Nunatsiaq News
NEWS: Nunavut December 01, 2015 - 3:40 pm

Nunavut health department failed family of deceased baby: report

“What they went through never should've happened" — Health Minister Paul Okalik

Katherine Peterson's report on the 2012 death of Baby Makibi in Cape Dorset, A Journey Through Heartache, finds that Nunavut health officials failed the community and the baby's family in many ways.
Katherine Peterson's report on the 2012 death of Baby Makibi in Cape Dorset, A Journey Through Heartache, finds that Nunavut health officials failed the community and the baby's family in many ways.

Cape Dorset residents and their health care providers continue to struggle with a strained relationship — marred by anger and a lack of trust — in the wake of the 2012 death of three-month-old Makibi Timilak.

That’s one of the key conclusions reached by lawyer Katherine Peterson who released her external review into the circumstances surrounding the baby’s death at a news conference in Iqaluit Nov. 30.

“Some, but not all, of this troubled relationship arises as a result of the death of Baby Makibi,” Peterson wrote in her 80-page report called, “A Journey through Heartache.”

“Other factors contributing to it likely also include historical trauma, dysfunctional family dynamics [and] substance abuse, to name a few.”

Peterson’s report, which includes 47 recommendations aimed at improving health care delivery to Nunavummiut, tells a story of broken policies, dysfunctional chains of communication, shoddy record-keeping and a loss of focus by Nunavut’s health department surrounding Baby Makibi’s death.

Paul Okalik, the territorial minister of health, who joined Peterson and South Baffin MLA David Joanasie for the report’s release Nov. 30, said he spoke to the family by video-conference just prior to the news conference.

“I offered my apology to the family for what occurred back in 2012,” Okalik said Nov. 30.

“What they went through never should’ve happened.”

Peterson concluded that a coroner’s inquest should be held, if the family wants one, to resolve important conflicting facts that arose during her research.

Okalik directed Peterson in February to conduct an external review into the steps taken by his department following the baby’s death.

His announcement came after a CBC story, published in November 2014, alleged that the health of Cape Dorset residents were put at risk by a troubled local health centre.

Peterson’s report confirms many of the allegations made in that story. 

Another key conclusion Peterson made in her report is that Nunavut’s chief coroner, Padma Suramala, provided conflicting reports to Baby Makibi’s family about their infant’s cause of death.

At the Nov. 30 news conference, Peterson said the coroner initially concluded the cause of death was Sudden Infant Death Syndrome — or SIDS — then changed it to a lung infection a few months later and then in October of this year, reversed the diagnosis back to SIDS.

“These conflicting facts and medical opinions are best addressed by a formal inquest in the community regarding the death of Baby Makibi,” Peterson wrote in her report.

Conflicts in fact arose while researching the tragic death, Peterson said, especially around the crucial moments before the he died.

Nurse Debbie McKeown — the only key player involved in the incident who refused to speak to Peterson — broke two government policies on the night Baby Makibi died when, just hours before the death, she advised Baby Makibi’s mother over the phone to bring the infant in the following day, Peterson wrote.

Two separate Government of Nunavut policies state infants must be assessed in-person at local health centres.

And despite facing numerous complaints of harassment against fellow nurses and patients, and despite a restriction placed by the GN on her nursing license, McKeown was promoted, Peterson wrote.

“That promotion was completely unacceptable,” Okalik said Nov. 30.

But Peterson’s recommendations address not just McKeown but a broken system involving numerous government workers and processes that failed Makibi Timilak and his family.

The recommendations, all of which are directed to the health department, are broken down into four categories: government process reporting and authority; human resource management; training and education; and, community and the health centre.

Overall, the recommendations speak to a glaring lack of proper documentation within the health department, a lack of oversight of the department’s human resources, and a breakdown in communication within the department, between government departments, and between the health department and other organizations.

The final category contains recommendations on how to rebuild the trust and relationship between Cape Dorset residents and their healthcare providers, including:

• holding meetings between department officials and Cape Dorset residents to discuss the findings of Peterson’s report;

• providing the community with mental health specialists to resolve the trauma Baby Makibi’s death has left, as well as to address other historical traumas; and,

• providing public information materials emphasizing that the delivery of quality health care is a shared responsibility between health care providers and community members.

Okalik said Nov. 30 that health department officials have had a chance to review the recommendations and he has instructed his staff to implement all of them.

Okalik did not provide a timeline for when those recommendations would be fully implemented, but he did say they would require a budget cycle beyond 2016-17.

A news release issued by the health department Nov. 30 says Okalik will table Peterson’s report when the legislature sits again in February 2016, and that the minister would provide an update on the implementation of the recommendations at that time.

You can read the full contents of the report below.

  A Journey Through Heartache by NunatsiaqNews

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