Nunavut RCMP should not assume unconscious Inuit are intoxicated: inquest

The late Paul Kayuryuk of Baker Lake, in a photo taken in 2005. (PHOTO COURTESY OF NANCY TOOKOOME)

Detained persons who need medical help should get it whether or not they’re intoxicated, and non-Inuit RCMP officers and civilian prison guards should challenge their own assumptions about alcohol use and intoxication among Inuit, a six-person jury recommended July 27 following an inquest in Baker Lake.

Those are two of 17 recommendations that flow from an inquest into the 2012 death of Paul Kayuryuk, a middle-age man from Baker Lake whose exact age is not given.

The RCMP held Kayuryuk in custody after the man was found unconscious at the Baker Lake dump on Oct. 14, 2012, under the belief that he was intoxicated.

But he actually suffered from a diabetic condition that likely produced a stroke, or broken blood vessel in his brain.

Police transferred him Oct. 15 to the Baker Lake health centre, where nurses diagnosed him with the stroke and had him medevaced to Winnipeg. He died Oct. 29 at a Winnipeg hospital, of bronchopneumonia, a lung infection that arose as a complication of the stroke, also known as an “intracerebral hemorrhage.” The jury found the man died of natural causes.

The jury also found the RCMP believed Kayuryuk “was taken into custody on some level of assumption and some evidence that he was intoxicated,” the verdict said.

“But he never drank,” Kayuryuk’s brother Zachary Kayuryuk told Nunatsiaq News in February, when the inquest was announced.

The man was diabetic—information a family member gave police many hours later, in the late morning or early afternoon of Oct. 15, 2012, when the family heard he was held in the drunk tank.

This meant Kayuryuk did not get treatment for his diabetes until the day after police found him.

Before then, police observed Kayuryuk in the cell more frequently than usual because they assumed he was highly intoxicated.

Three different guards monitored the man, “each with an increasing level of concern,” the verdict said.

In Winnipeg, Kayuryuk’s stroke was confirmed and “the prognosis was not good,” the verdict said. He died Oct. 29, at the Winnipeg Health Sciences Centre 29 of the bronchopneumonia lung infection.

The Baker Lake man who found Kayuryuk, the arresting RCMP officers, the three guards on duty, the unit commander, the nurse on call, the doctor on duty, a medical examiner, and Kayuryuk’s family members all appeared as witnesses.

Kayuryuk’s niece, Karen Kabloona, who live tweeted the inquest, included a July 26 quote from the nurse who said: “Once I had seen him, it looked like he’d possibly had a stroke, he was covered in vomit, he had been incontinent.”

Kabloona also tweeted a quote from the second civilian guard, who called for help when he saw Kayuryuk foaming at the mouth.

“When nobody came, I stayed by his cell door and prayed to God for him to be OK in there … this isn’t the first time nobody came when I called for help,” said the guard, as quoted by Kabloona on social media July 25.

“We will all remember him smiling because he always was smiling. My uncle Aglakuaq,” Kabloona wrote July 30.

The photo with this article, provided by relative Nancy Tookoome, was taken in October of 2005 when Kayuryuk was on his way out to a fishing trip.

In the photo, Tookoome said the man is laughing because her spouse said the ice was too thin to go fishing.

Some other recommendations made in the verdict are that:

• the RCMP use the circumstances of this inquest as an example for training within the year;

• civilian cell guards check cells no more than 15 minutes apart;

• an RCMP officer check every prisoner in cells for responsiveness at least eight hours from the time they were placed in the cell, and record results;

• all detachment cells have working video equipment within the year;

• cell guards have direct contact info for the officer on call, detachment commander, acting detachment commander and the local health centre;

• there be a translator available; and,

• the Government of Nunavut promote the use of medic alert bracelets.

Another inquest is underway July 31 to Aug. 3 in Rankin Inlet for Victor Kaludjak, a Rankin Inlet man who died in March 2013.

Kaludjak had been medevaced to Winnipeg from his community health centre when he was found in “medical distress.”

Coroner’s inquests are not fault-finding exercises.

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

Verdict of Coroner's Jury by NunatsiaqNews on Scribd