Jury urges better communication as Michael inquest ends

Jurors at the coroner’s inquest into the death of Elisapee Michael presented a list of 29 recommendations to the City of Iqaluit, RCMP, Qikiqtani General Hospital and the Government of Nunavut as the inquest closed in Iqaluit April 14.

Some members of the six-person jury wept as the foreman read out the findings, which also contained a message for Michael’s family.

“On behalf of society, we wish to deeply apologize to Elisapee Michael’s family,” the foreman said. He added Michael was not treated with proper respect and care the night of August 8, 2009 when she fell down the stairs of an Iqaluit hotel and sustained a serious head injury.

Michael was intoxicated that night and once taken to QGH became difficult for hospital staff to deal with. But despite showing signs of a head injury, she was taken into RCMP custody, where she stayed for 14 hours, until a police officer became concerned about her condition. She was taken back to QGH, then medevaced to Ottawa where she died four days later.

Michael’s sister Eva said the inquest process helped the family understand the events and people involved the night Elisapee fell.

“I think this process covered everything and we’re glad it’s over,” Eva told reporters after the jury presented its findings.

The jury’s recommendations are aimed at four organizations:

City of Iqaluit

The city’s fire department, which also operates ambulance services, should improve patient documentation, including a written log that tracks changes to files. The city says it’s already looking at changes to the way it handles patient information.

The jury also wants city building inspectors to ensure building entrances, especially at bars and public places, meet the national building code.

RCMP

Jurors recommended full time video recording of all cells at the RCMP detachment, with files saved for at least six months, and they suggested police install a camera monitoring the area where prisoners are brought in. All intoxicated prisoners should be checked every two hours.

The RCMP should improve training and certification for cell guards, upgrade record-keeping and ensure prisoners can be seen through cell doors at all times.

Inuktitut translation should be available around the clock.

Police should take written medical instructions, signed by a doctor, when they take a patient from QGH.

Qikiqtani General Hospital

The hospital should install a fully-equipped and staffed CT scanner as soon as possible and patients with suspected head injuries should never be handed over to the RCMP.

Instead, the hospital should create a secure area for unruly patients, provide more security and medical staff. Inuktitut translation should be available at all times and hospital staff should be better versed on policies governing the transfer of patients into RCMP custody.

Next-of-kin information should be collected more often and be more readily available, especially in cases where a patient is unable to communicate. Next-of-kin should be informed before a patient is medevaced out of the territory.

Hospital staff should be able to communicate with paramedics by radio.

Government of Nunavut

Future medevac contracts should stipulate that a plane be available at all times. The inquest heard that medevac service in Iqaluit may have improved since 2009.

The jury also said the Department of Health and Social Services should “implement a territory-wide drug and alcohol abuse treatment program immediately.”

Garth Eggenberger, the coroner who presided over the inquest, said the jury’s recommendations aren’t mandatory but are “morally binding” on the organizations named. He said the coroner’s office will follow up over the next six months to see how closely the recommendations are followed.

Eva Michael praised the jury’s recommendations, particularly the ones urging better access to Inuktitut-speaking translators. She said the cost of implementing the recommendations shouldn’t be an issue.

“My sister died,” she said. “I don’t care how much money it costs anybody to correct it.”