padded over and plunked herself in my lap. This was not usual behaviour: Maddy usually demonstrates such affection only if another dog is vying for my attention. I told myself she probably needed extra reassurance after all our separations this summer, and wrapped my arms around her furry body for a snuggle.

The next morning, when I sat down again on the rock with my bowl of granola, she did the same thing. It was odd but not unwelcome behaviour.

We spent the day in the canoe exploring several lakes nearby, all linked by reasonably short (if muddy) portages, and arrived back on Jubilee nicely tuckered out from our seven-hour expedition. My idea of rejuvenation isn’t necessarily to rest.

Installment #14: Circling beavers

My bladder woke me at 4:30 a.m. but I was reluctant to leave my cozy sleeping bag. As always now when I was awake in the night I wondered if Mom was up too, with Sandy stumbling groggily after her. It was Thursday: there would be fitness class, though not quite this early. I drifted back to sleep.

When I finally braved the morning chill, several hours later, Maddy followed me everywhere—around the campsite, into the woods for kindling, and even up the short trail to the biffy. (She normally draws the line at accompanying me to the boxed toilet.)

After breakfast, I settled on the sloped smooth rock near the shore with my journal and a novel: today I was going to rest.

As soon as I sat down, Maddy parked her bum in my lap once again. Throughout the day, as I journaled or took a break to read, I would suddenly feel her firm little body press into me and turn to see her sitting or lying right behind or beside me. Whatever her reason for this new behaviour—new after nearly six years together—I basked in the furry physical contact.

I was already caught up on my chronicles about my last visit to Mom. Instead I wrote about the previous day’s expedition and the few creatures we’d sighted so far: two loon families on two different lakes and, last night, a beaver whose presence Maddy alerted me to with her barking.

I was describing the way the beaver swam back and forth in front of the campsite, spiralling a little closer in to shore each time, when the sudden whine of a plane stopped me mid-sentence.

I nearly wrote, “Shit, there’s the plane.”

Instead I scrambled to my feet, heart pounding. Knowing even before it appeared just above the trees on the east side of the lake that it was going to be the park’s golden-yellow Turbo Beaver, and that it was going to land on the lake. I knew this even though four o’clock is not the normal time for the park plane to fly in to a lake unless to pick up rangers doing campsite maintenance (and I knew there weren’t any on Jubilee).

I watched the plane circle the little lake. And knew, with terrible, heart-pounding certainty, that it was here for with bad news for me.

Installment #15: A mission of mercy

The Beaver landed in a whoosh of waves and engine roar just beyond where the other beaver had glided back and forth in front of my site the previous evening.

From the shore, I watched the pilot climb down onto one of the pontoons and lower something into the water. He wasn’t paying any attention to me, and my heart rate slowed. Ok, maybe the plane wasn’t here to tell me Mom had died. Maybe the pilot was taking water samples or something.

Then two uniformed figures appeared on the other pontoon. They unlashed a canoe I hadn’t even noticed and launched it into the water. One swung a rucksack into the boat, and they got in. My heart returned to normal. Ok, they had a pack. They must be coming in to do campsite maintenance after all. Except they were wearing warden uniforms. Permit checks then.

I was now completely convinced their arrival had nothing to do with me, and even when the wardens headed straight for my site, I remained calm. Grabbing the bow to steady the boat as they pushed onto the marshy shore, I was even smiling. “Are you here to check my camping permit?”

The bowsman climbed out of the boat. He was young, somewhere in his 20s. “No, we’re here to deliver a message. Are you Brenda?”

My heart began to pound again. “Is it my Mom?”

“No, it’s your sister Kathryn,” he said. “She died.”

Kathryn?” I could not take it in.

“It’s not supposed to be Kathryn,” I added stupidly. “It’s supposed to be my Mom.” And I heard strange hiccupy sobs come out of me.

They didn’t have much information, just that it had been sudden. “We’re here to help you,” the bowsman said. “Whatever you need. We can fly you out.”

He led me over to the flat rock and sat down beside me to give me time to calm the tearless choking sobs. Maddy, I noticed, had positioned herself between his legs, and I remember thinking she was supposed to be comforting me.

After a few minutes, he brought out the contents of the rucksack: a satellite phone. Then he handed me a small piece of paper on which someone had written in tiny neat handwriting a list of familiar names and phone numbers.

Installment #16: A bubble of grief

The warden pointed to Sandy’s name, printed beside my mother’s number. I thought he must be assuming she was one of my sisters, whose cell numbers were below, but I followed his suggestion anyway. In addition to needing to know what had happened to Kathryn, I needed to know if Mom was alright. (How could she be alright?)

From Sandy I learned that they didn’t know for sure yet how Kathryn had died, but that the police had found her in her home. That Nancy and Lynne had come over that morning with their husbands to give Mom the news and sat with her for an hour. That all Mom could say was “Oh!” in a small voice, over and over. Then my sisters had flown to Ottawa to be with our niece, Kathryn’s daughter Harriet. They were so torn, said Sandy, between wanting to go to Harriet and wanting to stay with Mom.

After they left, Sandy continued Lynne’s efforts to figure out how to get word to me, and me out of the park, as quickly as possible.

I told her I would be there as soon as I could, and we ended the call. I was starting to shake, from the shock and the sudden coolness of the damp late-afternoon air.

The two wardens packed up my kitchen while I did the tent and personal gear. We paddled my boat out to the float plane, and they strapped it onto the pontoon and left theirs anchored in the middle of the lake for passersby to wonder at until they could come back for it. The pilot, with awkward condolences to me, lifted Maddy inside, and one of the wardens kept her reassured for the four minutes it took us to fly the distance it had taken me nearly four hours to paddle.

Approaching the dock at the far end of Rain Lake, we flew over the heads of tiny canoeists, who raised their paddles to us in greeting. We taxied to the dock, and several people at the campground rushed over to see the plane.

The two wardens carried the packs to my car and put the canoe on the roof for me. Tying it down, I was aware of the animated chat between the campers and the pilot, and felt in a strange, almost soundless bubble: set apart from the excitement the park plane always creates by the shock of unbearable news (of which the campers and canoeists had no inkling) that had brought it out today.

The rangers seemed willing to drive me all the way home if necessary, but I felt okay to drive and knew the three or four hours on the road would give me time to absorb my sister’s death. I thanked them from my heart for their compassion and assistance, told them it could not have been easy to deliver such news, and drove slowly down the long dirt road.

Installment #17: Beyond the veil of illusion

I drove in second gear, worrying about what had happened to Kathryn, praying she hadn’t suffered and was making her way to the Light. And trying not to crush the dragonflies…

Thousands of them. The big ones, with their baby-finger length wings. On the road, in the air, all around the car. I nosed through the throng, and more rose off the road, zooming and zigzagging and hovering: a strangely exuberant escort for a tear-blinded woman in a single-vehicle cortege. Whose progress, as slow as it was, put their own lives in danger.

And it wasn’t just a small pocket. They ranged over miles and miles of the dirt road. I had never experienced anything like it.

I made the slow journey in a cauldron of emotion: shock, disbelief, grief, worry, joy (in spite of everything) at the dragonflies. And guilt.

Guilt that I had not been nicer to my sister. Guilt that I had been so hard on her. Guilt that the last time I had seen her—when we had overlapped at Mom’s the previous month—I couldn’t wait for her to leave…

The memory of those few loving moments­ when we had shared an embrace on parting, and actually spoken our love, eased the guilt. A little.

But the real solace came from the dragonflies.

In some Indigenous spiritual traditions, Dragonfly is a symbol of transformation and light. With its incredible, nearly 360-degree vision, Dragonfly can help you see beyond life’s illusions. So now, in a slow-moving bubble of grief and guilt, surrounded by more dragonflies than I had ever seen (at one time, or ever) in my life, I asked for the veil of illusion to be lifted.

I asked, and in that moment everything fell away—all the clashes and hurts and upsets between Kathryn and me. The veil was lifted, and all that was left was Love, pouring between us. I saw my sister’s beautiful, joyful spirit, as I had never seen it. And, even more astonishing: she was smiling, serene. Happy.

That astonishing, beautiful, joyful spirit that was my sister accompanied me down the long dirt road amid—and possibly within—the helicopter-hovering escort of healing dragonflies. And stayed with me, even after the last few lifted into the air away from the car and vanished.

Installment #18: 911 (x 2) 

I sped for home on the ever-darkening highway, weeping, and worrying about how Kathryn had died. But each time a dark thought came, so did her smiling face. I wondered if it was my own wishful thinking. Except I knew I could never have imagined her so serene and joyful, especially not in my current state of turmoil.

At home I called my sisters at my niece’s in Ottawa. They had arrived to find Harriet surrounded by friends, with more coming throughout the day and evening. Now they retreated with Harriet to her bedroom to fill me in on what they had learned from the Ontario Provincial Police the previous night and the coroner that afternoon. Which was:

Earlier on the Wednesday (the day I was exploring lakes near Jubilee), concerned neighbours called 911. Kathryn was always coming and going, but for two days her car sat in the driveway—and her laundry stayed on the line and her house windows open, even in the rain. The OPP arrived to find her lying dead in her home office, the phone receiver on the floor beside her. The last number dialled was 911.

The OPP sergeant who reached Harriet told her that previous 911 call had been placed more than 48 hours before, on Labour Day (while I was packing for Algonquin). The dispatcher couldn’t hear anyone on the line, and the phone company reported that it was a faulty line, so no emergency responders were sent. (As appalling as these details were, we would later find out that some of this information was inaccurate and that there was much more—catastrophically more—to the 911 chain of events.) Although an autopsy had yet to be performed, the coroner suspected that cause of death was an asthma attack or anaphylaxis.

There were no words to comfort my niece. I couldn’t even say I was on my way. My sisters and I were torn, but felt we had to get back to Mom, who, from Sandy’s reports, was not doing well. Seeing all the support around Harriet, and hearing that her closest friends from grade school were on their way (and would stay as long as Harriet needed them)—and hearing, as well, that her father, Kathryn’s former husband, was going to take care of all the funeral arrangements—made us feel a little less terrible about abandoning our niece at such a horrendous time.

Installment #19: My happy sister

In bed in the dark after the call, I couldn’t stop the images: Kathryn alone and struggling to breathe. Kathryn calling 911 and unable to speak. Kathryn lying dead for two days before anyone knew. (Although our family was in regular email contact, especially that summer, it wasn’t unusual for several days to go by without hearing from one another. And Harriet had seen her Mum just the day before at their usual Sunday brunch together.)

But, as in the car, each time a disturbing image came, it was superseded by Kathryn’s smiling, serene face. Her serenity reminded me of the last time the five of us had been together—at our annual Girls’ Weekend, back in June, just three weeks before Mom’s tumour diagnosis. For many years I had hosted the weekend in my small winterized cottage. This was our second year in a rented cottage in Prince Edward County on Lake Ontario.

Five female family members sharing the confined space—and bedrooms­—of a small cottage… Well, there were bound to be a few fraught moments and irritations. But our enjoyment of each other far outweighed those minor moments, and this year we bravely added a third night.

And… it was our best Girls’ Weekend ever. We toured around the lower part of the peninsula, visited a winery or two, and showed Mom the dunes at Sandbanks Provincial Park (where if she seemed a bit unsteady on her feet we put it down to the difficulty of walking on sand). We dined out, and cooked meals at the cottage, and relaxed with our books and conversation in the living room or in the yard overlooking the bay. On Saturday we entertained Mom’s closest cousin (and travel partner) to lunch, along with a couple who were among our parents’ oldest friends. And we were blessed with a rare (for us) and delightful visit from a couple of trumpeter swans who dipped and bobbed and glided around in the bay right in front of the cottage.

The memory of this especially harmonious weekend together, captured in lovely photographs by Kathryn, was, and is, now a source of great comfort for Nancy, Lynne and me. (In addition to a fabulous photo of the five of us on the self-timer—see the photo on my home page above the Beyond Blame column—Kathryn had also taken an eerily prescient one of her three sisters, the three who remain.)

That weekend, Kathryn was particularly mellow and laid-back. She seemed to have come to a new place of contentment and ease in herself. (Which was apparent during her subsequent stints of caring for Mom.)

Now, lying awake, I realized that even as I was praying for my sister to make her way to the Light, I had no doubt of her ability. And if the effortlessness with which she kept appearing to me—and appearing so happy—were any indication, she was having an easy transition. I would try to keep my focus on that.

Finally, I slept. And got up three hours later to repack for Toronto. And Mom.

Installment #20: The blessing of sedation

I arrived at Mom’s before noon. The condo, usually filled with sunlight, and Mom’s light, was unnaturally dark and quiet. Nancy and Lynne, who had caught an early flight back from Ottawa, met me at the door, with Sandy. We shared a teary group embrace.

I peeked in Mom’s bedroom. The drapes were drawn, and in the gloom I saw her small form in the king-size bed, a fortress of blankets piled around her so she wouldn’t fall out. Her breathing was rapid and shallow and audible: the breathing, Sandy explained, of heavy sedation.

We retreated to the kitchen with the baby monitor, and over the sound of Mom’s breathing, the others filled me in on the previous day.

On their way to catch their flight to Ottawa, Nancy and Lynne had arranged for my niece Meaghan, Nancy’s older daughter, to go over to sit with her grandmother—who didn’t move from the couch all day, and who barely spoke or responded to anything said to her. When she finally stood up to go to bed, she was so weak she didn’t demur when Sandy brought the walker (which she normally refused to use inside). And she was so afraid of falling that Sandy—greatly alarmed at this sudden, and dramatic, decline in her charge—walked closely behind her, guiding the walker.

Mom couldn’t get herself on the bed. Sandy, struggling to keep her from sliding to the floor, finally just picked up our tiny mother and put her in.

Mom was so weak Sandy didn’t think she could manage and wasn’t comfortable staying the night on her own. With Meaghan unable to stay, a close friend of Nancy’s came over.

In the middle of the night, Mom became extremely agitated. Sandy phoned the on-call doctor, who arrived with a sedative. Discovering Mom had a fever, the doctor arranged for her to be admitted to hospital, temporarily, for tests. The patient transfer service was to come for her this afternoon.

Now Sandy looked exhausted. And sad. Convinced she was never going to see Mom again. I found myself assuring her she would. My sisters and I had no thought that Mom’s death might be imminent. Though we did wonder if it were going to be beyond Sandy’s and our capabilities to continue to look after her at home.

Sandy left, and while we waited for the transfer service, Nancy and I crawled into the pullout couch, which had been made up for her friend. When we woke up, an hour later, we found Lynne dozing on the bed beside Mom. Who—mercifully—slept on.

Installment #21: The blessing of a coma

Mom didn’t wake up when the transfer service attendants arrived to take her to the hospital, or when she was moved to a bed in the palliative care unit (which, despite its name, looked as unappealingly clinical as the oncology unit Mom had been in before). Nor did she wake up when the nurse came in to check her vitals and put her on oxygen. We were amazed a sedative could last so long.

It was Mom’s own palliative care physician, Dr. Leung, arriving not long after, who explained that the sedative had long worn off: Mom was in a coma.

When he walked in the room, his first words were for us. “When I heard the news about Kathryn my jaw dropped, so I can’t even imagine how you are feeling. I’m so sorry.”

At his sympathy, the three of us instantly teared up (the Missen women share tear ducts as well as a funny bone). “Please don’t be nice to us,” we told him, which made us laugh through our tears.

Dr. Leung turned to the bed then, and was clearly shocked by Mom’s decline. The last time he’d seen her, just two weeks before, she had been full of life and optimism and laughter and jokes. (She’d been this way even two days before: when Nancy and Lynne and their husbands arrived to give her the news, she was dressed for her exercise class and about to go out the door.) Now she lay in a coma, with a high temperature and an oxygen mask helping her breathe.

We brought chairs into the room to talk tests with Dr. Leung. Who was very patient as we quizzed him on the necessity of each of his suggestions for probing the progress of the tumour, and readily accepted our decision of only blood work to determine the source of the infection. Mom had been so firm on her wishes for no invasive treatment or tests I could hear her instructions, loud and clear!

We were anxious to get her back home as soon as possible (knowing how much she would have objected to being in hospital), and were vastly relieved when Dr. Leung said he would arrange for a hospital bed to be delivered to the condo, and for additional nursing care—likely after the weekend.

He didn’t think it would be too long now before she died, perhaps a week. And felt, as we did, that the news of Kathryn’s death had very likely caused her sudden decline. Under the circumstances, we were all in agreement that it was a blessing: it would be hell for her to wake up now and have to process and deal with her daughter’s death. Not to mention endure the more debilitating effects of the tumour.

Dr. Leung stood by her bedside again, and when he turned back there were tears in his eyes.

Installment #22: The blessing of a brother-in-law

I curled up as comfortably as I could in the recliner chair at the foot of Mom’s bed. In the dark, I could hear her breathing: shallow and rapid, but steady on. I doubted I would sleep, but that didn’t matter.

The fact that I could be here in the hospital overnight, and that the three of us could give our full attention to Mom right now, was a blessing. The blessing of a brother-in-law. (Although David hadn’t technically been our brother-in-law for the last 15 years, my sisters and I still thought of him as a member of the family.) It was thanks to David, and his generous offer to take care of all the funeral arrangements for Kathryn, that we were able to be here wholly for Mom. He had called earlier in the evening to let us know he had everything in hand. And his were eminently capable hands. As an Anglican priest, he was well versed in navigating the funeral system and personally knew the funeral directors, as well as the priest at Kathryn’s church. He knew she would want a full requiem mass. And after 15 years of married life together, he knew a good number of her friends: he was putting out the word. The funeral was to be held in a week’s time: Saturday the 13th.

David was also there for Harriet. This was no surprise—they had always been close. Still, his fatherly support eased my mind more than anything else. Arriving in Toronto, I had continued to feel conflicted about being there and not in Ottawa with my niece, especially when Mom seemed to be in a stable, if sedated, state. It was while sitting with Dr. Leung that afternoon, hearing that she was in a coma now and having our extensive conversation about the next steps for her, that I realized I was exactly where I was supposed to be. And David’s subsequent phone call reassured me even more: he would be with Harriet when she went to view her mother’s body and would help her pick out an urn.

I shook my head, trying to take it all in. Everything felt totally bizarre and out of kilter. Nevertheless, inside me sat an odd, quiet certainty that a perfect plan was in place.

Installment #23: A midnight revelation

I woke sometime after midnight, surprised I had actually slept and needing to pee.

Easing my body out of its cramped position in the recliner, I tiptoed past Mom, though there was no fear of waking her: she breathed on, in her light, steady, comatose way.

In the corridor, I paused to let my eyes adjust to the too-bright light before making my way to the visitor’s bathroom.

Not for the first time since I’d been flown out of the park (not too much more than a day ago though it felt like weeks), my thoughts went to the uncannily identical childhood photos of my 85-year-old mother, who was dying, and my 54-year-old sister, who had just died.

I was washing my hands in the bathroom sink when it came to me. Came in that barely awake state where my thoughts seem to originate from a pure source of truth, untainted by the biases and interpretations of my fully awake brain.

What came was that the connection between Kathryn and Mom went far beyond being “twins” in looks and personality: it extended to their very souls. If they were somehow connected on the soul level, it was logical that they would have to die around the same time.

Staring in the mirror, absorbing this revelation (which explained so much about their similarities and the ways they had challenged each other throughout their lives), something else struck me: Kathryn needed—or had chosen—to go first. Mom’s doubts about whether anything exists after death might well impede her transition to the Light. Kathryn was going to be there to assist.

In that moment, peace about my sister’s death settled in my heart.

Turning out the light, I had a sudden vision of her having a good laugh at giving me these insights while I was in the bathroom for a midnight pee.


The revelation that came to me that Friday night in the hospital wasn’t that crazy kind of middle-of-the-night thought you immediately dismiss in the light of day. It might have been crazy, but even in the light of day it felt right. If my mother and my sister were connected on the soul level, their lives would have to end at the same time. And that meant that Kathryn, even though she was so much younger (“too” young our society would say) had completed her life too­. And… was not meant to be saved.

I’m aware that writing this way can lead to serious misinterpretation, and want to stress that the view I hold about my mother and my sister (which is not necessarily shared by my family) in no way excuses the emergency response system for failing Kathryn. This was another matter entirely, and one we would be dealing with soon enough.

The reality is I hold in my head two paradoxical—perhaps even contradictory—positions. One is that everything happened the way it was meant to happen. The other (which is shared by all my family) is that the failures of the emergency response system are inexcusable, and that there needs to be a thorough examination of the system and its weaknesses, with recommendations made—and implemented—to fix the problems. This is what my sisters and my niece and I are looking for in the upcoming inquest—which we fought for nearly two years to get.

Installment #24: Whose obit are we writing?

Early in the morning—Saturday now—the nurse came in to check on Mom. From where I was still groggily curled up in the reclining chair, I mentioned the arrangements that Dr. Leung was making to get her back home after the weekend.

“I hate to tell you,” she said, in that gentle but firm way nurses often have, “but your mom won’t be going home. We would never send her home in this state.”

Her words dismayed me, and I didn’t believe her: Dr. Leung hadn’t expressed any doubts, and he had seen her in this same state. But I said nothing.

Lynne and Nancy arrived with a breakfast sandwich for me. And then the on-call doctor arrived with the test results (there was a serious infection somewhere), and confirmed that they really couldn’t send Mom home, mostly because she was on very high levels of oxygen that they couldn’t supply in her home.

It was Melissa, the marvelous social worker, who alleviated our guilt and regret that Mom couldn’t be at home, where we knew she would want to be. At this point, said Melissa, it would be very stressful for us to provide care at home, whereas here in the hospital, the doctors and nurses were right there when needed. And Mom, she added, wasn’t aware of where she was (though secretly I suspected she was): “The main thing for your Mom right now,” said Melissa, “is to have you with her.”

She was right. At home, we would have been in a state of constant anxiety about possible seizures or debilitating pain and whether we could manage or get help when we needed it or know what to do. Here, we could just be with Mom.

Though our attention that morning was somewhat divided. There was one thing David had asked us to do for Kathryn’s funeral. And so now the three of us sat down around Mom’s bed and I opened my laptop.

It was surreal to be writing our sister’s obituary while we kept vigil beside our dying mother. More than once I had to stop, momentarily confused about whose obit I was drafting.

Installment #25: A swoop of starlings

Mom gently snored on, in a peaceful way, so in the early afternoon Lynne left to get her teenage daughter Julia, who was asking to see her grandmother. And I drove back to Mom’s condo to change my clothes and freshen up.

At Mom’s I took my time. I had a shower, and scrounged something to eat. Her bedroom was still gloomily dark, and had that sickroom smell. I opened the drapes and blinds and windows, and pulled the sheets off the bed and carried them to the laundry room.

I was about to start the washing machine when a voice nearly shouted in my head: What are you doing here? Get back to the hospital. You need to be with Mom. What if she died and you weren’t with her because you were doing laundry?

Quickly I gathered my things. I was almost out the door when the phone rang. I ran to the kitchen. It was Nancy, calling from the hospital.

“I think you should get back here. There have been some changes.”

The 15-minute drive felt like 50. I prayed (definitely to Mom this time) to please hold on until I got there. I knew I would never forgive myself if I missed being with her in the moment of her death because I was doing domestic chores (the importance of which she had, ironically, instilled in me).

I was about to turn in to the parking lot when a huge flock of starlings swooped out of the trees in front of the hospital. In unison, they whirled and turned, hundreds of them, maybe thousands, in one fluid, undulating motion, as if they were one entity. An astonishing feat of unified swirling flight I have since learned is called a murmuration. The dark, ever-shifting cloud swarmed across the road, above and ahead of my car, and disappeared over the buildings and trees on the other side of the road. I couldn’t help but wonder if I was witnessing my mother’s soul soaring away.

And prayed I wasn’t.

Installment #26: A murmuration for Mom

I rushed down the hall and into the hospital room, to find Nancy, Lynne and my niece Julia gathered around Mom. They assured me I wasn’t too late and shifted to make room for me on the bed.

I sat on the edge, expecting to hear the same intermittent, peaceful breathing we had experienced in our father in his dying moments: a brief intake of breath, a slow exhale and an ever-longer pause before the next breath.

Mom was not peaceful. Her head and body were vibrating, and through the oxygen mask, she was repeating, “Ba ba ba ba,” over and over.

“We thought she was trying to say your name,” said Nancy, eyes brimming with tears.

I took Mom’s hands. “I’m here, Mom. We’re all here. It’s okay to let go. Kathryn is waiting for you. And Dad. And your Mom.”

But Mom wasn’t letting go. She was having a seizure.

It took three doses of anti-seizure medication, administered five minutes apart by the nurse, for her to become calm again. The on-call doctor assured us it was much harder for us to witness the seizure than for Mom to have it: she was not, he said, in any discomfort.

It won’t be long now, he added.

Lynne made the decision to stay overnight after taking her daughter home. But Julia, understandably, didn’t want to leave. So the four of us took turns getting something to eat in the cafeteria.

It was when we were all back in the room, around 6:30 in the evening, that Mom’s breathing became more intermittent. Her colour looked greyer. We gathered around her, holding her hands and each other. Through tears, we told her we loved her and it was time to let go. We told her Kathryn was waiting for her.

We sat with her, watching and listening as the pauses between her breaths grew longer. The oxygen mask looked so uncomfortable we wanted to remove it but didn’t want to cause discomfort.

As the light from the window began to wane, she breathed out one last time. And then we gently removed the mask she no longer needed.

She didn’t look at all like Mom, this grey, puffy-faced old lady who lay, so still now, in the hospital bed. It was easier to let this stranger go. She wasn’t Mom. It crossed my mind that maybe her soul had already left before her body’s death, the way people who have had a near-death experience report having found themselves above their body and not experiencing any of the trauma or pain. (I hoped this was the case for Kathryn, hoped dearly that her soul had left her body before the worst of her struggles to breathe.)

Driving out of the hospital parking lot for the last time, I remembered the starlings. I like to think Kathryn’s soul arrived in that graceful, undulating murmuration and swept Mom’s soul away with her into the eternal expansiveness of Light and Love that is beyond life, and death, and earthly time itself.

Installment #27: Shifting gears

Between Saturday evening, when we got back to Mom’s condo from the hospital (and raised a glass of Mom’s favourite Pinot Grigio in her honour), and Tuesday afternoon, when I drove home to spend 48 hours with my pooch, the three of us made all of the funeral arrangements. We called Mom’s closest friends and relatives, met with the funeral director, talked to Mom’s minister to choose a date (five days after Kathryn’s), picked out flowers and an urn, and wrote Mom’s obituary. (We were getting to be old hands at obit writing…)

The time and energy all this took made us appreciate even more all that David was doing for Kathryn. It made us appreciate each other even more too: we couldn’t fathom getting through without each other. Our shared tear ducts and funny bone got a lot of workouts in those few days (as they would continue to do so in the weeks and months to come). Though one morning Lynne arrived at the condo teary-eyed, and when I didn’t instantly tear up too we were so taken aback we ended up laughing, somewhat ruefully, together instead.

Arriving in Ottawa on Thursday, Nancy, Lynne and I shifted our focus to Kathryn, and Harriet. We gathered for a dinner that included Nancy’s and Lynne’s families and Harriet’s father and his wife. And the next day, our family, including David, made the 40-minute drive to Kathryn’s house in Casselman.

With hollow hearts, we stepped through the front door. And took in the dismaying mess. Even for Kathryn, the Queen of Clutter, it was unusually bad: the living room filled with gear from an August camping trip, the dining room table and kitchen counters invisible under layers of dishes and stuff. The bookshelves and filing cabinets upstairs overflowing with books and sheet music. And I didn’t dare look in the basement or the garage.

Kathryn’s clutter had never bothered me before. The difference seemed to be that when she was there, animating her living space, it wasn’t as noticeable. Now, without her there, it was just a house filled with too much stuff. A house crammed so full and yet so empty…

David took the lead in suggesting a plan for determining what needed to be done to get Kathryn’s affairs in order and how (in due course) to get the house cleaned out in the least painful way. And, again, we were immeasurably grateful.

At different times during that day and a half before the funeral, Nancy, Lynne and I would remember with sudden shock that Mom had died too. Which made us realize that it simply was not possible to hold both Kathryn’s and Mom’s deaths in our minds, and hearts, at the same time. It was a necessary, unavoidable, perhaps even sanity-saving, compartmentalization. This, too, we would continue to experience in the weeks and months to come, as we settled Mom’s estate and cleaned out her condo, helped Harriet with the heart-wrenching process of choosing which of her mother’s things she wanted to keep—and pressed for an inquest.

Installment #28: Launching the official complaint

Not two hours before Mom died on Saturday, September 6, a close friend of Kathryn’s named Lisa was pushing send on an email to Harriet, her father and her three aunties. Lisa and her husband lived at that time on a farm just outside of Casselman, not far from Kathryn. They were, in fact, a big part of the reason Kathryn had chosen to move to that area several years before—not just to be close to her good friends but also to be able to buy a house, which she could not have afforded in Ottawa.

It was, understandably, a day or two before my sisters and I read Lisa’s email. When we did, it brought great relief. Lisa was writing to introduce us to her husband, Steve, who had previously been a firefighter and had considerable experience with the 911 system, as well as with legal advocacy work. Her normally sanguine husband had, she told us, been incensed by what had happened to Kathryn and was offering to be an advocate for Harriet and the family in launching an official complaint. Steve had already made contact with the coroner’s office and the inspector in charge of the OPP 911 communications centre in Smiths Falls to try to get more information. To go any further, he needed Harriet’s consent (which Harriet willingly provided).

We were incredibly grateful for this offer. We didn’t even know who was in charge of the rural 911 system or how the system worked. Steve’s presence in Casselman, his friendship with Kathryn and his relevant expertise all seemed to have come together in a weirdly, sadly, “meant to be” kind of way.

Even if we had known how to go about making the complaint ourselves, Harriet, Nancy, Lynne and I were in no state to put our mental or emotional focus there: we had two dear family members to bury.

Installment #29: A murmuration for Harriet

On a rainy Saturday, one week to the day after Mom died, my sisters and their families and I followed our niece into the front pews in the understatedly elegant Church of St. Barnabas, Apostle and Martyr in downtown Ottawa. Filing in behind us from the side were our cousins and their families and our one surviving aunt.

Entering from the side gave us an unimpeded view of the congregation, and what we saw was overwhelming: every pew was filled. David had told us there would be plenty of room, the church held 300: we learned later that chairs had to be brought in for the overflow.

I looked beyond the congregation to the loft at the back. The choir members had come back from their vacation early to be here for their faithful fellow chorister, and we learned later that their director had even cut short his holiday in Nova Scotia.

The service was a requiem mass in the Anglo-Catholic tradition Kathryn loved so much. It was, to my own, non-church-loving surprise, beautiful. And so perfectly, entirely Kathryn—from the ethereal singing that filled the church from the loft (I swear I could hear my sister’s sweet soprano among the voices) to the poetry of the prayers and the solemnity of the rituals.

The urn that held Kathryn’s ashes was also so “Kathryn”: a simple wooden box made from sustainable, biodegradable materials. It was adorned with the image of the same angel that Kathryn and David had had chiselled into the gravestone of their second daughter, Madeleine, who had died at birth: David had made the hour-plus drive to the cemetery to take an etching so the image could be burnt into the wood of the urn.

Although a eulogy is not normally part of an Anglo-Catholic (or Catholic) funeral service, David had received permission for a university friend of Kathryn’s to speak, and her poignant portrait had us both laughing and weeping in recognition. And then came the homily. So much more than a message of the hope of the resurrection (the topic of most Catholic funeral homilies), Father Murray spoke in a heartfelt and affectionate way about a parishioner he had clearly known and cared about personally, and it brought us particular comfort to hear him mention what a good summer Kathryn had told him she’d had, including wonderful visits with our mother.

The most perfectly Kathryn touch—both healthy and humorous—was the unique bouquet someone had placed beside the urn. Sitting in a simple glass vase was a bunch of green, curly kale… When we spotted it, we smiled and nudged each other, and were so touched when we later found out it had been put there by Father Murray himself, with bounty from his own garden.

After the service we made our way to the reception hall to be enveloped in the caring crush of friends and relatives, and members of the congregation we were meeting for the first time.

From that emotionally intense day, one image etched itself into my memory: Harriet surrounded by her three oldest, closest friends from high school. Wherever she walked, they moved with her, in a protective circle, as one. A spontaneously choreographed murmuration of support and love for one who had just lost the dearest person in her life.

Installment #30: The comfort of dogs and damselflies  

Into the canoe I loaded my dog, my journal, and my too-full head and heart. It was 13 days since Kathryn’s funeral, eight since Mom’s lovely but understandably smaller (and more naturally celebratory) send-off. I had been home a week, and was finally starting to get the events of the past three weeks out of my head and onto paper. Indian summer had arrived, and the prospect of writing on a rock beside the water was luring me out onto the river.

I landed the canoe on a favourite sloped granite point. Maddy jumped out to poke about, and when I settled on the rock, dozens of damselflies with needle-thin crimson bodies—petite cousins of the dragonfly—flitted around, most hovering near a vegetation-topped rock down at the shore.

My last journal entry had, appropriately enough, got just up to the slow drive out of the park through the endless cortege of dragonflies. As my pen poured out that poignant experience, one damselfly landed on my shoulder, a couple mated on my bicep, and another stared up at me from the journal page.

With great emotion, I wrote out my mixed feelings about my sister, the irritation I had often felt, all the things I had previously been too ashamed to commit to paper.

Pausing, I felt a little warm body pressing into me from behind. The pressure reminded me how Maddy had demonstrated this same kind of unusual behaviour on our Jubilee campsite. It had begun the day we’d arrived—the same day, I realized now, that Kathryn’s body had lain lifeless on her office floor.

It hit me then, the reason for all her unusual closeness: my intuitive furry friend had known. She had known and tried to comfort me. As she was doing again now.

Through the blur of tears, I recorded how Dragonfly had lifted the veil of illusion to reveal Love—only Love—pouring between my sister and me.

Maddy wandered off, but minutes later I felt her rump press into my leg.

I scribbled on, and she got up to sniff around nearby, but every time (it did seem!) I wrote Kathryn’s name she was right there, leaning into me, occasionally licking my arm. With weepy certainty I knew this wasn’t just comfort from Maddy, though that was sweet enough: this was my sister herself, bringing her own comfort and assurances. Reminding me not to get caught up in life’s illusions, not to beat myself up for our difficult relationship, but simply and utterly to know—and never forget—that the only thing between us was Love, and that she was now a free spirit—zooming joyfully among the damselflies.

My damselfly companions fortified me to write out the terrible events of her death, though we still didn’t have the full story. We were scheduled to meet the following weekend with her friend Steve (now our official family spokesperson) to get an update on the official complaint he had made to the OPP, and talk about our next steps.

Many pages and hours later I was done for the day. I closed the journal and looked around.

The crowd of damselflies was nowhere to be seen.

Installment #31: Bracing for the truth 

The first weekend in October, my sisters and I met up with Harriet and her dad in Ottawa and made the 40-minute drive to Casselman. We were going to start boxing things Harriet wanted to keep and retrieve any family heirlooms and mementos she didn’t want. David had arranged for friends to pack up everything else—which was a huge relief for our overwhelmed niece, and for Nancy, Lynne and me, who were more than occupied now with our mother’s estate.

When we arrived in Casselman we didn’t stop at Kathryn’s but drove right through town: we had been invited to Steve and Lisa’s for breakfast.

We followed their directions on rural roads bordered alternately by pale fields and burnished woods, and soon pulled into the driveway of a large red-brick farmhouse.

Steve and Lisa came out to greet us with their dogs—two friendly German shepherds that Kathryn had often come to look after (along with the cats and farm animals) while their owners were away.

Lisa took us on a tour of the beautifully renovated house. It felt odd to be seeing the home we had heard so much about from Kathryn’s emails. In every room we peeked, I half expected to find my sister curled up in a chair with a book. She’d been here, Lisa told us, sharing a meal with them, just a couple of days before she died.

It could have been—maybe should have been—an awkward, painful visit: the only reason we were here was that Kathryn never could be again. But our hosts were so warm and welcoming, and had such obvious affection for Kathryn, that it felt natural to be there, despite her absence. In a weird, surreal way, she wasn’t absent at all.

We gathered around the table in the high-ceilinged dining room for coffee and croissants and innocuous conversation. And then braced ourselves for Steve’s update.

While we had been attending to Kathryn’s and Mom’s funerals, he had been busy on our behalf: he had made the official complaint to the Office of the Independent Police Review Director (OIPRD), initiated contact with the coroner, and pressed for information and investigative action through emails and phone conversations with the managers of various OPP departments. He had made formal requests for documentation, including the police incident reports and (when they were completed) the autopsy and coroner’s reports.

The people he had spoken with were, he explained, official, credible sources high up in management who, with investigations pending, would not go on record concerning the events. Nevertheless, after weeks of persistence, Steve elicited a fuller story than we had originally been given.

A much more chilling story.

Installment #32: A terrible tale

There was no way to soften what had happened to Kathryn. Steve recited the facts in the matter-of-fact tone of someone experienced in the field. But under his professional exterior was palpable fury that made it, strangely, more bearable: we were hearing the story from someone who spoke with both authority and deep personal concern.

The OPP had originally told Harriet that when her mother called 911 there was no sound on the line, and that because the call was deemed a technical problem, no emergency personnel were dispatched to her house.

This was not the case. Far from it.

There was, Steve had learned, 11 seconds of audiotape of Kathryn wheezing and moaning and struggling to make herself understood by the 911 call-taker. (We would later find out it was nearly 44 seconds.) In spite of this clear evidence of someone in distress on the line, there was no dispatch of emergency medical services. Instead, only police were sent—and not until an inexplicable lapse of one hour and 36 minutes. And then the constable didn’t go … though in his report he said he did.

We sat in stunned silence, wiping away tears, trying to absorb this new information. The errors—and so many—were shocking. Incomprehensible.

Steve looked at Harriet, and his voice was gentle: “The coroner suspects your mum died of anaphylaxis or an asthma attack, and told me she would very likely have survived if help had arrived within minutes, the way it should have.” His voice became emphatic again. “And could have. I drove the distances from her house.” He checked them off on his fingers. “The EMS station was less than two kilometres away. The firehouse 650 metres away. And there was an on-call firefighter at his house 40 metres from Kathryn’s.”

Again, it was almost too much to take in.

“This was a complete and catastrophic breakdown of the entire system,” Steve continued. “I’m a hundred percent confident that there was a reckless breach of procedure and gross negligence with the handling of this call at the 911 call centre—which, as you know, is under the jurisdiction of the OPP.” (Until Steve enlightened us, we had no idea who has responsibility for rural Ontario’s emergency response system—and most people we’ve informally polled haven’t known either.)

Steve went on to tell us about the multiple investigations now in the works. The OIPRD, an independent agency that investigates sworn police officers, would be investigating the conduct of the officers but not the (civilian) 911 call-takers and dispatchers. That 911 investigation would be done by the OPP internally—something we all agreed was less than ideal.

The coroner’s office was conducting its own investigation. Steve had been told it would be a few more weeks before the autopsy report was complete, and a few months for the coroner’s report. He suggested we request a meeting with the regional coroner to find out if an inquest was under consideration—though none of us could conceive why it wouldn’t be, especially given the mind-boggling errors Steve had just related. (And in time we would hear of even more.)

Heads swimming, and profuse in our thanks to both Steve and Lisa, we said our goodbyes and headed back to Casselman.

At the house we let ourselves in to the chilly, empty interior. Sad, angry, dumbfounded. And resolved. We couldn’t bring Kathryn back, but we would do our best to make sure this never happened to anyone else.

Part II

Installment #33: A sleepover with Harriet 

On a Sunday afternoon in late October, Maddy and I checked into the pet-friendly Lord Elgin in downtown Ottawa. I had booked a room with two double beds after texting Harriet that Maddy was officially requesting her “cousin” to stay over with us and share her bed, and receiving Harriet’s “I officially accept!”

It was a couple of weeks since our family visit with Steve and Lisa. My original plan for this trip had been to take Harriet out to Kathryn’s house again. But her grief counsellor had told her it was way too soon, too raw, to be sorting through her mother’s things, especially given the unexpectedness of her death.

My sisters and I felt badly that we might have been pushing her. We were in “business mode” with Mom’s estate, but it wasn’t the same for Harriet at all, and we completely supported her decision to wait until spring.

After Harriet arrived at the hotel, we dined on wine and cheese on our respective beds and watched nothing much on TV. True to her official request, Maddy jumped up to be with Harriet, resting her head on her cousin’s leg.

I kept wondering if we should be “talking.”

Conversation—real sharing—doesn’t always come naturally between an auntie and niece, but Harriet and I have a bond that dates back to our annual canoe trips in Algonquin Park when she was a teenager. However, it had been many years since we’d shared confidences, and though the bond was still there, I felt shy to ask how she was doing. I let Maddy do the comforting instead.

Conversation came, in a wholly natural way, the next day, along with our burgers and fries, at the Chelsea Pub, after a chilly, damp walk in nearby Gatineau Park.

“I feel bad that I let two days go by without calling her,” said Harriet. “My phone wasn’t working, and I knew if I called from work it would rack up long-distance charges. So I didn’t call.”

“Oh sweetie, you had good reasons for not calling, and if nothing had happened you wouldn’t have thought twice about it. Truly, you make the best decision you can moment by moment, and you can’t—or shouldn’t—go back and second-guess yourself.”

“I know. But I can’t help thinking about her lying there for two days, and the way she died—her struggle to breathe.” Her voice broke.

I paused. “From all I’ve read about near-death experiences, I think your mum’s soul left her body immediately and she didn’t suffer.”

I told her about the images that kept coming to me of Kathryn’s smiling, serene face, and about the dragonflies and Dragonfly symbolism. “Your mum was so connected to the Earth, and now she’s part of everything.”

We shared a tearful smile. I hoped sharing my experiences of her mum in spirit might plant a seed for her to be open to having her own. Though I also knew that deep grief was surrounding her like a heavy cloak, and until (with time) it began to lift, nothing and no one would be able to penetrate it.

“She’s not gone, sweetie. She’s with you. And she’s always going to be with you.”

Harriet wiped away more tears. “I know.”

I looked at her with compassion. “You won’t get over it.” I paused, trying to think of the right word.

Harriet supplied it: “I’ll adapt.”

She would. She was already.

Installment #34: A walk with Harriet’s mum 

I set out on a run around the “neighbourhood” with Maddy. Today’s route was on a trail across the highway that looped back to my road.

Pausing at the crest of a hill, I glanced into the woods to an even higher ridge that was more visible now that the trees were bare. I wondered if the river, nearly a kilometre away, could be seen from the top.

Leaving the trail, I weaved my way around the trees up to the ridge top, where I could, indeed, just glimpse a ribbon of blue in the distance.

At that moment, a dragonfly flew straight at me and landed on my jacket. Right over my heart. I glanced down and realized it wasn’t technically a dragonfly but its much smaller cousin—a crimson-coloured damselfly. The same species that had picnicked with me on my writing rock the previous month. It was startling to see a damselfly so late in the fall, let alone in the woods nowhere near water.

I let my thoughts go to my sister and felt her beautiful spirit around me. It struck me that without our personality conflicts getting in the way, we were very similar, especially when it came to awareness of our human connection to the Earth and its creatures. She would have known of my familiarity with the (so appropriate) symbolism associated with dragonflies (and damselflies), and it wasn’t surprising she was showing herself to me that way.

Keeping my eye on “Kathryn,” still perched on my heart, I turned to head back down the slope. As I set out, I extended a finger close to the damselfly, and she stepped delicately onto it. And so I carried her down to the road, chatting cheerfully.

Back on the main trail, I continued down the hill. By this time the damselfly had been hanging out with (and on to) me for at least 10 minutes. I thought about how I had just been with Harriet two days before, and all we’d talked about in the pub.

In my head, I asked Kathryn, “Is there anything else you want me to say to Harriet?”

Then, as if in response to an answer I’d just received, I heard myself say out loud, “I’ll look out for her.”

As I spoke, I looked down at my hand, and the damselfly, which had been on my finger nano-seconds before, was gone. I didn’t catch even a glimpse of it zooming away: it was as if it had never been there.

I had to laugh. My sister had delivered her message.

“I will,” I assured her. “I will.”

Installment #35: The scent of loss

The three months from October to December were a blur of trips to Ottawa to be with Harriet and to Toronto to sort through Mom’s things with my sisters. Mystifyingly, there was still no autopsy report, which meant the regional coroner could not complete her report or make a decision on an inquest. Steve was trying to get us a meeting with her. He was also keeping us apprised of his contact with the investigative coroner (the one who had been called to Kathryn’s the night she was found), as well as with the OIPRD investigator. We were grateful for Steve’s persistence in pushing for results while we attended to Mom’s estate and tried to absorb our double loss.

In Toronto, I stayed at Mom’s condo, as usual. I even took to sleeping, quite comfortably, in her king-size bed. It surprised me to feel equally at home when she wasn’t there as when she had been. Though it was hard to miss her presence when she was right there, telling me what to do…

I could hear her instructions on where to put away the laundered towels and sheets and how to make her bed. And one clear message was to gift her car to Sandy the caregiver. It made sense, given how much Sandy had driven her around in it that summer (and, incidentally, needed a car), and Nancy and Lynne were in complete agreement.

Staying at Mom’s was surprisingly easy (and my sisters experienced the same peacefulness when they came over) until the morning I stepped into her walk-in closet with an armload of clothes I’d washed after finding them mouldering in the hamper.

They say smells bring back the strongest memories. The moment I walked into the closet, my nose filled with her familiar smell—a smell I had never paid any attention to when she was alive: a mix of Ivory Snow (her favoured laundry soap) and natural body aroma somewhat “enhanced” in the airless closet.

Mom’s friendly (if mildly bossy) spirit hanging around was one thing; Mom’s overwhelming olfactory presence was quite another. I stood in the middle of the closet and gave in to tears. And ignored Mom telling me there was nothing to cry about. What did she know? She was the one being missed, not the one doing the missing.

Installment #36: A cemetery rings with laughter

On a remarkably sunny day for mid-November, we gathered in Burlington’s Woodland Cemetery to bury Mom’s ashes in her family plot. There were a dozen of us, mostly immediate family, including Harriet’s dad, who was to lead the short interment service.

When we arrived, the hole had already been dug, and over it the gravedigger had spread a square of green indoor/outdoor carpeting so no one would fall in. The gravedigger himself was just driving away in a small work vehicle, the removed earth piled on the back.

With the decisiveness of a seasoned graveside-service officiant, David pulled the carpet away from the hole. He didn’t believe in glossing over the reality of death: ashes to ashes, and dust to dust, and what has come from the earth shall go back into it.

The hole was about a half-metre square and a metre deep. We gathered around it in a circle while David recited the burial-service prayers. Then, at his suggestion, we passed the beautiful porcelain urn from arm to arm around the circle, each taking a moment to cradle it and, if we wanted, share a memory of Mom. Then 15-year-old Gavin, the youngest grandchild, was charged with setting it down into the hole, and David recited the final prayer.

At David’s signal, the gravedigger, waiting at a discreet distance, drove back, and, one by one, we took the proffered shovel and poured in a little of the dark earth, just enough to cover the urn. The gravedigger would return later to fill in the rest.

We stood chatting, in no hurry to leave. Nancy began to clear overgrown grass from the footstones of Mom’s parents and relatives so she could photograph them.

Lynne and I were in an embrace with her teary daughter when we heard a collective gasp. We looked over to see Nancy sitting on one side of the hole, her legs dangling into the hole. While engrossed in her photography, she had apparently taken a step backward….

At the sight of her sitting, sheepishly, at the side of the hole, looking for all as if she were trying to get right in with Mom, the rest of us burst out laughing.

While one of her daughters helped her up, David spoke over the laughter. “In 33 years of doing graveside services, I’ve never had anyone fall in the grave before.”

That had us laughing even harder, filling the cemetery with a sound it may never have heard before.

It could well have been no laughing matter at all. The way Nancy had stepped backward, into the gaping hole, she could have been badly hurt. But, miraculously, she didn’t fall right down into the hole. As she told us, it hadn’t been a sudden, hard fall but a soft landing on the side—along with a strange sensation, as of someone catching her.

Her daughter Sarah, who had seen it happen, later reported that it looked like she was falling in slow motion, that she had raised her arms to shoulder height—as a child does falling back into the waiting arms of a trusted parent—and that it looked as if she had been set down gently at the edge of the hole.

The question was: set down by whom?

Whoever caught her, I’m convinced Mom was the one who engineered it (perhaps impishly doing the pushing, while Kathryn did the catching), in a ploy to get us to laugh instead of cry.

We are, after all, she would have said, a laughing family.

Installment #37: Silent Noon

After Mom’s interment, Harriet and her dad stayed overnight with me at the condo. Amid the half-packed boxes and the card tables spread with Mom’s things still to sort, we sat up late, talking about the emotional wrench of dismantling a life (two lives).

I found myself relating my dragonfly experiences—the latest one, of my “walk” with her mum, for Harriet and all of them for her dad.

David didn’t seem sceptical, or even surprised. Instead, he told me that Kathryn’s favourite line in a sonnet by Dante Gabriel Rosetti had been about a dragonfly.

At my blank look, he explained that the sonnet, Silent Noon, had been set to music by Ralph Vaughan Williams (a composer beloved, I knew, by both Kathryn and him).

He recited the two lines Kathryn had loved to sing:

Deep in the sun-searched growths the dragon-fly / Hangs like a blue thread loosened from the sky.

This wasn’t the only connection of Kathryn’s to dragonflies I was to hear about. That blue thread loosened from the sky was to keep unspooling. The next spring I was to have tea with her dear friend Madeline, who would tell me that when we cleared out her house, we were going to find lots of dragonflies, that Kathryn had had a particular affinity and love for them.

I did indeed later find, among her jewellery, a pair of delicate pewter dragonfly earrings. And going through boxes in Kathryn’s basement one afternoon, Harriet, crouched over a carton, lifted something out and extended her arm up to me with a wry, “well, we know who this is for” expression on her face.

I took from her hand a heavy iron-plated sundial, whose dial was an elegant dragonfly, its tail curved upwards to catch the sun’s shadow.

Learning of Kathryn’s love for dragonflies has made all the encounters my sisters and niece and I have had since (and there have been many—stay tuned) even more significant and special: our dear Kathryn likes to zoom in to say a comforting hello now and then.

Installment #38: The log jam breaks at last

Nearly six months after Kathryn’s death, we still had no autopsy report from the pathologist, which meant the regional coroner’s office could not release the coroner’s report, which meant we still didn’t know if an inquest was going to be called.

We also had no results from the OIPRD investigation into officer misconduct (though the investigator was keeping Steve apprised of his progress) or from the OPP’s internal investigation into the 911 call centre.

Of all the delays, the autopsy report was the most frustrating. On February 25th, 2015, Steve filed complaints with the Office of the Chief Coroner for Ontario, the Ontario Forensic Pathology Service, and Ontario’s Death Investigation Oversight Council, “regarding the unacceptable delay and lack of action with the sudden death investigation for Kathryn Missen.” He copied the minister and the deputy minister of community safety and correctional services (the ministry that oversees the OPP), the premier of Ontario, and the member of provincial parliament for the riding where Kathryn had lived.

Within an hour of sending his complaint, Steve received an email back from the chief forensic pathologist committing to look immediately into the matter. The chief coroner responded the next day, stating that he would wait to hear from the chief pathologist to determine whether any additional steps were needed on his part.

Steve emailed us this update the day after sending the complaint, at 11 am. Two hours later, he sent a second update: the chief pathologist had emailed to say the autopsy was complete and had been sent to the regional coroner.

We had an autopsy report at last.

In his 11 a.m. update, Steve also told us he had received word that the OIPRD was wrapping up its investigation of the officers, and that once it had been approved, we would receive the report.

And to that same email, he attached a PDF file of a letter he had just received in the mail from the chief superintendent of the OPP’s Professional Standards Bureau regarding the internal investigation of the 911 call centre. As Steve pointed out, it wasn’t the actual report but did at least outline the chain of events.

I could not bring myself to read the letter, especially after Lynne called me in tears: she had opened it at work and found herself reading a timeline of the disturbing chain of errors in Kathryn’s 911 call.

We texted a warning to Harriet but it was too late. My phone rang, and I picked it up to hear my niece sobbing. It was heartbreaking to be so far away, to be unable to wrap her in a hug, to be able only to sit in compassionate silence, hoping she could feel my love through the line.

Installment #39: Overwhelmed by the facts

It was a couple of weeks before I worked up the courage to read the chief superintendent’s letter. It took the arrival, on March 12th, of another email from Steve. The subject line gave no indication of what was in it. I opened it to read that the investigating coroner had called Steve to go over the results of the autopsy.

There, without warning, on my computer screen, was the cause of Kathryn’s death—acute bronchial asthma (though no reason for the attack was ever established)—and a statement Steve put in quotation marks from the investigating coroner that “had a response been made by 911, Kathryn’s survivability would have been very high,” that she would likely have needed only an administration of adrenalin.

Steve had already given us this information during our visit the previous October. Nevertheless, reading it in stark black and white hit me hard: if the emergency response system had operated the way it was supposed to, Kathryn would in all likelihood still be alive. (We were also later to learn that it’s very rare for anyone to die from an asthma attack because treatment is so readily available.)

I tried to call Nancy and Lynne. Unable to reach them, I phoned a close friend, who completely empathized with my distress, even though it was at odds with the peace she knew I felt deep inside about Kathryn’s death.

Since I was already upset, it made a sad kind of sense to open the chief superintendent’s letter. I asked my friend to stay on the phone, and read it to her.

The letter offered the OPP’s sincere condolences, assured us that our complaint had been taken very seriously, and outlined the investigations—the OIPRD looking into officer misconduct and the OPP looking into the 911 call centre errors. The latter investigation, now complete, had revealed that “the 911 call from Ms. Missen was not dispatched and responded to in a timely manner.” It ruled the delay “unacceptable.”

To my horror, the summary indicated that Kathryn’s moaning, wheezing and struggles to speak lasted 44 seconds—much longer than the 11 seconds we had originally been told. (Although our family has a copy of this audio, we can’t bring ourselves to listen to it, but have confirmed it was 44 seconds.)

The letter included a chronology of the events from the time Kathryn called 911 to the dispatch of the OPP officer an hour and 36 minutes later. It was an almost impossible-to-believe series of miscommunication, errors, and delays, all the way down the dispatch chain.

Almost as disturbing to find out was what a complicated dispatch chain it is.

CBC Radio interviews on the inquest into Ontario’s 911 system

As “fate” would have it, the day before posting installment #40 below, I was interviewed by the CBC Radio program Ottawa Morning about Kathryn’s death and the inquest—which, at the time of this posting, was already underway in Sudbury (for the Sudbury case) and came to Ottawa for Kathryn’s portion from October 22nd to November 1st. Click here to hear the interview, which could be considered “supplementary” material to Installment #40 below. For a follow-up interview that Ottawa Morning did with my niece Harriet after the inquest was over, click here.

Installment #40: A little lesson on the OPP’s 911 system

From the chief superintendent’s summary of events, we gleaned that Kathryn’s 911 call was handled by two call centres and three operators (and we were later to learn of the involvement of two more operators). And this was not unusual—it’s the process for all calls in the 911 system that is managed by the OPP.

The complexity of the system and process came as a shock to us, as it has to everyone we describe it to. (As a note, this system applies to any municipality within Ontario that contracts its emergency service delivery with the OPP. It doesn’t apply to other jurisdictions, particularly large cities, that have their own emergency response system.)

Here’s how (we think) the OPP-managed 911 system works:

A 911 call made from anywhere in Ontario is answered by an operator at the primary Public Safety Answering Point (PSAP) in North Bay. [North Bay is, for reference, more than 400 kilometres from Casselman.]

The primary PSAP operator asks if the caller requires Police, Fire, or Ambulance. Rather than contacting the appropriate agency for dispatch (as you might expect), this operator, or call-taker, transfers the call to one of five secondary PSAPs across Ontario, depending on where the call originated. In Kathryn’s case, this secondary PSAP was in Smiths Falls. [Smiths Falls is 100 kilometres from Casselman.]

In transferring the call, the North Bay primary call-taker speaks to a call-taker at the relevant secondary PSAP call centre. In taking over the call, the secondary PSAP call-taker asks the caller for more information and sends this information electronically to the console of a dispatcher at the same secondary call centre. It is this dispatcher—the third 911 operator involved in the call—who dispatches the appropriate emergency responder.

Our biggest question, and concern, is why we even have this two-tiered system, involving two call-takers. The only role of the primary PSAP call-taker in North Bay seems to be to transfer calls to the call-taker at the relevant secondary PSAP call centre—and there is potential for miscommunication from call-taker to call-taker to dispatcher. (Another major drawback is that, as we have recently learned, the secondary PSAP operators have no access to the audio-recording of the call, which might give them additional, crucial information that could be provided to emergency responders on their way to the call.)

Here’s what should have happened in Kathryn’s case:

The North Bay primary PSAP operator recognizes Kathryn’s breathing and communication difficulties as a medical emergency and provides this information to the Smiths Falls secondary PSAP call-taker when transferring the call. The Smiths Falls call-taker in turn electronically communicates this information to a Smiths Falls dispatcher, who immediately dispatches EMS, Fire and Police (police to be included because of the unknown circumstances surrounding the call). This all happens within 30 to 60 seconds.

(In a more streamlined system, there would be only one call-taker, who would communicate the information directly to a dispatcher, saving time, as well as risk of miscommunication.)

Due to their proximity, Fire and EMS arrive at Kathryn’s house within three to four minutes, revive Kathryn at the scene, and transport her to hospital for follow-up care.

Simple. Effective. Efficient. Potentially life-saving.

And not what happened.

Installment #41: When Kathryn called 911…

Here’s what did happen when Kathryn called 911:

The North Bay primary call-taker spent nearly one minute trying to get Kathryn to state her emergency. Kathryn, remember, was wheezing and moaning and having difficulty speaking. In transferring the call to the Smiths Falls secondary call centre, the North Bay call-taker did not mention Kathryn’s breathing distress. The only information the Smiths Falls call-taker received was that there was a woman on the line who had not said anything and her emergency was unknown.

The Smiths Falls call-taker tried to make voice contact with Kathryn, but now no sound of any kind could be heard on the line. (The investigating coroner would later tell us that at that moment Kathryn likely lost consciousness: the phone was found beside her on the floor, the cord pulled out of the wall.)

Unable to make voice contact, the Smiths Falls call-taker ended the call and attempted to ring back: unlike with normal calls that are still open at the caller’s end, which will get a busy signal, 911 dispatchers will get the open line.

When there was still no response from Kathryn, the Smiths Falls call-taker contacted the Bell maintenance centre to report a technical issue for investigation. While on hold, the call-taker created a computer-generated message that appeared on the console of a Smiths Falls dispatcher assigned to dispatch police. (Police are dispatched when the emergency is unknown.) When Bell confirmed (within a couple of minutes) that there was a technical problem and that a repair ticket had been created, the call-taker sent that information to the dispatcher as well.

Under the impression that the call was a technical malfunction of the phone line (and with other issues going on), the Smiths Falls dispatcher did not dispatch the call for another hour and a half.

The short explanation of these events is that because Kathryn’s call was not communicated as a medical emergency by the primary PSAP operator in North Bay, it was deemed to be a technical problem with the phone line—commonly referred to as “Trouble on the Line”—a perception confirmed almost immediately by Bell itself. The importance of Kathryn’s call was therefore downgraded in the minds of all the call handlers and the dispatched OPP officer. As a result, no one went to Kathryn’s aid—contrary to OPP policy that all 911 calls shall be attended, regardless of a possible network malfunction.

Clearly human errors were made, and we’re not disputing that. Our concern is that the complexity of the 911 structure creates greater potential for these kinds of errors, and needs to be simplified. We are also concerned that there appears to be no monitoring or oversight that would prevent such errors: no one, for example, seems to have checked on the Smiths Falls dispatcher to ask why the call hadn’t been dispatched yet and whether she was alright. Checks and balances are needed as much for the well-being of employees working in such a high-stress environment as for callers whose life may be on the line.

Installment #42: Inching closer to a meeting with the coroner

From the chief superintendent’s letter, we learned that as a result of the internal review, the OPP had immediately implemented a number of actions and made recommendations “to reduce the possibility of this service [i.e., the 911 dispatch] failure repeating itself.” The chief superintendent didn’t elaborate on what these actions and recommendations were. He did say that the civilian employees involved (the 911 call takers and dispatchers at the Smiths Falls Provincial Communications Centre) had been “the subject of a comprehensive investigation” and that “appropriate disciplinary action is being taken.”

Disciplinary action against individuals was not the result we were looking for. We were looking for an independent review of the whole emergency response system at an inquest. And now that the autopsy report was finally complete, we could see no reason for the coroner to delay her decision. In fact, in a heartening development, she solicited a meeting with us through Steve.

Although Steve did tell us that the purpose of the meeting was to discuss the findings of the autopsy report prior to the completion of the coroner’s report, we fully expected the coroner to be in favour of an inquest, even if she didn’t announce it formally.

We immediately responded with dates that we were available. However, the date chosen by the coroner wasn’t for another five weeks. (Sadly, we were starting to get used to waiting.)

On April 21st, 2015, nearly eight months after Kathryn’s death, our family, including Harriet’s dad, and Steve and Lisa arrived at the Office of the Regional Supervising Coroner for Eastern Ontario to meet, at last, with the regional coroner and the investigating coroner.

Installment #43: First family meeting with the coroner

In a small meeting room with a table large enough to accommodate us all, the coroner made introductions and gave us her condolences. She then explained that the mandate of an inquest is to prevent deaths in similar circumstances, and not to lay blame. Hearing this only confirmed for us that we were on the right track: it was exactly what we were looking for. So far so good.

We listened as the investigating coroner summarized his attendance at Kathryn’s the night of September 3rd and then as the regional coroner reviewed the autopsy report (she didn’t give us a copy). It was hard to hear such a clinical discussion of the facts surrounding Kathryn’s death. It didn’t seem to matter how many times we heard the details, it never got easier.

The coroner turned next to the OPP’s internal review of the 911 call centre. Again, she had been provided with a copy of the report but wasn’t, she said, at liberty to distribute it to us. Instead, she read from it, including summaries of the interviews that had taken place with the call takers and the very remorseful dispatcher. She also read the list of “actions and recommendations” that the chief superintendent had referred to in his letter.

As the coroner read from the list, she kept looking up, clearly pleased with the OPP’s response. It was her view that the mistakes were the result of human error—that policies were in place (i.e., to treat all calls as an emergency until proven otherwise), that these policies simply had not been followed, and that the OPP was taking steps to ensure policies were followed in future.

Except for a couple of actions that seemed like too-easy fixes, the OPP’s solutions did seem reasonable to our family.

But not to Steve. When the coroner finished, he was edifyingly vocal in his professional opinion that all these “solutions” were simply icing on the cake and that the real issues were embedded in a seriously flawed system. Using flowcharts he had prepared in advance, he took the coroner through the process: first as it should have worked and then as it had failed to work in Kathryn’s case. He highlighted the two-tiered structure and lack of oversight as particularly problematic.

As the meeting went on, it became clear that the coroner was not about to tell us she was in favour of an inquest. At our outright question, she explained that more investigation was needed and that she needed to receive the results of the OIPRD investigation before she could make a decision. Steve assured her he would forward the report as soon as he received it.

The coroner also mentioned several possible alternatives, including a coroner’s review, which would not be open to the public (or us). And she invited our family to write a letter indicating our preference for an inquest.

We left the meeting deflated by the coroner’s apparent satisfaction with the limited actions already taken by the OPP, her seeming resistance to calling an inquest, and the plodding wheels of justice.

Installment #44: Kale for Kathryn

The day of Kathryn’s interment—Saturday, May 30th, 2015—was warm and overcast. I arrived in Eganville prepared for rain and had never given a thought to a bug jacket. Parking my car in the lane beside the cemetery, with no sign of bug-drowning rain, I wished I’d brought it: May is prime blackfly season in rural central Ontario…

Eganville was the parish that David, Kathryn’s then new husband, had been assigned in the mid-1980s. It was during their few years in this town that Harriet had been born and, not quite two years later, Madeleine.

Madeleine Joy Gabriel, induced at seven and a half months and smaller than her sister’s doll, had lived only long enough to be baptized by her father in the delivery room: she had been born with parts of her brain, skull and scalp missing, a birth defect called anencephaly. Her grave was here in the Anglican church cemetery, and here Kathryn would be joining her, the daughter she had grieved the rest of her life, the sister Harriet had never met.

Walking up the lane, I joined the rest of my family and friends of Kathryn’s and Harriet’s. I need not have worried about the blackflies. As soon as we passed through the cemetery gate, I spotted the dragonflies…. Dozens and dozens of them, the big guys, with their aviator eyes and long tails and impressive wing spans. They zoomed over our heads, vacuuming up the bugs (thank you).

We crossed the grass—actually a carpet of fragrant wild thyme—and gathered around the open grave. This time, the service was led by the current incumbent of the church, and David was among the mourners. He stood somberly beside his infant daughter’s footstone, from which he had taken the etching of the angel that adorned Kathryn’s urn.

The service was longer and more formal than Mom’s, as Kathryn would have wanted. After the final hymn, the priest went to get a shovel to fill in the hole. But the skies looked threatening and there was one more important task to be done, so Harriet’s friends simply dragged over the tarp holding the excavated earth and dumped the dirt back into the hole. Then, as rain sprinkled down, they planted two small pots of Kathryn’s favourite salad green.

And then came the deluge. Perfectly timed to water the kale but not to have drowned out the graveside service. It watered the thyme, too. Kathryn, I thought, as I ran across it, would be right at home among the herbs and greens.

Reaching the gate, I was reminded of the last time I had left this cemetery, with my toddler charge, Harriet, after her sister’s interment. As I paused to open the iron gate, little Harriet had looked up at me and said, “Go in?”

“Go out,” I’d responded, automatically. Then, rethinking, I corrected myself: “Yes, go back in.”

And now, here we were, opening the gate again 28 years later, going back “in”… Leaving behind our beloved sister/mother and our dear never-known niece/sister, leaving behind the all-seeing dragonflies, leaving behind the truth beyond the illusion that we are but ashes and dirt, that we “die,” that deaths in middle age are “tragedies,” that someone must be to blame…

We went back “in” to the earthly reality of our continued wait for the results of an investigation into police misconduct and—much more important to us—our ongoing, determined push to get an inquest to examine the flaws in the emergency response system, so that the reason we were here today would never happen to anyone else.

Installment #45: The post-dispatch chain of events

On July 16th, 2015, Steve emailed us electronic copy of the 70-page OIPRD investigative report, which he had received in the mail. He emailed the PDF to the coroner, too, as promised.

The report summarized interviews held with 14 uniformed OPP officers (including supervisors and the inspector) and two civilian OPP employees at the Smiths Falls call centre: the daytime dispatcher who dispatched the call to the constable and the nightshift dispatcher who cleared the call with him hours later.* It did not include interviews with the North Bay or Smiths Falls call-takers—since they had not been in contact with uniformed officers.

The report noted that the interview included for the daytime dispatcher was simply a summary of the interview that had already taken place for the OPP internal investigation of the call centre—the results of which we were now trying to obtain through a Freedom of Information request.

The interviews painted for us a fuller picture of the events that took place after Kathryn’s call was finally dispatched at 6:17 pm on September 1st.

When the daytime dispatcher phoned the Russell County OPP detachment in Embrun (a 10-15-minute drive from Casselman), she spoke to Constable A and advised him (on incorrect information) that there had been no voice contact from the caller and (also on incorrect information) that Bell Canada had confirmed that the call was “trouble on the line”—i.e., a technical problem with the phone line—and had created a repair ticket.

Before he left the detachment, Constable A received two other calls for service. By the time he had finished with the second one, around 8 pm, he admitted to the investigators that he had forgotten about Kathryn’s 911 call—whose importance, he added, had been considerably downplayed by the information he’d received that Bell had confirmed it was a technical problem with the phone line.

At 3:15 am, the nighttime dispatcher radioed Constable A to advise him that Kathryn’s 911 call had not been cleared. He cleared the call with the words, “911 activation confirmed trouble on the line, NFA [no further action].”

On September 3rd, Kathryn’s neighbours, concerned that they had not seen her for two days, called 911. Constable B was dispatched to her home and found her lifeless body on the second floor. Learning, through an “address check,” that a 911 call had been placed two days earlier and that Constable A had been dispatched, Constable B called the off-duty constable at home.

In his interview, Constable B reported that Constable A had told him he couldn’t remember if he had gone to the call. This statement by Constable B contradicted the statements of several other interviewed officers, including his own supervisor, who all reported that when they arrived at Kathryn’s house on the night of the 3rd, Constable B told them that Constable A had told him that on the 1st, he (Constable A) had come to the house, knocked on the door and left.

Whichever version of these events was true, it had no bearing on whether Kathryn would have survived if help had arrived in a timely way. Still, accountability was important, and the report went on to deal with just that.

*In these installments I’ve chosen not to name any of the involved 911 operators or OPP officers: naming them would feel too much like “blaming” them.

I’m calling the two constables who were charged with misconduct Constable A and Constable B. Their disciplinary hearings are now part of the public record, and any curious reader can find the decisions, and therefore their names, elsewhere online, but I am not choosing not to name them (see footnote above).

Installment #46: Charges are laid

The OIPRD investigators determined that there was sufficient evidence to show that Constable A had failed to attend Kathryn’s 911 call on September 1st and that he had subsequently misled others about his attendance. The investigation also found that Constable B had attempted to mislead the investigators concerning the information he had received from Constable A about whether he had attended the call on September 1st.

The OIPRD investigation report outlined the resulting charges that were laid against the two constables under the Police Services Act. (Note these were not charges under the Criminal Code.) Constable A was charged with neglect of duty and discreditable conduct in failing to attend a 911 call and with two counts of deceit. Constable B was charged with deceit. As a result of the charges, the constables were each to be subject to a disciplinary hearing conducted by the OPP.

We were surprised to learn we were to be granted standing at the hearings. As the complainant on our behalf, Steve (and therefore we) had the right to participate fully in the proceedings, including asking questions and making  submissions. Steve’s full-party status also meant that the OPP were obliged to disclose all relevant material to him. We hoped this meant that we would finally receive the elusive internal report of the call centre investigation, and all other information and reports concerning Kathryn’s case.

There was one possible hitch: the time it had taken to complete the investigation meant that the six-month limit for giving notice of hearing to the two constables had been exceeded and that an extension would need to be requested. Steve seemed confident the extension would be granted and hopeful that the hearings would get underway in the fall.

We could do nothing but wait to find out.

Installment #47: Benevolent timing

As frustrated as we were by the plodding pace of progress, I couldn’t help feeling there was a benevolent force at work, taking into account the emotional state and mental energy of each family member, and guiding and arranging the timing of events and progress accordingly.

It began with the delays in receiving the autopsy report (not to mention the coroner’s report and decision) over the fall and winter of 2014 and into 2015. During those months, Nancy, Lynne and I were able to focus our attention and energies on clearing out Mom’s condo, and we had everything completed by the closing date, March 11th, 2015—which was just a few weeks after we received the letter from the OPP superintendent about the investigation results.

Harriet had, for understandable reasons, put off dealing with her mum’s house until that spring. The delays in receiving the OIPRD report (and, again, not to mention the coroner’s report and decision) meant she could put her focus on packing up and moving the things she wanted to keep (with the limited assistance of her aunties). Arrangements were made for others to clear out the rest of the house, relieving her of that overwhelming task. The house went on the market in late spring, and by early summer a buyer had been found.

The OIPRD report—catalyst for movement forward—arrived in our in-boxes in mid-July.

(As the wheels of justice continued to turn grindingly slowly, we continued to experience such silver, synchronistic linings, which gave us the time we needed to replenish our emotional and mental energy and focus on other aspects of our lives after each lurch forward and grinding halt in the process.)

By July 2015, with the two estates settled, the police investigations concluded, and the OIPRD report in hand (as well as in the regional coroner’s hand), the four of us were ready, emotionally and mentally, to renew our push for an inquest.

Toward the end of the month, we set up a teleconference call with Steve from our various homes to discuss our next steps.

Installment #48: To sue or not to sue

On July 21st, 2015, Nancy, Harriet, Lynne and her husband Brad, Steve, and I each dialled in to a free conference call service I had found online.

The first item of business was the upcoming hearings for the two constables. Steve expressed what we were all feeling—frustration and ire that the OPP seemed to be trying to focus all attention on the officer who hadn’t responded to the call—an officer who hadn’t even been dispatched for an hour and a half.

The much more serious issue, we all agreed, was the failure and mismanagement of the North Bay and Smiths Falls call centres. And adding to our frustration was the fact that our Freedom of Information request for the results of the OPP internal investigation into the call centre (and for all other information relating to Kathryn’s case) had been denied—the stated reason being that the investigation was ongoing. This made no sense since, as Steve had learned, the internal investigation was now closed.

Steve also updated us on his stymied efforts to get information from the OPP about exactly how the organization runs the 911 call centres and what purpose the two-tiered system serves.

As he saw it, there were two parallel but independent streams of action for us to take: to keep pushing for the coroner’s report and inquest and—because he was by no means confident the coroner would call an inquest—to file a lawsuit against the OPP…

Filing a lawsuit was not a new idea for our family: we had been talking about it for some months. Talking, rather than pursuing, because it was not action we particularly wanted to take, and our motivation for considering it was not financial gain. Rather, with the coroner continuing to delay her decision, a lawsuit seemed like it might be the only way to draw attention to the serious problems with the 911 system. In addition, Steve also thought we might be able to put conditions on any settlement, stipulating systemic changes that had to be made. This possibility became our main motivation for considering a suit.

There was also the effectiveness of any inquest to consider. Steve cautioned us that even if the coroner did call an inquest there was no guarantee any real change would come out of it because of the non-binding nature of recommendations made by inquest juries: the OPP could, it seemed, choose to disregard them.

By the end of the call, we had agreed on two courses of action. The first was to write the letter the coroner had suggested, to urge her to call an inquest. We would explain that we had been holding off writing until we had received the results of the OPIRD investigation—since she had told us she needed this report before making a decision.

The second course of action was to consult with a lawyer about the possibility, and viability, of launching a lawsuit against the OPP.

Installment #49: In which we consult with lawyers

In the first half of August 2015, our family, along with Steve, consulted with two lawyers, one in Toronto and one in Ottawa.

Of the two, the Ottawa lawyer had more experience with police cases and was closer, geographically, to where the hearings would be held (should we hire him to represent us).

This lawyer’s immediate response, after hearing the details of Kathryn’s 911 call, was, “It calls out for an inquest.”

We told him that (as we had just found out from Steve several days before) the coroner was asking to meet with us in early September. We didn’t mention how hopeful we were that this request for a meeting meant she was going to announce that she had decided in favour of an inquest. We could conceive of no other reason she would ask to see us. (It’s only been recently, on rereading Steve’s emails of the time, that I’ve discovered he was the one who pushed for this second meeting, after sending her the OIPRD report. Apparently, it’s not only love that’s blind—hope can be too…)

We turned then to the OPP hearings. Steve told the lawyer about the extension that had to be requested since the six-month limit for giving the notice of hearing had been exceeded. He added that the extension had just been granted and that the date for both constables to make their first appearance before the tribunal adjudicator had been set for September 9th.

The lawyer warned us that even though the appearance date had been set, there would likely be further delays, with defence counsel arguing that the officers needed more time to review the discovery documents. He thought the hearings might not get under way until the new year.

We weren’t surprised to hear such a prediction….

As for the question of pursuing a lawsuit against the OPP, there was no question in the lawyer’s mind that we had a strong case. There was, however, no reason to rush into it—we had, he explained, two years from the date of Kathryn’s death in which to launch a suit. He suggested that we wait at least until after the OPP hearings had wrapped up, which would give us more information to make an even stronger case.

We left the meeting with lots to ponder, and some homework too: the lawyer had asked us to write a “history” of Kathryn so he could learn as much about her as possible. In turn, he would provide us with an analysis of our case and his costs.

Installment #50: In which we meet again with the coroner

On September 8, 2015, Nancy, Lynne, Harriet, David, Steve, and I reconvened at the regional coroner’s office in Ottawa’s east end. Nancy and Lynne had made the trip from Toronto, while I had driven from the Madawaska Valley.

The coroner seemed very cheerful, which had the effect of further raising our hopes that she was going to announce an inquest.

She began by handing out copies of the list of recommendations and actions from the OPP’s internal review of the Smiths Falls call centre (the same document she had read to us at our previous meeting). She explained that she had received permission to share this list—but not the actual report—with us. “There are a lot of human factors,” she added. “A lot. A domino effect from the initial human error.”

It was dismaying to hear her talking again, as she had at the first meeting, about human error. It sounded as if she was working up to tell us the errors were human, not systemic, and there was therefore no basis for calling an inquest.

Her summation of the results of the OIPRD investigative report as “a performance issue” did nothing to alleviate our fears.

Steve agreed that there were performance issues but stressed that there were also serious systemic issues. “We need to go beyond the internal police hearings, because they’re trying to focus on two individuals, and we aren’t satisfied that they’re just going to throw these two officers under the bus. Firing one individual, if it comes to that, is not going to fix the problem. No one’s monitoring. No one’s supervising. This is what we would expect to come out of a public inquiry: recommendations to fix the serious systemic problems.”

“We all know how these internal investigations work,” added David. “It needs something to shine a spotlight from the outside on the whole system.”

The coroner maintained that the systemic problems were being addressed in the two-page OPP handout she had just given us. And then she asked for another letter from us….

She needed more detail, she said. She needed us to convince her that there were issues above and beyond those being addressed by the OIPRD and the OPP. “It’s not cut and dried because the call centre and the OPP have both taken steps to address the problem. So I need you to put in the letter why you believe the 911 actions and recommendations have not addressed the systemic problems.”

This made it sound like the onus was on us to drive the process—that we had to convince her of the need for an inquest.

The coroner said she was sorry we had that impression. “I appreciate Steve’s expertise,” she clarified, “and want to hear specific details of what you believe the issues are.”

She again mentioned the option of a regional coroner’s review, involving the regional and investigating coroners, the OPP, and the 911 call centre (but not us or other members of the public).

We left the meeting even more disheartened than we had been after the first, five months before. Clearly things were moving even more sluggishly than we expected. And it was starting to sink in that we might not get the result we were looking for. A lawsuit might after all be the only way to achieve our goals.

Installment #51: In which we wait some more

Aside from our August consultations with the lawyers and our September meeting with the coroner, progress was again stalled. In the meeting with the coroner, she had told us she was gathering a package of information—including the OIPRD and OPP internal investigation reports and the letter she wanted Steve to write—which would go to the Inquest Advisory Committee, the body that makes the recommendation of whether to hold an inquest. The committee’s decision would then go to the chief coroner to make the final decision. This process could take several more months.

The coroner had also told us that even if she called an inquest, it could not take place until after the OPP hearings were complete, because if a witness felt something they said could be held against them in a subsequent process, they might not share it, even in this “no-blame” forum. In addition, if something came up that brought criminal activity to light, the inquest would have to be shut down.

So, as with the lawyer’s opinion with regard to the timing of launching a possible lawsuit, everything hinged on the OPP hearings—hearings that we felt were detracting from the much more serious issues on the dispatch side.

Steve certainly did his best to convince the coroner of those issues. She had asked him to put them in writing, and he went far beyond a mere “letter”: he produced a 26-page report outlining how the OPP’s 911 system works (as far as we understood), how it should work for maximum efficiency of response, and exactly where all the systemic weaknesses and failures lie. He concluded with nearly 10 pages of comprehensive recommendations for improving the OPP’s emergency response system. He forwarded this report to the coroner in early November 2015.

And then we waited some more—because, as the Ottawa lawyer had predicted, even the hearings were being delayed…

Although the two constables appeared before the tribunal adjudicator on September 9th as scheduled, the matter was put off until November 4th and then until December 9th to give them time to review the discovery documents.

Finally, on January 21, 2016, Steve received notice from the office of the prosecutor (in the OPP’s Professional Standards Bureau) of hearing dates that had tentatively been set for Constable A (in late April) and Constable B (in late May).

Four days later, the hearing dates were firmed up with new dates of May 24-27 for Constable A and June 28-29 for Constable B.

We hoped these dates were indeed “firm”: two months after the second hearing ended would be the second anniversary of Kathryn’s death.

Installment #52: Writing a sister’s story

The words “Write K’s bio” stayed on my erasable fridge board all through the fall and winter of 2015 and into 2016. As the writer in the family, this homework assignment from the Ottawa lawyer had naturally fallen to me, and I welcomed it, even as daunting as the prospect was to try to sum up a life about which I had only a sister’s and a family’s perspective.

The one thing I had done after the meeting with the lawyer was to go into the crawl space under my house, where I was storing one box of Kathryn’s journals and another of her personal papers (the contents of both boxes to be burned or shredded, at Harriet’s request). When packing all this up in Kathryn’s basement the previous spring, I had glimpsed the printout of a short autobiography she had written in 2001 and updated in 2005 for a course she had taken on personal transformation.

Rescuing the 13-page autobiography from the shredder was as far as I got in my homework assignment until early March 2016, when the lawyer contacted Steve to find out if we planned to launch a lawsuit: the two-year window of opportunity to do so would be up in the coming September. Steve set up a meeting between the lawyer and our family for March 16th.

Well, that spurred me to action. I pulled out Kathryn’s autobiography and steeled myself to read such a personal document—a document that began with our shared family history but from her own, wounded point of view.

Reading through it, I saw, with relief, that she had done most of my work for me, especially with respect to chronology and key events in her married and post-married life.

It also came to me to ask two of her closest friends to write something that would provide a more recent, and a more deeply personal, perspective. Those writings are posted on my website here, as Kathryn’s biography is here.

To my surprise, it took only a couple of days to get a draft out of me. And it wasn’t as emotionally difficult as I had feared: my inner writer simply got to work. Then I sent it off to Harriet and my sisters for their feedback.

It wasn’t until I heard how emotional the reading had made them that my own emotions surfaced. Which made me realize that for the past number of months I had pushed Kathryn—and the whole situation—aside. I didn’t blame myself: I knew I had very likely needed the break. We all had.

Now we were about to be thrust back into it: the meeting with the lawyer the very next week, the OPP hearings in a couple of months, and—presumably, at some point—the whole inquest decision. Here it was, a year and a half after Kathryn had died, and we were still waiting for a response from the coroner.

Installment #53: Shared tear ducts

It was time for a family conference. It was mid-April 2016. I sat down at my computer to book the call through the free conference call website. My slideshow screensaver was scrolling through my collection of photos, and before clicking on the Internet icon, I paused to watch. Interspersed with the many familiar ones from canoe trips and family gatherings were photos from the first dozen years of my life that I had barely ever seen before. These were photos my father had taken on slide film and had therefore never found their way into our well-thumbed family albums. (From the late 1950s to the early 1970s, he had alternated slide with print film.)

Nancy had found a shoe box full of the small, slim plastic boxes when we were going through Mom’s condo. And that summer of 2015, she took the boxes—containing nearly 600 slides—to a photography store to have them scanned onto CDs. She asked for three copies to be made (for herself, Lynne and me). The saleswoman made her promise to pick them up by a certain date because that store—and in fact the entire chain—was closing.

Lynne and I totally forgot about Nancy’s slide-scanning project until months later, when our family gathered on Christmas Day.

When it was time for the gift exchange, Nancy handed Lynne, Harriet and me each a small wrapped gift. Opening our identical packages, we each discovered a CD of Dad’s slides from 1957 to 1972.

Even more touching than the CD gift itself was the story that came with it.

When Nancy went to pick up her order (making sure to get there before the permanent closure of the store), the woman who had taken her order handed her not three but four CDs. “I know you asked for three,” she explained, “but there were four little girls in the photos, so I did a fourth.”

As Nancy quoted the words “four little girls,” she teared up, and instantly Lynne and I did too.

With great emotion, Nancy went on to tell us how she had explained to the saleswoman about Kathryn and how she had later realized that the fourth CD would make the perfect gift for Harriet.

Now, sitting at my computer, watching the (digital) slide show, the saleswoman’s description of the “four little girls”—and her thoughtfulness—made me tear up again.

And then I tapped a key and the slideshow disappeared. I typed the URL of the free conference call website to get a phone number and code for our family call the next evening.

Installment #54: Shared funny bone

The designated conference call phone number wouldn’t work. After my second try, I phoned Lynne on her landline to see if she was having trouble too. She was, and in fact had Harriet on her cell phone: Harriet hadn’t been able to get through either and had called her.

Lynne put both phones—landline and cell phone—on speaker and held them close together so Harriet and I could say hello to each other.

We were delighted at how well we could hear each other, which gave me the idea to call Nancy on my cell phone.

When I reached Nancy (who had also been unable to dial in), I held my cell phone and landline close together and on speaker, as Lynne was doing with hers, and the four of us could hear each other perfectly well.

We were so tickled by our improvised, and ingenious, conference call technology that simultaneously we all burst out laughing. And for the next five minutes, we just laughed and laughed.

At last I said, “Well, that was good. Thanks for calling, everyone.”

That set us off for another five minutes.

When we finally stopped laughing, we decided we really should just get together once a week on the multi-phone conference call to laugh for ten minutes, for sheer family “best-medicine” therapy.

That first, and most important, item of business complete, we went on to the next (not so fun) items: the inquest and the OPP hearings.

We had met again with the Ottawa lawyer the previous month, as Steve had arranged, and had formally hired him to represent us at the OPP hearings. And since we were still getting nowhere with a coroner’s report or a decision on an inquest, we had also hired him to become our liaison with the coroner, relieving Steve of some of his work on behalf of Kathryn.

On our improvised conference call, the four of us decided it was time to ask the lawyer to write the next letter to the coroner to ask for a decision on the inquest. We would also follow up with him on his cost estimate for representing us at the OPP hearings and for possibly pursuing a lawsuit, about which we still had not made a decision.

We were all dreading the hearings—dreading coming face to face with the constable who hadn’t gone to Kathryn’s call. Both the lawyer and Steve had told us that families often didn’t show up at police hearings after making the complaint that led to charges. They wondered if we really needed to go. The only reason, they felt, would be if we were going to pursue a lawsuit—in order to arm ourselves with as much information as possible.

But we knew we needed to go, regardless of whether we went ahead with a lawsuit. There was never even any family discussion about it. We knew we needed to stand behind Steve’s complaint on our behalf. We needed to show the OPP that this was not going to go away. Most of all, we needed to be there to put a face and family to “the victim”—to make sure no one lost sight of the fact that the “deceased” was Kathryn Missen, a mother and sister, a woman with a life and a family, a woman dearly loved.

Part III

Installment #55: Constable A’s hearing (take 1), day 1

On May 23rd, 2016—Victoria Day—I arrived in Ottawa to pick up Nancy and Lynne at the train and drive us to our new home away from home: the hotel we had stayed at for Kathryn’s funeral and the two meetings with the coroner. We were here for the hearing for Constable A, which was scheduled for four days at the OPP Regional Headquarters in Smiths Falls. We would be back for Constable B’s two-day hearing at the end of June.

It was to become an all-too-familiar routine for the three of us to collect Harriet early in the morning and make a stop for coffees and breakfast sandwiches to eat in the car on the hour-long journey. Before the hearings were complete, we would make not just two but five trips to Ottawa—and would drive to Smiths Falls (and back) a total of seven times­—over the next eight months.

On that first morning, we were buzzed into the big grey square OPP building on the outskirts of town. Seated in the vestibule were a uniformed officer and a young man in civilian clothes. Only the uniformed officer returned our greetings, with a nod and a compressed-lip smile, an acknowledgement of us as “the family” and of the gravity of the situation that had brought us here.

Steve and our lawyer emerged from the hearing room to tell us that the proceedings were to be delayed because the constable was conferring with his lawyer: it looked like he was going to plead guilty to the charge of neglect of duty (for failing to go to Kathryn’s call).

While we were relieved Constable A was going to admit to the more serious of the charges, Steve explained that it also meant that the 911 dispatcher would not be required to testify, so we would not hear the details of why there had been such a long delay in the dispatch of the call, as we had hoped.

An hour later, the hearing finally got underway. The four of us took our places at a long table behind Steve and our lawyer on the “prosecution” side of a large room that looked like it was normally used for lectures or conferences. At the front were three tables: one for the adjudicator, one for the woman recording the proceedings, and one for the witnesses.

On the “defence” side stood a suited man who was clearly Constable A’s lawyer, from the Ontario Provincial Police Association. And sitting beside him was a young-looking man of slight build: Constable A.

Just before the proceedings began, a young woman wheeled a large brief case up the aisle and sat down at the table beside our lawyer: the counsel for the prosecution.

The adjudicator, Superintendent Robin McElary-Downer, came in through a door at the back, and we all stood. She read the charges, and Constable A pleaded guilty to the charge of failing to go to the call and not guilty to the charge of deceit.

An hour and one witness later, we broke for lunch.

Installment #56: “Her name was Kathryn…”

After the sluggish morning start, the afternoon testimony rolled along. Constable A had pleaded not guilty to the charge of lying about whether or not he had gone to the call. The charge was based on discrepancies the OIPRD investigators had found between his account of events and the accounts of the other officers who had attended the call two days later. Each officer’s testimony focused on what had been said or heard.

For my sisters, my niece and me, it really wasn’t relevant whether Constable A had lied about whether he’d gone to the call. We were here to give Kathryn a face—the face of a caring family.

Through the long afternoon, we steeled ourselves to hear, over and over, the details spoken in that overly formalized, dehumanizing language law enforcement seems to use  to describe people and events. Kathryn was the “deceased,” or “a female found VSA” (vital signs absent).

Then the officer who had greeted us with his sympathetic smile took the stand, and we learned he had been the supervising officer the night Kathryn’s body was found: Sergeant C.

Sergeant C testified that one of the things he had done after arriving at the “scene” was to confirm Kathryn’s ID. In a quiet but clear voice, he said, “I discovered her name was Kathryn Margaret Missen.”

Hearing my sister’s full name spoken by a uniformed officer at a hearing that until now had been characterized by dehumanizing language brought sudden tears to my eyes. I felt gratitude for this simple recitation of Kathryn’s identity. This quiet acknowledgement of her humanity.

By the time we adjourned, we had got through four of the six witnesses. It seemed likely we would finish the next day.

Outside, Sergeant C gave his condolences to Harriet. When she caught up to us at the car, she was teary-eyed but also smiling. “I just saw a dragonfly—it hovered around me for a few moments.”

A blue thread, hanging from the sky. A blue thread stitching Harriet to her mother. A reminder for us to stay focused on the bigger picture. A reminder that Kathryn was with us, giving her daughter gentle, winged comfort and all of us support and love.

Installment #57: Constable A’s hearing (take 1), day 2

Harriet wasn’t able to come with us the next day: she was chef at an Ottawa restaurant and had to work. It was just as well. One of the two remaining witnesses was the forensic identification officer, who provided physical details of Kathryn’s body that Harriet didn’t need to hear.

As each witness testified, we were forming a vivid picture of all the officers who had descended on Kathryn’s house the night of September 3rd, the state they had found her body in, and the investigation that had taken place to try to figure out what had happened. We weren’t, however, learning anything new about the errors that had taken place the day she had died—that is, until the final witness, the detective sergeant, took the stand. And then it was a passing mention we almost missed.

As we had previously learned from the chief superintendent’s February 2015 letter, the term “trouble on the line” had played a role in the lack of response to Kathryn’s call for help. The Smiths Falls call-taker had told the dispatcher that Bell Canada’s maintenance centre had confirmed the call was “trouble on the line,” and the dispatcher had passed this information on to Constable A.

We had also previously learned, from Steve, that Bell Canada had created the term back in the 1980s when the 911 system was conceived, to identify a state where there was a technical issue with the physical line. Problems with its use emerged after dispatchers began using it to categorize other anomalies with 911 calls, including lack of sound on a line and, in more recent years, pocket dials from cell phones.

In their OIPRD interviews, all the officers were asked what they understood the term to mean. While most gave the Bell definition, some said it meant Bell had confirmed there was a problem, while others said the problem could be caused by anything, including a disconnected line or the cord pulled out of the wall. Most stressed that, regardless, they were to attend the call. However, two, including Constable A, admitted that hearing a call was “trouble on the line” did, in practice, decrease the priority somewhat.

That is certainly what happened in Kathryn’s case, to the extent that her call wasn’t considered an emergency at all.

Now, in response to a question from our lawyer, the detective sergeant was explaining that the only way to confirm whether there is a technical issue with the phone line is for a Bell technician to go to the house to perform a test on the physical line, or for an officer to go inside to check the phone. He added that since September 2014, dispatchers and officers had been instructed by memo to refrain from using this term.

My sisters and I exchanged a look of pleased surprise. It was a small victory, a small sign that Kathryn’s death had already led to an important change. Not nearly enough, but a start.

An addendum to the Trouble on the Line thread

In the decision the adjudicator was to write after the hearing, she addressed the issue of trouble on the line:

Regardless of how one may interpret ‘trouble on the line’, the OPP critical policy is clear with respect the action an officer must take. It states:

…a uniform member shall respond forthwith to a 911 dispatch, regardless of a possible network malfunction, and proceed to the location, treating the incident as an emergency until proven otherwise.

Subject to this policy, I find the uncertainty created by the term, ‘trouble on the line’, bears no relevance on the course of action an OPP officer must follow. It is simple – a uniform member shall respond forthwith to a 911 dispatch.

For our family, the superintendent’s statement served as an important message: we were not to let anyone get sidetracked into thinking that the use of this term was a major reason for the lack of response to Kathryn’s call for help, or that a memo instructing employees to avoid using it in future would solve the problem (although we are happy it is no longer used). As Steve was to remind us, the problems were systemic and needed the probing light of an inquest to be shone on them.

Installment #58: Perceptions and misperceptions

The detective sergeant’s testimony—the last for the prosecution—was finished by 11 a.m. While the defence lawyer conferred with Constable A to determine whether he would take the stand, Lynne, Nancy and I stepped outside to enjoy the warm sun and fresh air. The counsel for the prosecution followed us out.

To our surprise she came over and introduced herself, apologizing for not having done so the previous day: “It makes me nervous when families show up with a lawyer,” she explained, adding that she’d just asked our lawyer if it was okay to speak to us.

We were astonished. We had never considered that bringing a lawyer with us would make us look “adversarial.” We had done so because we’d been given standing and because we hoped his questioning might glean more information about how the system had failed Kathryn. If we had thought about it at all, we’d have assumed our pleasant demeanour and greetings, even to “the other side,” would have shown how approachable we were.

The prosecutor’s admission gave us a heightened awareness of who did, and who didn’t, speak to us over the three days of the hearing. On the non-speaking side were the younger male officers—Constable A, Constable B, and Constable A’s riding partner. Their avoidance of even simple polite greetings extended to, and possibly originated with (even if just by example), the counsel for the defence, who also never once spoke to us, acknowledged our presence or looked our way. (I highlight all this only to provide context for the marked change that was to come.)

Back in the hearing room after the break, we learned that Constable A would not be testifying: we were now into the lawyers’ submissions. The defence lawyer asked for a recess for the rest of the day to prepare, which he was granted. We were to reconvene for a third day at 9 a.m.

Installment #59: Rejuvenating on Kathryn’s bench

My sisters and I might have been dismayed by the protraction of the proceedings except for the silver lining that we were going to be able to spend some enjoyable non-hearing family time together.

It was Nancy who remembered Kathryn’s bench. Months before, Father Murray, at Kathryn’s church, had let us know that the congregation was exploring ways to honour Kathryn’s memory and her many contributions—singing in the choir, producing the newsletter, photographing events, taking care of the gardens. A motet had been commissioned, which the choir was to premiere at the morning service in a couple of weeks. And a bench was to be installed on the church lawn.

We had recently heard from Father Murray that the bench was now in place, and so, at Nancy’s prompting, we drove back to Ottawa to see it.

St. Barnabas sits on the corner of busy Kent Street and quiet, residential James Street. It was on the latter side that we found the bench, on a pad of interlocking brick beside a tree, with a little path of the same brick leading to it from the sidewalk. The perfect place for someone to pause and sit quietly as they went about their day.

Sitting in a row on the bench, Nancy, Lynne and I did not sit quietly (that not being Missen family tradition). We were trying to get a selfie that showed both the three of us and the bench. This caused a great deal of hilarity, since photos taken with cellphones at arm’s length can create some rather amusing expressions and distortions, with heads cut off or sides of faces missing. Not to mention that the main subject, the bench, wasn’t showing up at all.

We began to look out for a passerby we could rope into taking a photo that would show us actually sitting on the bench. It was simple and elegant, made of durable composite materials resembling metal, with clean, straight lines that perfectly suited Kathryn’s non-flowery tastes. (Father Murray had kindly consulted with us, showing us the designs they were considering, so we already knew what it looked like.) The plaque was not yet in place—that would come in time for the dedication ceremony in the fall.

We spied a man coming along the sidewalk but he seemed intent on not looking our way and seemed, in fact, to quicken his pace—perhaps frightened by three giggling females, who were trying, not very successfully, to hide their amusement at his alarm.

Finally, a woman called out from the sidewalk: “Are you just having fun taking selfies or would you like me to take your picture?”

Gratefully we handed her our phones and she perfectly captured the three sisters rejuvenating on the fourth sister’s beautiful bench.

Installment #60: Constable A’s hearing (take 1), day 3

We arrived in Smiths Falls for the final day of Constable A’s hearing more than a little tired. We’d been up late the previous evening after meeting up with friends at the restaurant where Harriet was chef (chosen so we could see her too, as well as enjoy her always-stellar food).

After the restaurant emptied out, Harriet was free to come and sit with us, and our phones came out for more photos. No one can remember what set us off but we have photo-documented evidence that something got us: my photos show Nancy and Harriet laughing so hard Harriet’s eyes are squeezed tight and Nancy’s head is down on the table. Truly, it was either laugh or cry after all that gruelling testimony. Crying and laughing both give the tear ducts a workout but it’s much more fun to laugh than cry and—being Missens (or Missen derivatives)—when we have the choice we opt for laughter: in this case extreme hilarity for an extreme release.

The previous evening’s fun was a sharp contrast to the morning’s dry lawyer submissions. Finally they were finished, and the adjudicator explained that she was now going to go away and write her decision, though it would take a bit longer than the usual four weeks. “Then we’ll meet again, or have a video conference, for the penalty decision.”

And that was it. We were done. We were spent but relieved. The first hearing, at least, was over. (Or so we thought.)

In the warm sun in the parking lot we chatted with our lawyer. As we did, we were joined by several other entities. They hovered around us, on dragonfly wings, bringing smiles, and maybe a tear or two, to our weary faces.

Installment #61: A motet and a pair of treble clefs

On the morning of June 12th, 2016, Harriet and I set out on foot from her apartment in our “Sunday best.” Apart from attending Kathryn’s funeral, neither of us had ever been in St. Barnabas the Apostle & Martyr Anglo-Catholic Church. But that was where we were heading: at this morning’s service the choir was to premiere Salvator Mundi (Saviour of the World), the motet that had been commissioned in Kathryn’s memory.

In my purse I carried a little mesh bag holding a pair of my sister’s earrings. Shaped like treble clefs, and inset with marquisite, they had been among the jewellery pieces that Harriet had gathered for her aunties to divide up the previous Christmas. Along with the treble clefs, I picked out several other sets of earrings, including, yes, a pair of silver dragonflies. The treble clefs seemed an appropriate accessory for the motet premiere. Unfortunately, as I was getting ready, I discovered one of the backs was missing, and Harriet didn’t have a spare. That was when it came to me to bring them along to give to one of the choir members—whichever one felt appropriate.

Harriet and I chose a pew midway from the sanctuary. When it came time for communion, we listened for the opening bars of the motet. Because the choir sings from the back gallery, unseen, the music that filled our ears seemed to emanate from the vast space of the church itself.

It was a sombre piece, a little too minor key for my personal liking. Glancing at Harriet though, as the final notes ended, I saw tears in her eyes and heard her say, softly, “Mum would have really liked it.” Chastened, I realized she was right: Kathryn had a much more sophisticated appreciation of music than I did. She would have loved it.

As Father Murray had suggested, Harriet and I snuck out during the last hymn so we could greet the choristers as they came down the back stairs from the gallery. It was quite awhile before anyone appeared. At last we heard footsteps on the steep steps. A woman walked past us with a warm hello, went out the door, then reappeared and climbed back up the stairs. Moments later she was back, holding up an iPod for our benefit. “Forgot it,” she explained, smiling.

This time I noticed she was wearing dangly earrings and asked if she were a choir member.

“Sometimes,” she replied. She introduced herself, adding, “I was Kathryn’s singing teacher.”

Harriet and I knew her name very well—Kathryn had spoken often, and fondly, of her singing teacher.

I pulled the little bag out of my purse.

The exchange—treble-clef earrings for teary gratitude (“I will treasure them”)—was made discreetly and efficiently, before any of the other choir members came down the stairs. Kathryn had flawlessly orchestrated the giving of this most perfect gift to a beloved teacher who had taught her so much about singing.

Installment #62: Constable B hearing (take 1)

On June 26th my sisters and I booked again into “our” Ottawa hotel and the next morning made the hour-long drive—with Harriet, breakfast sandwiches and coffees—to Smiths Falls. This time it was for Constable B’s hearing.

Although we had a new adjudicator (an inspector), all the other players were the same as at Constable A’s hearing: the counsel for the defence, the counsel for the prosecution, and of course our lawyer.

Constable B pleaded not guilty to the charge that he had “willfully or negligently made a false/misleading statement” with respect to his account of what Constable A had told him about whether he had gone to Kathryn’s call.

The first witness was the OIPRD lead investigator. We recognized him: he had sat in on Constable A’s hearing. The prosecution, and then our lawyer, took him through the interview he had done with Constable B.

The testimony limped along, with the defence making many objections (most overruled), until the cross-examination, when the proceedings came to an abrupt halt.

At issue for the defence lawyer were the personal notes he had seen the investigator make during Constable A’s hearing. The defence lawyer wanted a copy of the notes, citing that they went toward credibility.

The adjudicator was unsure how to proceed and wanted guidance from his legal counsel—who couldn’t be reached. The hearing therefore had to be adjourned, a mere two and a half hours after it had got under way.

It was, our lawyer bluntly put it in the parking lot before we parted ways, a farce. There was nothing in the investigator’s notes that could possibly affect his testimony, which was based on his interviews, which were all on tape, as well as in written summary. (Not to mention that it is standard practice for investigators to sit in on other testimony before and/or after they take the stand.)

The hearing resumed the next morning, with the adjudicator asking for a discussion concerning the relevance of the investigator’s notes.

The counsel for the prosecution read a note from the OIPRD director that the investigator’s notes were protected by litigation privilege. Any ruling, she quoted, would have serious implications for all notes of all investigators in cases under the Police Services Act.

The defence lawyer would not back down. And so, 40 minutes into day two of the hearing (which would most likely have wrapped up by the end of the day), we were again adjourned. And it was to be for at least two weeks while the issue was resolved. And then new dates suiting everyone’s schedule would need to be found.

My sisters and I had spent travel time and money for less than three and a half hours of testimony over two days—testimony that had got us nowhere.

As it turned out, the hearing would not resume for another five months and would not be concluded until the new year. And for a much more serious reason than the issue of the investigator’s notes.

Installment #63: Decisions

July 2016 was to be a month of decisions.

First, the two-year window for launching a lawsuit was going to close in September, and our lawyer was, reasonably enough, asking for our decision so he would have time to prepare.

After yet another family discussion, we decided against a suit. The clincher was learning from the lawyer that we could not carry out our primary motive for launching it—that is, we could not impose conditions that specified changes to be made to the system. A secondary motive was to bring attention to the issue, but the lawyer pointed out that while we might get our few minutes of fame when we announced the suit, the settlement might very well include a confidentiality clause. That “settled” it for us: we wanted to retain our freedom to speak about it. Not being a litigiously minded family, I think we were all relieved—if no further ahead.

We still had no decision from the regional coroner, despite many emails sent to her office by our lawyer (who had taken over from Steve as our official representative). The regional coroner had responded, in February, that she was still waiting for information from the OPP, and then, in April, that she had sent all the materials, including our call for an inquest, to the Inquest Advisory Committee. In early June, she wrote that she was still waiting for the committee’s response but once received she would do her final review of the file and make a decision.

In early July, we received Superintendent McElary-Downer’s “Decision with Reasons” in the case of Constable A: she found him guilty of deceit.

A week later, six weeks shy of the second anniversary of Kathryn’s death, we finally received the regional coroner’s decision: it was no to an inquest.

Installment #64: Corks in a leaking dam

To say we were disappointed by the regional coroner’s decision is an understatement. We were completely flattened and frustrated—especially when we read the reasons for the denial.

The principal reason boiled down to this: as a result of its internal review, the OPP had, the regional coroner said, already made recommendations and actions to change the 911 system (the eight “action items/recommendations” she had shared with us at our meetings with her). Both the regional coroner and the Advisory Committee were satisfied that “many of the recommendations that a jury at an inquest in to the death of Ms. Missen might make to prevent future deaths have already been addressed.”

In our previous meetings, the regional coroner had mentioned several possible alternatives to an inquest, including a Regional Coroner’s Review. In the letter containing her decision, she revealed that she had, in fact, held a Coroner’s Review with the OPP the previous September, just two weeks after our second meeting with her. As she now explained in her letter, during the Coroner’s Review she had asked additional questions about “oversight, responsibilities, communication, protocols and standards, and quality assurance.” And she had received a written response from the OPP to these questions in March—a 10-page “Information Package with Reference to Kathryn Missen.”

The regional coroner had actually forwarded this report to us, through our lawyer in June, although we’d had no idea then that it was the result of a Coroner’s Regional Review. Nor did we feel that the actions outlined by the OPP went nearly far enough to fix the flaws in the system. As Steve put it, the OPP’s actions were the equivalent of “sticking a few corks in a leaking system; it merely delays the inevitable.”

In addition to the disappointing decision and reasons, the regional coroner’s letter quoted statements from the Advisory Committee that implied that our family did not understand the purpose of an inquest and that we were advocating for one to serve our own “private interests.” The regional coroner also quoted the committee’s comments that “a coroner’s inquest is not the vehicle by which someone is held responsible or accountable for a death, and would not be the appropriate venue for dealing with these matters.” We were vexed by these statements. Over and over, in both our meetings and correspondence with the regional coroner, we had clearly stated that our intention was precisely not to blame individuals but to improve the system so that what had happened to Kathryn never happened to anyone else.

On our lawyer’s encouragement, we wrote the regional coroner a letter, expressing our family’s vexation, deep disappointment, and indeed our alarm on behalf of public safety, that she had decided against an inquest.

Installment #65: In which we learn of a major conflict of interest

In August 2016, two months after the aborted hearing for Constable B, we learned that his hearing was not just to be further delayed—it was to begin all over again. And the reason was something no one had realized back in June: in showing up to represent Constable B, after having cross-examined him in Constable A’s hearing, the defence lawyer was in a total conflict of interest.

We learned this news in a phone call from our lawyer, who added, “They want to start both hearings again, with new lawyers for each constable. They are seeking your input.”

The thought of starting both hearings again was dismaying to say the least. And in Constable A’s case we didn’t see why it was necessary: the conflict of interest had not occurred until the defence lawyer had shown up to defend Constable B.

Two proposals for Constable A were put on the table.

The first, from the OPP, was to declare a mistrial and schedule a new hearing, this time with a stated penalty of dismissal rather than demotion.

The second, from the Ontario Provincial Police Association (the provider of the constables’ legal representation), was to stay the charge of deceit and to penalize Constable A only for his previous plea of guilty to the charge of negligence of duty.

Our lawyer reported that Superintendent McElary-Downer, the adjudicator, was very uncomfortable with the proposal to have a new hearing. She was concerned about the emotional, financial and time costs to our family—concern that we very much appreciated.

It was gratifying to hear that we were to have a say in the proposal. We learned that, under the Police Services Act, any informal resolution proposed by the prosecution and defence requires the consent of the public complainant—in this case, our family (through Steve). The OIPRD director also had to be on board.

After conferring as a family, we asked our lawyer to convey our objection to both proposals—though we added that if a new hearing did have to be called, we supported the penalty of dismissal. (We were to regret voicing that support, which implied we were “blaming” Constable A, and I believe the reason we made it was out of sheer frustration at the situation rather than any desire to punish him.)

Discussions were to drag on into the fall. By then Constable A had a new lawyer, who put forward a third proposal: in lieu of a new trial, Constable A would plead guilty to two counts of negligence and receive a penalty of two years’ demotion (rather than the three he had been subject to after the first hearing). Our family was to support this proposal.

But we weren’t there yet. It was still summer, and we were badly in need of down time from all the meetings, discussions, hearings, writing and digesting of emails and letters, and phone consultations. For me, that meant lots of time on my dock.

Installment #66: An impromptu (if incomplete) Sisters’ Weekend 

Nancy, Maddy, and I sat on the dock in the shade of my big yellow umbrella. Nancy was here for her annual summer visit.

On our laps were our books and, in my hand, a letter I had just received in the mail from the regional coroner. We had not been expecting a response to the letter we had sent off expressing our disappointment in her decision. This letter was brief but gratifying: it advised that we could, as per the Coroner’s Act, appeal to the chief coroner to review the regional coroner’s decision. The letter noted that the appeal had to be made within 20 days of receiving the decision.

Doing some mental calculations, Nancy and I realized that window had already closed. However, we agreed—as did Lynne and Harriet later—that we had nothing to lose by making the appeal anyway and asking the chief coroner to overlook the lapsed appeal period. I would draft the letter. Tomorrow….

We went back to our books. Minutes later my reading was interrupted by a sudden exclamation from Nancy. “A dragonfly just landed on your hat! Darn. Why didn’t I bring my camera down?”

My cell phone was in the bag beside my chair. Keeping my head still, so as not to startle away the dragonfly, I extended my hand for the phone, and then aimed the screen in the general direction of the top of my head.

I clicked a photo and, again being careful not to make any sudden moves, brought the phone down to eye level to have a look.

I smiled. The dragonfly was one of the “big guys” (or, in this case, probably “gal”…). She sat right on the top of my ball cap, looking quite at home. What I had forgotten until I saw the photo was that this particular hat—a gift from my friend Asante—had the word “Angel” embroidered on the front. The word now seemed an amusing label for the dragonfly perched above it.

I raised the phone to click more blind photos, and the dragonfly—whom Nancy and I naturally began to call “Kathryn”—obligingly turned to give me her best profile.

She stayed put an unusually long time for a dragonfly, maybe 10 or 15 minutes. There was no doubt for Nancy and me that she had come to join in a mini “Sisters’ Weekend,” relaxing with us on the dock, where the four sisters had sat together many times. We were just sorry Lynne wasn’t there to complete the foursome.

Although many a dragonfly has touched down on my dock to rest for few moments, this was the first time one has ever settled in for a visit on the top of my head. Kathryn always did like to linger…

I like to think she was also having a good laugh perched on a hat that labelled her an “angel.”

Installment #67: Constable B hearing (take 2)

I peeked out the hotel window and called out to my sisters that we were going to have to leave extra early. Then I pulled back the drapes to reveal the newly white world.

It was December 5th and we were back in Ottawa for take 2 of Constable B’s hearing, which was scheduled for three days. We were still waiting for a resolution to the proposal for Constable A. The good news was that we had succeeded in our appeal to have the chief coroner review the regional coroner’s decision. Our request was to be considered first by the Death Investigation Oversight Council, which provided advice to the chief coroner. This process would take four to 12 weeks. We were asked for our patience….

We left Ottawa for Smiths Falls in good time, but without Harriet. She had been working late for the past seven days in a row, and we left her to get some much-needed rest.

In the snowy slow-traffic conditions, it took almost twice as long to get to Smiths Falls but we made it in time for a 9 a.m. start—only to discover that the hearing hadn’t been scheduled to begin until 10. And then it didn’t get underway for nearly another hour because everyone else was delayed by the weather.

The three of us were feeling just a little grumpy about the effort we’d made, not just to get here on time but to have taken time off work to be here at all. Whether or not Constable B had covered up for Constable A had absolutely no bearing on whether Kathryn would have survived, and nothing we heard today would likely shed any light on how the system had failed her two days before the events to be examined.

We finally assembled in the hearing room, with a new prosecutor (a more senior member of the OPP legal team) and, of course, a new lawyer for Constable B.

The prosecutor announced that one witness was on leave until the end of December and that another (Constable A) might not be able to come today. My sisters and I exchanged a look. We wouldn’t be finishing the hearing this trip, let alone this day.

We heard from three witnesses, and then no more witnesses were available. The counsel for the prosecution asked for the hearing to resume in January. It was agreed that the lawyers and the adjudicator would hold a teleconference to come up with a date.

After the hearing was adjourned, our lawyer turned around from his table and expressed his regret that we hadn’t been be able to finish. No doubt sensing our frustration, he added, “It’s a great testimony to Kathryn that you sisters keep coming to these hearings.”

To our surprise, he added, “Not many families attend the hearings after making the complaint. Your presence keeps everyone focused on Kathryn.”

Here was the reminder we needed: the reminder of why we were here, no matter how many delays there were, or how many times we had to return.

Installment #68: Constable B speaks

We were packing up our things to leave when we realized Constable B was standing at the end of our table. It was the first time he had approached us.

He spoke quickly, perhaps unsure how we would receive him. “I didn’t have a chance before to tell you how sorry I am you have to keep going through this and hearing the details over and over.”

“And we’re sorry you have to keep coming back too,” Lynne immediately responded.

I added, “We want you to know we don’t bear you any ill will.” As I spoke, I realized it was true. It was something I had been feeling for a long time and wanting to say.

“I appreciate hearing that,” said Constable B.

It was a brief exchange but one that touched us immensely. In a hearing room that by its very nature is adversarial (and even more so, apparently, when the family shows up with its own counsel), it takes courage to approach “the other side.” We gave Constable B a lot of credit for coming over to speak to us.

His gesture had the effect of further dissipating our frustration from the weather delays, the witness delays and yet one more hearing adjournment. We hoped Constable B would go home feeling a little easier in his mind too.

It was on the drive back to the hotel that I began to wish there was a way to get this same message to Constable A. We would be seeing him again as a witness when Constable B’s hearing resumed, and presumably at the resolution of his own hearing—though we still had no decision on the proposals that had been put forward.

It was true that his sullen demeanor didn’t make him very approachable. And my sisters and niece and I were possibly not as brave as Constable B had been in approaching “the other side” when there was no certainty of how we would be received. But I began to pray there would be a way to let him know.

We drove back to Ottawa thinking of the implications of a simple exchange such as the one we had just had with Constable B. We were learning that it’s possible to hold systems, and people, to account without holding blame, resentment or anger toward the individuals. We were learning that it’s possible to forgive everyone involved—the 911 call-takers and dispatchers, the OPP constables and supervisors—everyone who had fallen down on the job to one degree or another—and still strive to make changes to improve the system.

Installment #69: Back in the waiting game

The new year, 2017, arrived with more snow and ice and yet more hearing delays for Constable B and Constable A.

New dates of January 17th-19th had been set for Constable B. In Constable A’s case, the OIPRD director had yet to agree to the third proposal (a lesser penalty in exchange for a guilty plea to both charges).

In mid-January, despite the OIPRD director’s continued lack of blessing, the adjudicator, Superintendent McElary-Downer, set the date of January 23rd for everyone to reconvene in Smiths Falls. She made it clear she wanted everything resolved that day. She would hear submissions from all the parties. If she ruled in favour of the proposal, a new charge sheet would be made up, Constable A would plead guilty, and she would sentence him to two years’ demotion: all this would happen in that one day. We were relieved and impressed with her decisiveness and proactiveness in getting the process moving again.

And, then, on January 16th—the day before Constable B’s hearing was to resume—the prosecutor had a bad fall on the ice and was unable to travel. Constable B’s hearing was therefore postponed until February 24th and the meeting for Constable A rescheduled for January 30th.

Since we were back in a waiting game, I decided to check with the chief coroner’s office on where our appeal on the inquest decision stood. I felt comfortable asking, given how receptive this office had already been: we had received a response within three weeks of our request back in September—which was pretty immediate given that both letters had been sent by “snail mail.”

My follow-up email also received an immediate response, letting us know that the Death Investigation Oversight Committee had completed its review in mid-November and that the file was now with the chief coroner. We would receive a decision by mid-February.

Dared we hope that the chief coroner would reverse the regional coroner’s decision and call an inquest?

Installment #70: The chief coroner calls 

When I answered my ringing phone on the morning of January 27th, 2017, and the caller identified himself as the chief coroner for Ontario, I was both surprised and honoured: I had been expecting to receive his decision by email or letter. But even as he was offering his condolences for our family’s loss and how difficult it must be to be pursuing an inquest in the midst of our sorrow, I was, for some reason, certain he was going to tell me that he had decided to uphold the regional coroner’s decision.

My negative assumption was proved happily wrong. He was calling, he said, to say that after careful review, he had made the decision that an inquest should be held. It was to be a joint inquest with another appeal that had come across his desk at the same time. The particulars of the two cases were very different (the other involved a boating accident in Sudbury with the call for help made by cell phone), but both highlighted concerns with the 911 system, and he felt there was merit in having a public discourse on Ontario’s emergency response system. The purpose of the inquest, he explained, would be to review the system through the lens of the two very different cases in two different parts of the province.

He had, he told me, advised the regional coroner of his decision and she was very happy. He added that he believed both the advisory committee’s recommendation and the regional coroner’s decision had been reasonable, and stressed that it was the fact that the two cases amplified each other that had led to his decision.

“Since it’s an inquest,” he went on, “there will be a specific scope to it, and we will be deciding what that scope is, within the framework of the two events. You may not get specific answers you’re seeking.”

To which I responded, “If you’re going to examine the 911 system and potentially make recommendations for improvement, then that’s exactly what we’re seeking.”

He explained that it was going to take some time to figure out the logistics—how to get both communities involved and able to participate given that the locations were so far apart. So there was no timeline yet. “It could be many months, or even a year.” But not, he assured me, years.

He indicated that a media release would go out the following week, and asked me to keep it confidential until then.

“I hope I can tell my sisters and my niece?” I asked, half joking.

He laughed. “Of course.”

I thanked him profusely for his decision—and for his call. I couldn’t wait to share the news with Nancy, Lynne and Harriet. All our persistence, and Steve’s, had paid off. We were going to get an inquest. At last.

Installment #71: Constable A’s hearing (take 2) 

On the morning of Monday, January 30th, 2017, Nancy, Lynne, Harriet and I made the all too familiar drive from Ottawa to Smiths Falls for the resolution of Constable A’s disciplinary hearing. The weather was good—cold of course but just a few flurries.

There had been some family discussion about whether all of us needed to come for today’s proceedings, especially Nancy and Lynne, who had to travel the farthest and book days off work. The proposal—Constable A’s guilty plea to both charges in exchange for a lesser penalty—was a formality that would not likely take long, especially with everyone (we understood) now on board. Was it worth all our travel efforts? In the end, we decided that since all of us had been there from the beginning, we all wanted to see it through.

We arrived in the hearing room to find a large screen had been set up on “our” side of the room. It turned out that the new counsel for the prosecution still couldn’t travel because of her injuries and was going to attend by video link. (This senior member of the prosecution team was replacing the original prosecutor, as she had at Constable B’s previous hearing in December.)

As soon as Superintendent McElary-Downer opened the proceedings, the prosecutor—larger than life on the screen—announced that her “client” (the OPP) was not on board with respect to the penalty (a two-year demotion). Her client, she said, now wanted the original penalty of a three-year demotion. She was concerned, however, that opening up the penalty discussion would open the door for the defence to change their position and ask for any penalty they wanted.

Nancy, Lynne, Harriet and I looked at each other in dismay. Was the hearing going to have to start again after all?

The new lawyer for the defence, Vincent Clifford, stood up and announced that he was not going to change his position­; he would maintain the penalty position that had been agreed to for the previous six weeks.

All of the parties, including the prosecutor, agreed that in the absence of agreement it would be up to the superintendent to decide on the penalty: she would declare an administrative mistrial with respect to Constable A’s previous hearing, have a new list of charges prepared (to which Constable A would plead guilty), and hear the lawyers’ submissions. She would then go away to decide on the penalty and write a new Decision with Reasons.

Within an hour and 40 minutes, the superintendent was reading the new charge sheet to Constable A.

Constable A stood up and pleaded guilty to both charges.

There was a silent, collective sigh of relief from the family table. So far so good.

Installment #72: A room with no sides

After Constable A’s guilty plea, we were into submissions from the three lawyers.

Constable A’s new lawyer, Vincent Clifford, spoke first. His demeanor and delivery were calm, conciliatory, articulate. He provided background on Constable A that his first lawyer had never offered: we heard about his first-class ranking, a commendation he had received, his lack of any previous disciplinary issues. We also heard details of his health and well-being that had led to his leave from the OPP. These were not, said Mr. Clifford, offered as mitigating factors, but to show that Constable A now had in place appropriate support mechanisms to get back to active duty.

“One thing Constable A has not acknowledged in this hearing yet,” continued Mr. Clifford, “is that he had a duty to perform and he let down his employer and he let down Ms. Missen and he let down the family. He’s sorry. And he’s embarrassed.”

In this very unexpected apology on behalf of Constable A, it was the word “embarrassed” that caught my attention. Embarrassment would explain his inability to meet our eye or give us even a simple greeting at his previous hearing. What had come across as sullenness was very likely a deep sense of shame and guilt. I found myself hoping even more that we would have the chance to tell him we bore him no ill will.

In her submission, the counsel for the prosecution outlined the stiffer penalty the OPP were seeking. Although unable to find an identical case, she quoted from other cases where officers had been convicted of neglect of duty. Notably, the penalties were much less than what the OPP was now seeking for Constable A.

In the midst of her submission, it struck me that there were no longer any “sides” in the hearing room. There was, rather, a group of people all working together. Even the prosecutor, video-linked from Aurora, 350 kilometres away, was right there, part of a group that was working very hard to find a way to bring a painful, protracted process to resolution.

Installment #73: Constable A speaks

After the three lawyers had made their submissions, the superintendent asked Constable A if there was anything he wanted to say (something that, again, had not been done at his previous hearing).

Constable A stood up. He turned to face Kathryn’s daughter and her three sisters, who were tearing up before he even said a word.

Seeming to struggle to keep his composure, Constable A told us he was sorry for his part in the events that had led to Kathryn’s death. He told us that he took full responsibility for his role in those events and—his voice breaking and tears now streaming unchecked—that he hoped we would accept his apology.

We could only nod at him through our own tears, and he sat back down.

Superintendent McElary-Downer then made her closing statement. This was, she said, the worst case she had ever sat through, hearing about all the bungles that had been made the day Kathryn had called 911.

Turning to Nancy, Lynne, Harriet, and me, she said she felt badly for all we had been through, adding that whatever it was we were hoping for, she hoped we would get it. (This was a reference to the fact that at the end of his submission, our lawyer had started to announce that an inquest had been called but we’d had to stop him because we weren’t at liberty to make it public yet.)

The superintendent turned next to Constable A to say that his standing up and taking full responsibility spoke well of him. She was sure that what he had done wasn’t really who he was, and she hoped he would get the support he needed.

As soon as the proceedings were completed, the four of us had a quick family consultation and then, for the first time in the half dozen times that we had come for the hearings, crossed the room.

Installment #74: Kathryn’s family speaks

When we approached Constable A standing at his table, he was still looking very emotional.

“We want you to know we don’t hold you personally responsible for Kathryn’s death,” I told him. “We aren’t blaming any individuals. We know that the more serious problems were with the 911 dispatch and with the system. We hope you’re going to be okay.”

At my words, Constable A broke down again. His tears triggered more of our own, and one by one, Harriet, Nancy, Lynne, and I embraced him.

We weren’t aware that anyone was watching this emotional reconciliation. But a little later, when we were gathering up our things to leave, the sergeant major in charge of organizing the hearing told us how rare it was to see the family reaching out to the convicted officer.

This was more sad than gratifying to hear. True justice, we had just experienced, does not consist in seeing the one you feel has wronged you punished for their actions. True justice lies in forgiveness  and reconciliation. Through forgiveness comes healing—both to those who feel “wronged” and to those “in the wrong.” (We were to experience this in an even more powerful way, with the dispatcher and the call-taker as well as Constable A, at the inquest to come.)

I had never blamed Constable A for what had happened to Kathryn, so you could say that forgiving him (for his actions/non-actions the night she died) was easy. Forgiving him also had nothing to do with his remorse. His new vulnerability and openness had just made it easier for us to approach him and tell him. And I was doubly glad we had done so: from his very emotional response, it was clear he needed to hear that we didn’t blame him.

In fact, his extreme emotion seemed to indicate he was blaming himself. And much more important than receiving our expression of forgiveness was whether he could forgive himself. The fact that he had been able to stand up and take responsibility for his actions, to feel and express remorse (perhaps for the first time), was an important start. I hoped hearing that we didn’t blame him would help him to let go of his own sense of inner blame.

(During his testimony at the inquest 21 months later, Constable A was to tell us that when we had approached and hugged him at this hearing it was like 10,000 pounds had been lifted from his shoulders, although he added that he hadn’t forgiven himself yet. But I believe Kathryn is on that job. As he also testified, he dreams of her almost every night and she’s smiling at him—an indication, I do believe, that she is urging him to be at peace inside.)

On the way back to Ottawa, the atmosphere in the car was one of great emotion: astonishment, relief, and, perhaps most of all, a joy-filled poignance. As with Constable B’s previous hearing, we realized there was a reason we had all come here today.

Harriet went further, putting into perspective all the frustrating delays and restarts we had experienced over the past eight months: “Maybe,” she said, “we needed to wait until we had all the right people in the room.”

Installment #75: Superintendent McElary-Downer speaks

It took only two weeks for Superintendent McElary-Downer to write her decision for Constable A. She began by offering a moving apology to our family, and remarked several times on our diligence in being present for the entire proceedings. She also commented, in an insightful and compassionate way, on the “heavy weight of shame” that Constable A was carrying on his shoulders.

In the section on procedural fairness, she said:

I respect the OPP’s principled position in relation to the sanction and cannot argue that PC __’s guilty plea has come late in the day and he has benefited from the reduced charge of neglect of duty. Notwithstanding, I cannot ignore how far the parties have moved to salvage a proceeding dirtied by the unprincipled conduct of PC __’s former counsel. Commendably, they collectively found a way to move forward despite this unprecedented irregularity. Yes, PC __did not plead guilty at the first opportunity and yes, I believe he has benefited from a lesser charge. That said, had it not been for his cooperation today, this matter would not have been resolved, and the cost and emotional damage to the family would have only deepened. This weighs heavily in favour of PC __.

She commented that his choices, including his choice to plead guilty, were indicative of one who had accepted responsibility and was prepared to be held accountable. “Further, his choices prevented the family from further grief and allowed them to at last bring finality to this matter.”

The need to protect the family’s interests in this matter is paramount in my view. They not only experienced the tragic loss of their loved one, but they suffered emotionally and financially in pursuit of the truth. They joined with the officer in an agreed to sanction, illustrating to me their strong desire to bring finality to this proceeding. Had they not done so, I would not land on the two-year demotion in light of the serious nature of his misconduct.

My sisters and Harriet and I were very moved by her concern for us and her apology, and happy with her penalty decision.

If you would like to read an insightful, concise, compassionate and sensitive summary of those extraordinary two hours in the hearing room at OPP Regional Headquarters in Smiths Falls on January 30th, 2017, here is the link to Superintendent McElary-Downer’s Disposition with Reasons.

Installment #76: In which we step out of our roles

Several weeks after Constable A’s hearing, we were buzzed in the door of the Smiths Falls OPP Regional Headquarters for what we sincerely hoped would be the last time: we were here to finish Constable B’s hearing.

In the waiting area, we spotted Constable A, who was here as a witness. He approached us with a shy smile and told us that the chief coroner’s office had already contacted him, and the dispatcher too, to ask if they would testify at the inquest. They had each indicated their eagerness to do so. We were very glad to hear this, and pleased that the inquest ball was already rolling.

The atmosphere in the hearing room was, again, completely transformed. There were few objections, no delay tactics, and no “attitude” on the part of the witnesses. When Constable A and Constable B each took the stand, they answered the lawyers’ questions calmly and patiently, even when the same questions were put to them over and over.

After the lawyers had made their submissions and the hearing was over (at last!), Constable B came over to tell us he was relieved this was over for us now. We shook his hand and told him about the inquest, which by now had been officially announced.

Whether Constable B had told the truth in his testimony was impossible to say—and in any case was irrelevant to us and to Kathryn. If he had lied, it was, I felt, out of a misguided attempt to help out a colleague in a (serious) jam. I knew I would be just as happy if he was found not guilty. (And this turned out to be the case, as we learned when we received the adjudicator’s Disposition with Reasons in late April.)

In the days following that final hearing for Constable B, I couldn’t shake off the strange feeling that we had become a kind of “family” with the two constables. As a result of the courage each had demonstrated in speaking to us at their previous hearings, we had established a rapport, and there was now a connection—a sympathetic connection—despite what they had, or hadn’t, done. It was as if we had taken on roles in a play—“Accused,” “Witness,” “Complainant”—and once we had reached the end of the script and left the hearing room “stage,” we could drop those roles and interact amicably with each other, as our real selves.

It seemed to me that Kathryn and I, too, had taken on roles in our difficult sibling relationship. After her sudden death, all our personality clashes from those roles dropped away, as if we had walked out of a room with “sides” and judgements. Now we, too, could simply be our true, loving selves with each other.

Not to say that the roles aren’t important. From my experience, it’s through the roles we play in each other’s lives that we (hopefully!) learn our toughest lessons. Kathryn, in death, was teaching me greater compassion and tolerance. Similarly, I hoped Constable A and Constable B would each take from this experience whatever it was they needed, and carry on in their policing (and non-policing) lives with a new consciousness. A consciousness of Kathryn.

Installment #77: Harriet speaks

On February 21st, 2017, the Ottawa Citizen reported on the results of Constable A’s hearing (the first press Kathryn’s death was to receive), and Harriet wrote the following Facebook post, which she has given me permission to reproduce:

Hello Friends,

Many of you know the circumstances surrounding the tragic death of my beloved mum. But we as a family have not put it out in the open for all until now. After two years of lobbying and some hearings there is finally going to be an inquest into my mum’s death in conjunction with another tragedy in Sudbury. I am very relieved this is going to happen as it has been a tough go. I am very hopeful that the inquest will bring about some much needed change to the 911 system. I am very grateful to my family and friends for being my rocks to help us through this hard time. All I wish is that my mum did not die for nothing and that something good and potentially life saving can come out of her death.

The Citizen has written an article about it that is in today’s paper, the bottom of the front page. The reporter has placed a focus on the officer who did not attend my mum’s call. I would like to say that I do not hold him personally responsible and feel strongly that it was the entire system, especially the tiered call centre response, that failed my mum. It was a domino effect in the worst possible way and no one person is to blame.

This is why I am hopeful for the inquest. If we can prevent this from happening again then my mum’s death will have meaning and we can all find strength through it.

I am so thankful to everyone, especially my aunts (Nancy, Brenda and Lynne), my father and his wife, and Steve Dick for helping me navigate this. And if nothing else comes of it, this ordeal has brought my family closer together, and for that I will be eternally grateful.

I miss my mum more than words could ever describe. She was the most wonderful woman, kind, strong, opinionated, smart, funny and, above all, wise and forgiving. I am lucky to have had such a strong woman influence and teach me, and it is through her teachings that I am able to find it in my heart to forgive the individuals who were involved. I do not condone what happened but I think we need to find humanity and forgiveness in light of terrible circumstances. I have my mum to thank for this and I want that to be the message you take away from this.

Installment #78: Kathryn’s friend Cynthia speaks

In July 2017, I received an email from Kathryn’s good friend Cynthia (whose tribute to my sister you can read here). She was writing to ask if she could share with me something that had been “quietly rumbling around” inside her since Kathryn’s death—something that was weighing on her heart.

Her email went on to say that the day before she died, Kate had spent the evening with Cynthia and her husband. Because it was raining heavily and a long drive to Casselman, they asked if she would stay overnight but Kate preferred to sleep in her own bed. She emailed them later to say she had made it home safely.

Cynthia prefaced this story by saying she does believe that everything happens for a reason and that Kate was meant to go when she did. Still, she couldn’t help wondering if events would have unfolded differently if she had insisted (and Kate had agreed) that she stay over. In closing she expressed her hope that by writing this she wasn’t indulging a whim of guilt or causing me distress.

Far from distressing me, I found it comforting to hear that Kathryn had been with such good friends the evening before she died. And it was heartening to hear that Cynthia, too, felt that Kathryn’s time had come and that (beyond any natural “human” regret and guilt) she really did know there was nothing she could have done to prevent her death.

In turn I shared with her the revelation that had come to me in the hospital—that Kathryn and Mom were connected “soul-wise” and meant to die at the same time, and that I felt Kathryn had chosen to go first to show Mom the way.

Cynthia’s response blew me away. During that last visit, she wrote, Kate had shared her concerns about some recent conversations she’d had with our mother about what happens when we die. “Apparently your mother had given up hope that there is a greater place for the spirit to rest. Kate was going to speak to her about this.” (Kathryn had been due to go back to Toronto the following Thursday—several days after she died—while I was still in Algonquin Park.)

Cynthia went on to write that the following Friday night—the night I spent with Mom in the hospital, the night the revelation came to me in the bathroom—she felt Kate with her. “She was telling me she was alright, she was good but she was very busy just now and couldn’t linger. So I was not surprised to learn that your mother passed hours later. Kate had been there to receive her and it was something they had agreed to. I haven’t had any further visits but I know she fulfilled her role.”

I have never doubted my own “bathroom revelation.” Nevertheless, reading this message from a woman who I had met maybe only once, and who had never met my mother, brought me great comfort, and joy to my heart.

Cynthia similarly told me how lifted she felt in sharing with me her misplaced guilt, knowing there was nothing she could have done to change the course of events.

I have no doubt our correspondence was engineered by Kathryn, who now knows so thoroughly and compassionately what is in each of our hearts and wants only peace of mind and heart for all of us.

Installment #79: Kathryn speaks

My sister was a closet poet—at least to me. The only poem I ever knew her to write was a whimsical, poignant one she shared with me back in the 1980s, called “The Proof Reader.”

However, when Harriet and I were sorting through her things in the spring of 2015, I found two more poems in the same box where she had filed her autobiography. Both written in 2005, the poems were called “The Song of her True Self” and “Old Kate,” and you can read them here.

At the time, I merely gave them a glance, though I remember assuming that the title of the second poem referred to her former self.

In the summer of 2017, after the OPP hearings were finally done and I was looking for things to post on my website’s tribute page to Kathryn, I found the poems again. This time I took them down to the dock to read with more attention.

When I got to “Old Kate,” I realized the title was a reference not to her former self but to her future self. An imagining of herself as an old person and a celebration of her newfound—and hard-earned—acceptance of and contentment in herself. As she writes in the poem,

This work took many years because I loved my inner blocks. / But finally I’ve done it, and I’m free and I’m at peace.

The “work” she had done over so many years was, as she writes, to “shovel ego, pride and fear out of the way” and “put in place a hollowness, a conduit for grace.”

All this was necessary so she could fulfill her “Purpose”:

I have come to terms with Purpose; it’s not grandiose or large / It’s simply to be open-hearted and a channel for God’s love.

As the breeze ruffled the pages in my lap, I read these lines with joy and (if I’m honest) not a little astonishment, as well as with a sheepish inner apology to my sister for ever doubting her wisdom. It was clear now her wisdom had effectively been hidden from me by the clashes in our personalities (in those roles of difficult siblings we had taken on).

What was clear now was that my sister had “got it”—why we’re here. And had expressed it so beautifully in her poem. (As our mother had similarly got it, and expressed it in her “Trinity,” which you can find in Installment #11 above).

Although Kathryn did not reach “real” old age, she has left us with an enduring poetic imagining of her life as “Old” Kate—a Kate who (in “The Song of Her True Self”) is “rich in love, wise in thought,” and who has

left gifts for my family and for my friends / who will laugh with me and carry on in this world.

Looking back now, from the vantage point of mid 2019, with both the OPP hearings and the coroner’s inquest behind us, I see what precious gifts Kathryn, or Kate (however you knew her), has left us: forgiveness, reconciliation, healing, and ever-expanding love.

My hope is that we will each stitch these gifts into our hearts (with blue thread), as we “carry on in this world.”

As for laughing with you, dear sister, well, that goes without saying: it’s a family tradition.

Installment #80: The scribe sister speaks…one last time

Preparations for the coroner’s inquest were to occupy our family’s time, off and on, for the rest of 2017 and into 2018, and the inquest finally got under way last October, first in Sudbury, then in Ottawa. In coordination and scope, it was a huge undertaking by the coroner’s team, and we were impressed by and grateful for all their hard work and their diligence in having the issues so thoroughly, and sensitively, examined. (You can find links to media coverage below.)

After three weeks of often very emotional testimony, the jury came up with 27 recommendations for improving Ontario’s emergency response system. For our family, the most important was to implement a protocol for those who cannot communicate their emergency verbally when they call 911. The disappointment was that there was no recommendation to create provincial legislation governing 911—as exists in several other provinces.

Our disappointment was soon alleviated. In late February this year, we were contacted by the office of the NDP Member of Provincial Parliament for Nickel Belt, France Gélinas, and found out that Ms. Gélinas had drafted a private member’s bill to improve 911 services in Ontario—called the 911 Everywhere in Ontario Act, 2019.

The bill (Bill 75), which incorporates a number of the inquest recommendations, was introduced in the Ontario Legislature in March 2019. In early May it passed second reading and was referred to the Standing Committee on Social Policy. In their consideration of the bill, the committee may seek public comment and/or make amendments before reporting it to the House for the third (final) reading and vote. (Links to media coverage on the bill are also below.)

My family and I have wholeheartedly supported Bill 75 from the beginning: we collected signatures on a petition, participated in press conferences, and attended the first and second readings in the Legislature. We’re so grateful to France Gélinas and her team for their efforts in getting it to this stage and remain hopeful it will be passed into law: it would be a powerful legacy for Kathryn.

With the inquest recommendations and 911 legislation now in the government’s hands, my attention has turned to writing the story of my sister and me. It’s the story of a years-long conflicted siblings relationship that ended in grief-masking guilt for one sister after the sudden death of the other during a medical emergency. It’s the story of the astonishing healing and reconciliation that came from beyond the grave—and that led to startling revelations about the true nature of their bond. It’s the story of the ripple effect of healing and forgiveness that enveloped even the emergency personnel and their heavy weight of guilt in failing to respond to a 911 call for help. The working title is Blue Threads Loosened: The Untangling of a Sisters’ Story (after the line in the Dante Gabriel Rosetti sonnet Kathryn loved so much—see Installment #37 above). Stay tuned!

Thank you for reading Beyond Blame: Kathryn’s Story. I have appreciated your interest and encouraging feedback, which primes me for the memoir writing.

Brenda Missen

July 2019

Media coverage of coroners inquest and Bill 75


Inquest into botched 911 call begins in Ottawa, October 22, 2018 

911 operator breaks down at inquest into caller’s death, October 22, 2018

Inquest jury handed proposals for fixing 911 system, October 30, 2018

27 recommendations but no call for legislation in Ontario’s 911 inquest, November 1, 2018

NDP MPP introduces bill to improve 911 access in Ontario, March 6, 2019

Bill to improve 911 service in Ontario up for debate, May 9, 2019


Inquest into mishandled 911 call begins in Ottawa, October 22, 2018

News clip, October 22, 2018

Jury recommends 27 changes to fix Ontario’s 911 system, November 1, 2018

News clip, November 1, 2018

Ottawa Citizen

Inquest into death of Casselman woman reveals complexities of Ontario’s 911 system, October 22, 2018

Family’s forgiveness ‘like 10,000 pounds off my shoulders,’ OPP officer tells Missen inquest, October 24, 2018

Missen family pleased after jury makes 27 recommendations to revamp Ontario’s patchwork 911 system, November 1, 2018 

Casselman woman’s death sparks bill to improve Ontario’s 911 system, March 6, 2019

The Review (local paper in Kathryn’s region)

Inquest into 911 system failure in Casselman woman’s death wraps up testimony and evidence, October 30, 2018

Inquest jury makes 27 recommendations to improve 911 system, November 6, 2018


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