Train more Inuktut-speaking social workers, Nunavut inquest verdict recommends
Jury recommends education on dangers of cannabis to children
A verdict reached yesterday in a coroner’s inquest states there is no known reason to explain how or why baby Amelia Annie Leah Onalik-Keyookta died on July 29, 2015 while in the care of the Government of Nunavut’s Department of Family Services.
But there are ways the GN can prevent a child from dying in its care again, a six-person jury said in 22 recommendations attached to their verdict.
Northwest Territories coroner Garth Eggenberger presided over the inquest this past week at the Nunavut Court of Justice building in Iqaluit.
Hiring more Inuktut-speaking social workers and translators, training foster parents in safe sleeping practices for babies, and educating parents about the damage that cannabis smoke can inflict on young children are listed in the jury’s recommendations.
The day before her death, on July 28, 2015, social workers apprehended the four-month-old infant after they found excessive amounts of marijuana smoke in the home.
Keyookta was pronounced dead at the Qikiqtani General Hospital, at about 3:30 p.m. the next day after she was found not breathing at the home of an unlicensed care provider contracted by the GN.
“Amelia was put down for an afternoon nap, when a community social services worker attended the day care in the early afternoon to return Amelia to her parents,” the jury foreman said in delivering the verdict.
But the social worker found that the child was limp and unresponsive.
At a time when they expected to be reunited with their baby, Amelia’s parents were instead rushed into the hospital.
The coroner was to have released a written version of the verdict on Monday but some of the 22 recommendations from the inquest jury, read in public at the end of the proceeding, are:
• Train more Inuktut-speaking social workers and make interpretation services easier to access within the front-line work done by Family Services.
• Educate parents on the dangers of second-hand smoke and the effect of cannabis use on children, especially with the pending legalization of marijuana.
• Teach social workers, foster parents and child caregivers about safe sleep practices for children and the risks of sudden infant death syndrome, or SIDS. And make First Aid training a priority for staff.
• Rebuild trust between the Department of Family Services and the families it provides services for.
• Consider opening a licensed and on-site daycare in Iqaluit for children in the care of the Department of Family Services, and a secondary safe space where families can go together instead of having a child apprehended.
During witness testimonies, parents made it clear that they thought the social workers were taking their child away for a long time.
Because of this, Amelia’s father became upset and the couple left the residence they were staying in temporarily, taking the baby in her mother’s amauti.
Social workers and RCMP witnesses said the separation was explained as being temporary, until thick smoke in the home was cleared out.
Both parents gave their testimonies in Inuktitut.
Amelia was apprehended from her parents two weeks before for the same reason—marijuana smoke—though neither parent had any recollection of this.
Social workers initially visited the home to check up on a premature baby that lived there too.
Amelia was laid to sleep on her tummy when she was found not breathing at an unlicensed child day home.
This sleep position, and second-hand smoke, are both risk factors for the sudden death of infants.
A pediatrician who tried to resuscitate Amelia and a forensic pathologist who performed an autopsy said the baby appeared healthy and there were no signs indicating why the child died.
Nunavut has the highest rate of infant mortality in Canada.
The verdict calls for more support programs for families, foster parents and front-line workers within the Department of Family Services.
A dedicated team of people trained to respond to critical incidents could help make sure this support happens, the verdict says.
Jurors also said the department should hire more staff to do front-line child services work, and then make sure staff workloads are not too high.
At the time when Amelia died, Family Services social workers could have caseloads of 30 to 35 children each, witnesses said.
And investigations like the one into Amelia’s death were done on top of all that work.
An inquest is not a trial and is not a fault-finding exercise.