VANCOUVER — A recent investigation into a death scene in East Vancouver has raised serious questions about the practices of the BC Coroners Service. Three years ago, police discovered the body of Jimmy Van Chung Pham in a single-room occupancy building. However, they overlooked the remains of two other individuals: missing Indigenous teenager Noelle O’Soup and a woman named Elma Enan. Their bodies were found months later in the same room, which was described as being occupied by an “extreme hoarder.”

The attending police officer is now under investigation for neglect of duty by the Office of the Police Complaint Commissioner, which oversees police conduct in British Columbia. However, the community coroner assigned to the case also failed to notice the two bodies because they did not attend the scene in person.

Former community coroner Sonya Schulz explained that the BC Coroners Service had stopped requiring coroners to attend certain death scenes in person to cut costs. Instead, the coroner for Pham’s case conducted their investigation remotely, communicating with the police officer by phone. Schulz stated that this alarming oversight has been a topic of discussion among coroners, who believe that the bodies would have been discovered sooner had a coroner been present. "We all were like, oh, yeah, so that’s what happens when you don’t send a coroner to scene," she said.

Schulz noted that residents of the building had complained about an “odour of decomposition” prior to Pham’s death, which could have led to the discovery of the other bodies. She linked the failures at the scene to a broader issue of neglect within the BC Coroners Service, citing low pay for field coroners, who earn $32 an hour and are unpaid while on call.

The BC Coroners Service has not provided a clear explanation for why a coroner did not attend the scene. When asked, they stated they could not comment due to the ongoing investigation into Pham’s death. In 2019, a group of field coroners expressed concerns about a policy directive that reduced in-person attendance at death scenes, fearing it would compromise the quality of service.

The service acknowledged that the directive was a response to a government request for fiscal prudence but claimed that limitations on scene attendance had since been restored. They stated that coroners typically attend most reported deaths but may use discretion to attend virtually in certain circumstances, such as unsafe scenes or competing priorities.

Current and former coroners have reported that low pay and poor working conditions have led to high turnover rates and low morale within the service. Schulz and others have suggested that the treatment of field coroners has broader implications for the quality of death investigations.

Sue Brown, a lawyer with the advocacy group Justice for Girls, emphasized that the Pham case highlights systemic issues within the BC Coroners Service. She has called for a coroner’s inquest into the deaths of O’Soup and two other Indigenous women, Tatyanna Harrison and Chelsea Poorman. Brown stated, "Their job is to determine the manner of death and the cause of death, and I simply do not see how that is possible if they don’t also have first-hand knowledge about the circumstances in which the person was found."

Vancouver police confirmed that investigations into the deaths of O’Soup and Enan remain open.

Schulz, who joined the BC Coroners Service in 2018, described her role as a calling. However, after four years, she resigned due to the emotional toll and lack of support for coroners dealing with traumatic cases. She noted that aftercare for coroners is virtually non-existent, leaving them to manage their mental health alone.

Efforts to improve the working conditions for community coroners have been ongoing for years. A report by a former B.C. auditor general in 2011 criticized the on-call staffing model as problematic. The report indicated that nearly 70 percent of coroners felt that their unique employment status negatively impacted the effectiveness of the service.

In 2019, a former community coroner filed a complaint regarding unpaid on-call wages, but the tribunal dismissed the case, stating he could not be considered at work while on call from home. The service is currently facing another complaint regarding unpaid on-call time, highlighting ongoing issues within the BC Coroners Service.