On July 11, 1988, Katie and Peter Ross, an Aboriginal couple from the Chilcotin were shot. Peter died instantly. Katie lived long enough to seek medical attention where she was treated for shock, but not for the gunshot wound. Katie died the next day in the hospital and the gunshot wound was not found until after her death by the pathologist (Ross Inquest, 1989). Katie and Peter were shot while in the bush, 3–4 hours west of Williams Lake and a significant distance from the main road. Katie made her way back to their camp where, a couple of hours later, her son found her and drove her to a nearby ranch, at which point the police were called. Due to the vast region and the remoteness of the area, it took several hours after she was shot before the first contact was made with the systems designed to serve and assist people in difficulty.

The first of several missed opportunities to save Katie’s life occurred when a Royal Canadian Mounted Police officer talked with Katie and she told him that she had been shot. The Royal Canadian Mounted Police officer testified at the inquest that he checked her over and yet did not discover the gunshot wound.

The second missed opportunity was during the initial contact with the health care system. Katie was taken to the outpost nursing station by her son where the nurse was told of Katie’s stomach pains and she began the examination by taking Katie’s pulse. Katie’s son told the nurse that her husband had been murdered and Katie had been in the bush for several hours. The nurse did not continue the examination. Instead, she diagnosed emotional shock and told the son to take Katie to the hospital in Williams Lake, about 100 kilometres away. Although the son told the nurse he had to find transportation, the nurse made no effort to assist in this process. An ambulance was not called, nor did the nurse suggest this as an option. The recommendation from the inquest to the Red Cross Outpost Station reads: “That the staff not be reluctant to call the ambulance to transport patients, regardless of the color of skin or what community the call is from.” The interaction between Katie and the outpost nurse was the second missed opportunity to fully investigate and begin to address Katie’s medical condition.

The third and final missed opportunity was in the hospital. After her son finally found a ride into the city, and after the hour-long drive, Katie was finally admitted to the hospital in Williams Lake around midnight that night. After an examination by a local physician, who was told of the incident, Katie was diagnosed with anxiety. She was admitted to the hospital and given a sedative. Katie was very restless and nauseous, and kept getting up to use the washroom and to try to vomit. The nurse on duty requested extra staff to assist in the supervision of Katie, but she was refused. Katie continued to be given sedatives and was eventually restrained in the hospital bed as a safety precaution. In the morning, with no change in her condition, the doctor prescribed a stronger sedative.

Around 4 pm, the day after Katie was shot, she was found dead in her hospital bed. The cause of death was determined by the pathologist to be an infection due to a gunshot wound in her back, which penetrated the abdomen (Ross Inquest, 1989). A pathologist at the inquest stated that Katie’s life could have been saved with prompt surgical attention. In all, Katie spent more than 15 hours in the hospital where several different health professionals had opportunity to assess, diagnose, and treat her injuries. During her ordeal, she spoke to and interacted with health and emergency professionals, including the Royal Canadian Mounted Police, outpost nurse, and numerous hospital staff.

“…there appeared to be little appreciation of and less dedication to the duty of care owed by custodial authorities and their officers to persons in custody. We found many system defects in relation to care, many failures to exercise proper care and in general a poor standard of care. In some cases the defects and failures were causally related to the deaths, in some cases they were not and in others it was open to debate…in many cases death was contributed to by system failures or absence of due care”