Nunavut coroner’s jury makes 13 recommendations after in-custody suicide

The community hall in Hall Beach, which hosted a coroner’s inquest last week into the death by suicide of Tommy Anguilianuk in January 2013. (FILE PHOTO)

Tommy Anguilianuk died by suicide on January 21, 2013 after escaping custody from the Hall Beach RCMP detachment.

That’s the jury’s verdict from a coroner’s inquest held at Hall Beach’s community hall from May 2 to May 5.

The inquest was mandatory under Nunavut’s Coroner’s Act, because Anguilianuk, 18 at the time of his death, died while under police supervision.

After four days of testimony from 18 witnesses, including Anguilianuk’s family members and forensic experts, the jury deliberated for six hours May 5 before coming back with 13 recommendations, chief coroner Padma Suramala told Nunatsiaq News May 6.

Those recommendations are aimed at preventing similar deaths in the future.

Ten of the recommendations are directed towards the RCMP, four towards the Government of Nunavut and two towards Nunavut Tunngavik Inc., the territory’s Inuit land claim organization.

“I would like to thank the six jury members for their excellent work and realistic recommendations,” Suramala said from her Iqaluit office.

“This was a very emotional inquest, but the family expressed their appreciation for the many questions it answered. Despite their difficult emotions, they told me the inquest helped their grieving process and to move on with their life,” said Suramala, who presided over the inquest herself, a career first.

Nunatsiaq News contacted Anguilianuk’s grandfather in Hall Beach, but he said the family was not ready to comment publicly on Tommy’s death.

According to Suramala, testimony at the inquest revealed that on Jan. 20, 2013, Anguilianuk complained repeatedly to the civilian guard that his cell was too hot. Anguilianuk was in custody for several charges, at least one of them serious.

The Hall Beach detachment was having problems with their boiler, Suramala said.

Just after midnight on Jan. 21, 2013, Anguilianuk convinced the guard to lend him the guard’s winter jacket and a cigarette to smoke for a brief moment of fresh air, Suramala said.

The guard did not accompany Anguilianuk outside, the coroner said.

That’s when Anguilianuk escaped custody, running first across town to his uncle’s house, where he picked up a gun, and then to a hiding place underneath the front porch of a house near the fire hall, Suramala said.

At about 2:30 a.m. on Jan. 21, 2013, residents of the house Anguilianuk was hiding under testified at the inquest that they heard a loud bang, the coroner said.

RCMP officers found Anguilianuk, dead, about half an hour later, said Suramala, although the family was never allowed to see Anguilianuk’s body.

The jury also heard testimony that Anguilianuk, who had been arrested Jan. 20, 2013, on four charges, was scared about his impending transfer to the Baffin Correctional Centre in Iqaluit, where he had already spent some time.

The inquest’s jury ruled that Anguilianuk’s cause of death was a head wound, and his manner of death was a suicide.

The 10 recommendations made by the jury to the RCMP include the following, that:

• civilian guards receive certified two-day training, in Inuktitut and English, before working, with a refresher course every six months;

• the RCMP immediately fix any building maintenance issues;

• the RCMP post the phone number for the Suicide Helpline at local detachments;

• the RCMP instruct guards to call RCMP officers to escort prisoners for fresh air; and,

• investigators allow family members to see the deceased’s body if possible.

Suramala said she will send these recommendations to the Nunavut RCMP and monitor implementation of the recommendations every six months.

But some of the issues addressed in the jury’s recommendations have been addressed by juries issued by other coroner’s inquests.

It’s not clear whether the RCMP have followed up on those recommendations.

For example, a 2014 coroner’s inquest in Igloolik heard that another in-custody death involved a detachment facility in disrepair, inadequate training for workers at local detachments and family members of the deceased unable to see the body of their loved one.

That 2014 inquest recommended an investigation be re-opened, but the Nunavut RCMP has not yet done that.

The other recommendations will be sent to the organizations addressed in the recommendations.

The coroner’s jury in Hall Beach also recommended May 5 that:

• the GN’s Department of Health coordinate a strategy for assessments and interventions when dealing with male depression and suicidal thoughts;

• the GN develop culturally-appropriate information to help a door-to-door trigger lock campaign for firearms; and,

• members of Nunavut’s Suicide Prevention Plan continue to support recommendations made by jury of the 2015 coroner’s special inquest into suicide.