Coroner's report recommends inquest following review of COVID-19 deaths of migrant farm workers

The province's deputy chief coroner is recommending his own office conduct an inquest into the COVID-19 deaths of temporary foreign agricultural workers in order to prevent further suffering and death among that vulnerable population.

It comes in a report released Tuesday that also includes 35 recommendations for various levels of government and agencies, stemming from the deaths of Bonifacio Eugenio Romero, Rogelio Munoz Santos and Juan Lopez Chaparro in May and June of last year.

All three men were Mexican citizens and worked on Ontario farms. Two of them came through the federal Seasonal Agricultural Worker Program. Their deaths in the early months of the pandemic put a focus on the poor working and living conditions many migrant farm workers faced, especially as COVID-19 started to ravage several farms across the province. The coroner's report noted that migrant farm workers faced a higher risk of getting COVID-19 and dying from it due to their congregate living and working situations.

"Most importantly, we should not forget that this review and its recommendations arise out of the unfortunate and untimely deaths of three men who left their home country to work in ours," wrote Dr. Reuven R. Jhirad, Ontario's deputy chief coroner, in the report. "My deepest condolences go out to the families of these three men, their friends, co-workers, employers, and others impacted by their loss. It is our hope that these recommendations provide some comfort to those mourning their loss as the lessons learned from these deaths strive to prevent further deaths."

The report stated that the recommendations were the result of the death investigations and consultations with participants of the review, which included Canadian and Mexican governments, employers, families of the three men and other stakeholders including members of the Migrant Worker Health Expert Working Group.

One recommendation included in the report states that the "Office of the Chief Coroner and Ontario Forensic Pathology Service should consider calling an inquest into the death of TFAW(s) during the COVID-19 pandemic."

This comes after the Toronto Star reported in February about the launch of the review amid calls from advocates for an inquest.

"While one may ask why make recommendations to our own office when the changes could potentially be simply instituted, we wished to ensure open and transparent disclosure of what was learned through this process," the deputy chief coroner wrote in a comments section after the recommendation.

"An inquest is a public hearing held in order to ascertain the facts around a particular death and, where appropriate, make recommendations to prevent further deaths. While the focus of this review was on the more immediately achievable recommendations, it may be appropriate to conduct an inquest into a TFAW death(s) in order to more deeply analyze the structural systems, issues, processes and working relationships that, if improved, could prevent further deaths," Jhirad wrote.

The deputy chief coroner went on to say that a coroner initially declined an investigation into one of the deaths because "it was felt that because COVID-19 is a natural disease, the case did not warrant an investigation by a coroner."

"Further review resulted in reversing this decision as the importance of understanding the risks to TFAWs, increased by the presence of the pandemic, from a public health and societal point of view was noted to meet the standards for requiring an investigation," Jhirad stated.

Janet McLaughlin, co-founder of the Migrant Worker Health Expert Working Group, said she "strongly supports" the recommendation for an inquest. 

"An inquest would provide a crucial opportunity to further reveal the structural conditions that lead to heightened risks among migrant workers, and would generate much-needed recommendations to improve their conditions, which, if followed, could ultimately prevent future deaths," McLaughlin said. 

She said migrant agricultural workers have been disproportionately impacted by the pandemic, which has "revealed and deepened pre-existing conditions of vulnerability."

"We owe the workers who grow our food a full understanding of and reckoning with the circumstances in which they live, work, and die in Canada," she said. "We owe it to the workers who died to ensure that no other workers lose their lives under preventable circumstances – this message is all that more pressing in the wake of the deaths of additional migrant agricultural workers just this week."

The report also recommended that the provincial government, with help from its federal counterpart, establish and maintain a database of temporary foreign agricultural workers that includes emergency contacts, dates of arrival and return and employment details; develop a strategy to "improve conditions" for these workers including undocumented workers; and ensure workers have access to information about living and working in the province.

When it comes to workers exposed to COVID-19, the report recommended that the three levels of government, public health units and health-care providers ensure there are sufficient isolation centres to manage outbreaks at any time during the pandemic and that the province make sure the centres are managed 24-hours a day and provide workers with access to phones or internet for "effective, timely transport to hospitals as needed" along with "adequate and culturally appropriate food, physical distancing, and access to safe outdoor activities."

The deputy chief coroner commented on the use of isolation centres during the pandemic, saying some challenges were noted when it came to information sharing and overlapping responsibilities of the different groups involved in offering services at these sites.

"Some of the workers discussed during this review did have issues obtaining emergency care and treatment of their medical concerns," the deputy chief coroner said.

The report also recommended that the province develop a "culturally appropriate education campaign" specifically for migrant agricultural workers on the risks and benefits of the COVID-19 vaccine, that they be considered "high priority" for the vaccine and that their work eligibility not be dependent on whether or not they get inoculated.

In his commentary, Jhirad stated that these workers are listed for vaccine eligibility in Phase 2 of the province's vaccine plan, with the provincial government noting that it has set up a clinic at Toronto Pearson International Airport to provide temporary foreign workers with vaccines before they go their quarantine location.

The report called on the Ministry of Labour, Training, and Skills Development to consider "enhancing access to an anonymous phone line for temporary foreign workers, or those communicating on their behalf, to report any workplace concerns."

The deputy chief coroner acknowledged existing phone lines through the ministry but said issues like the service only being available in English and French were flagged as challenges.

Meanwhile, Minister of Agriculture, Food and Rural Affairs Ernie Hardeman thanked Jhirad for the report.

"We are saddened by these tragedies and extend our condolences to the workers’ families, friends and co-workers," said Hardeman in a statement. "We are carefully reviewing the recommendations in the report and my ministry will work with experts to address the deputy chief coroner’s recommendations in a timely and responsive manner."

He called temporary foreign workers "valued members of Ontario’s agri-food sector," saying their health, safety and well-being are important to the government. He pointed to measures that he said have been aimed at protecting workers including labour inspections on farms, greenhouses and other agricultural settings, rapid tests for several work sites, the issuing of COVID-19 resources in different languages to farms and other sites and funding for personal protective equipment, cleaning and disinfection, housing modifications.