VANCOUVER — When police attended a single-room occupancy building in East Vancouver three years ago, they found the body of “Jimmy” Van Chung Pham, a man with a criminal history who would later be described as a predator by the Union of British Columbia Indian Chiefs.
What police did not notice at the time were the bodies of missing Indigenous teenager Noelle O’Soup and a woman called Elma Enan, whose decomposing remains were only located months later in the tiny room that Vancouver police told the CBC was occupied by an “extreme hoarder.”
The attending officer is now facing a neglect-of-duty investigation by the Office of the Police Complaint Commissioner, B.C.'s civilian police oversight agency.
But the two bodies had also gone unnoticed by a second investigator — the community coroner, or field coroner, tasked with Pham’s death scene.
The coroner had missed the bodies for a very simple reason: they did not attend in person.
Former community coroner Sonya Schulz said the BC Coroners Service stopped requiring coroners to attend certain death scenes in person as a way to save money several years ago.
She said one of those scenes was Pham's apartment, and the coroner attended the scene "remotely" by speaking to the investigating police officer by phone. The Canadian Press has independently confirmed that account.
Schulz said the alarming case had been widely discussed among coroners and she and her colleagues believed the bodies would not have gone unnoticed if a coroner had attended in person.
"We all were like, oh, yeah, so that's what happens when you don't send a coroner to scene," she said.
She said she believed the two other bodies could have been found sooner because of signs including an "odour of decomposition" that other residents of the building complained about before Pham's death.
Schulz drew a direct line between the investigative failures in the foul unit at 405 Heatley Ave. in February 2022 and years of neglect for the service — encompassing low regard for their important duties, financial restrictions on the service, and low pay for field coroners who receive $32 an hour and are not paid at all while waiting on call.
It's unclear exactly why the BC Coroners Service allowed a scene like Pham's apartment to be cleared without a coroner physically attending.
Asked why no coroner originally attended the scene, the service said it could not comment because Pham's death was still an "open investigation."
But in November 2019, a group of field coroners wrote to their regional director to push back against a policy directive they said had been implemented in the Lower Mainland a week earlier, worrying it would mean “reduced attendance” at certain death scenes.
“We recognize the fiscal constraints imposed on BCCS and are cognizant that efforts are needed to reduce expenditures,” the letter obtained by The Canadian Press says.
“But we worry that reduced scene attendance will result in a lower quality of service to families during the most difficult time in their lives.”
The service said in a statement that the 2019 directive was indeed "in response to a government-wide request for fiscal prudence."
But it said the resultant limitations on "scene attendance in certain circumstances" had since been restored.
The service said in an earlier statement last month that coroners “attend the majority of deaths that are reported; however in certain limited circumstances, a coroner may use their discretion to attend virtually or over the phone instead of in person."
These could include death scenes that were unsafe, in a care facility, or when there were "competing priorities (i.e. multiple reported deaths within a short period of time) on the coroner’s availability and capacity."
It said the service was working with the Ministry of Public Safety and Solicitor General to find “the best path forward in addressing compensation” for field coroners.
Current and former community coroners in B.C. said the low-pay on-call work with the service had damaged morale, spurring a high turnover of experienced investigators while calls for improved working conditions went unheeded.
But Schulz and others suggested the treatment and expectations on field coroners had wider implications.
Sue Brown, a lawyer with the advocacy group Justice for Girls, said the Pham case highlighted long-standing issues within the BC Coroners Service over inadequate resources allocated to front-line coroners to ensure deaths were thoroughly investigated.
Justice for Girls has called for a coroner’s inquest into the deaths of O'Soup, who was 13 when she went missing, and two Indigenous women, Tatyanna Harrison and Chelsea Poorman.
Brown said her work on their cases led her to believe there were "systemic issues" within the BC Coroners Service.
Brown said it was unclear why the service didn't initially attend the apartment of Pham, whom the Union of B.C. Indian Chiefs called a "known predator and sex offender" in a news release in May.
"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, and they can only obtain that, in my view, from attending the scene," Brown said.
She said her organization's advocacy typically focuses on the adequacy of police investigations.
"I didn't expect that we would have to be doing the same level of advocacy and have the same concerns with the coroners service," Brown said. "(O’Soup) was found in (a single-room occupancy) in the Downtown Eastside. And I believe that the coroner and the police had tunnel vision in her case."
Vancouver police said investigations into the deaths of O'Soup and Enan remained open.
'I WAS PRETTY FED UP'
When Schulz joined the BC Coroners Service in 2018, she balanced her nursing practice with her new part-time duties as a community coroner, visiting death scenes to determine cause of death.
She considered her work as a coroner a "calling" that fit in with her desire to serve others while also satisfying a deep curiosity in the science of human physiology.
Schulz lasted about four years on the job before going on a medical leave due to personal circumstances. But she said she had also come came to a point where she felt she couldn't put in "one more shift" and resigned.
Former coroners had attempted to unionize to no avail, while others made ill-fated complaints under human rights and employment standards laws to highlight the perils of the on-call job working with dead bodies, without health benefits, a pension or an hourly wage increase for nearly a decade.
"I was pretty fed up. I did have some horrendous cases," Schulz said.
She said one case involved the death of a child, and police officers on scene told her she would need a "critical incident debrief" afterwards to deal with the gruesome circumstances.
But she said aftercare from the service for traumatic scenes attended by part-time field coroners is "non-existent."
"I looked at the police officer and I said, 'That sounds nice, but we don't have that,'" Schulz said. "It was awful and there wasn't very much followup from the coroners service. Nobody reached out to me, for instance, to ask me how I was doing.
"I was completely on my own to take care of my own mental health following that scene."
Schulz said she was involved in a union drive in 2021 to organize community coroners, who sought the right to unionize. That would require legislative change because they're excluded from the definition of "employees" under B.C.'s Public Service Labour Relations Act.
A form letter addressed to lawmakers outlining the failed bid still lives online, saying working conditions led to poor morale, burnout and high turnover.
The letter echoes a recent push for better pay by community coroners who made an "urgent" plea to the service's leadership and policymakers in a letter circulated earlier this year.
"The financial strain imposed on field coroners by the failure to update wages has led to recruitment and retention challenges,” the letter says. “Many experienced professionals are forced to leave the role in search of more sustainable employment, leading to service gaps in our communities.”
Efforts to overhaul how community coroners are paid go back years, including a report by former B.C. auditor general John Doyle in 2011 that said the "as and when required" on-call staffing model for community coroners was "problematic."
"The community coroner model relies on upstanding community members taking on the role of coroner as a public service more than as employment," the report said.
Doyle noted that community coroners' employment status was "unique" because "they are the only government employees paid hourly who are not hired under the Public Service Act."
The report said a survey of employees found nearly 70 per cent "felt that this different employment structure for community coroners versus salaried coroners negatively impacts the effectiveness of the BC Coroners Service."
A former community coroner named Kenneth MacAulay went to the province's Employment Standards Tribunal in 2019 over the service’s failure to pay on-call wages.
He said he was sometimes on call 24 hours a day, seven days a week, and wasn't allowed to drink alcohol. His mobility was also restricted while on call.
But the tribunal found that because MacAulay worked from home, he "could not be deemed to be at work while on call from his residence," and dismissed his case. MacAulay could not be reached for comment.
The service also faced an employment standards complaint over unpaid on-call time filed in November 2023 by a field coroner named Dawn Giles, but a delegate of B.C.'s director of employment standards ruled against her in March this year.
The coroners service argued it wouldn't be able to maintain current coverage by field coroners if on-call time was paid.
"The cost of maintaining field coroners across the province would be prohibitive, considering the unpredictable nature of their work and the amount of on-call time the work necessitates," the decision said.
Some of the conditions faced by field coroners are also described in a human rights case brought in 2019 by a coroner named David Thanh. He claimed the service didn't accommodate his return to work after he "suffered a serious mental injury while working as a community coroner."
He said he struggled after attending what the tribunal ruling called a “gruesome and complex” industrial accident in 2015.
Thanh claimed the service failed to accommodate him by finding a role that would allow him to avoid working with dead bodies.
But the tribunal decision said it was "uncontested that the coroners service is in the business of death and coroners are employed to investigate and report on certain deaths."
There was no way to "modify the job of a coroner to avoid dead bodies," the tribunal ruled, dismissing his complaint. Neither Thanh nor his lawyers returned a request for comment.
Merrily MacIntosh was a community coroner in the Fraser Valley for nearly 10 years who left the service in October last year.
She said community coroners last got a pay raise to just over $32 an hour in 2016, but she said the raise was offset by a reduction in duties that meant they no longer stayed on death files from beginning to end.
"Yes, we got a raise, but then over the next two years, 70 per cent of our work was taken away," she said.
She said the process to get community coroners a raise is long because it must be approved by the Treasury Board.
"The main focus has always been the almighty dollar, the micromanaging and the buck chiselling and the absolute, you know, penny pinching that takes place with the field coroners is absolutely mind blowing. It's unbearable, like nobody can work in those conditions," she said.
"I just couldn't take it anymore because it wasn't worth it. It was too stressful."
Both MacIntosh and Schulz said they supported the current crop of coroners seeking to improve working conditions, but wondered if they'd succeed where others had failed.
"It's still so sad and so unfortunate that a complete work group is being treated as poorly as they are, and if so many people can feel that way and so many people have said things and tried so hard and that it still falls on deaf ears is astounding," MacIntosh said.
The grim nature of the work at death scenes and the pressures facing the service may have combined in the bungling of the Pham case.
Schulz said a scene like the Heatley Avenue apartment, involving dead bodies and hoarding, would typically attract insects and vermin.
Such scenes were often so “malodorous” that police might wait outside in their car or in a hallway or lobby while the coroner investigated, she said.
“And if the police are doing the call with a coroner who's remote over the phone, there wouldn't be the presence on the scene to do an adequate scene assessment," she said.
"Had someone from the coroners service attended, they would have spent enough time doing the scene assessment to realize that there was something else. It's not quite right."
This report by The Canadian Press was first published Aug. 28, 2025.
Darryl Greer, The Canadian Press
