Inquest into Nunavut man’s death exposes emergency care shortfalls

An inquest looking into the 2013 death of Victor Kaludjak found a disagreement between nurses and doctors at the Kivalliq Health Centre may have delayed his transport to a Winnipeg hospital, where he died hours later. (PHOTO BY SARAH ROGERS)

A coroner’s jury that last week examined the medical treatment and subsequent death of a Rankin Inlet man says the incident should serve as a lesson for Nunavut’s health care system.

They said the Nunavut health department must develop stronger guidelines for emergency treatment, documentation of care and proper training for practitioners, according to recommendations released Aug. 4 from the Chief Coroner of Nunavut.

Victor Kaludjak was admitted to the Kivalliq Health Centre at 10:30 a.m. on March 20, 2013, suffering from double vision, muscle weakness and an unstable gait.

After he suffered a cardiac arrest at around midnight, staff at the centre gave him CPR and called for a medevac, which took him to Winnipeg at around 2 a.m. March 21. He died at the Winnipeg Health Sciences Centre at 11:02 a.m. that day.

Complaints from family members about the circumstances around Kaludjak’s death prompted the Chief Coroner of Nunavut to convene an inquest, held in Rankin Inlet between July 31 and Aug. 3.

The six-member jury released 24 recommendations, which touched on the treatment of patients in Nunavut, and the responsibilities and capabilities of health care workers

The jury called on the Government of Nunavut and its Department of Health to develop guidelines and policies to handle disagreements or “communication issues” between nurses and physicians, and to maintain a “conflict log book” for disputes.

According to a statement of facts provided by the coroner, nurses treating Kaludjak said he should have been sent to a southern facility for more testing, but Kaludjak remained in Rankin Inlet until he went into cardiac arrest.

The jury recommended that Nunavut’s health department create policies requiring that any patients exhibiting abnormal signs or unexplained neurological symptoms—without showing improvement—be sent to a centre “where more investigation and high level of monitoring is available.”

That would take some of responsibility for emergency transport away from the discretion of the most responsible physician on duty at the time of an incident.

All orders to transfer patients via medevac or scheduled flight should be reviewed in a “non-punitive process” to determine their appropriateness, another recommendation said.

Nurses across Nunavut should be given mandatory training, as well as clear guidelines for intravenous and other forms of care leading up to “code blue” emergencies.

The Department of Health was also asked to finalize and implement an orientation handbook for nurses throughout Nunavut by the end of the year, and that nurses be provided with additional cultural orientation.

Any end-of-life care provided by Nunavut physicians or nurses should be established under legislated guidelines and policies to assist caregivers in contacting next-of-kin if a patient is incapable, the jury recommended.

And all medical treatment at community facilities should be rigorously documented, so that critical care can be examined by the centre’s staff after the event for debriefing exercises, the jury said.

The coroner’s inquest into Kaludjak’s death followed another inquest in Baker Lake over the 2012 death of Paul Kayuryuk.

The jury in that inquest demanded that Nunavut RCMP officers challenge their assumptions about intoxication and alcohol abuse among Inuit, after Kayuryuk died from complications of diabetes after the police mistakenly identified him for being drunk.

The recommendations from the Rankin Inlet inquest echoes many of the same themes outlined by the Auditor General of Canada during its audit of Nunavut’s Department of Health in March.

That report called for increased support of nurses working in community health centres, who the report concluded were not being given enough training or oversight from the Department of Health.

Coroner’s inquests are not fault-finding exercises.

Their purpose is to determine the cause of a person’s death where the cause of death is in doubt and to make recommendations for avoiding similar deaths in the future. Coroner’s jury recommendations are not binding on government.