BCC inmate died of heart attack

Coroner’s jury recommends changes to departments of Justice, and Health and Social Services.



A Baffin Correctional Centre inmate who collapsed in a dormitory bathroom died of natural causes, Nunavut’s first coroner’s inquest ruled last week.

Aipeelee Oshutsiaq, 33, died March 13, 2001, from coronary thrombosis, a type of heart attack caused by blocked blood-flow to the heart.

He was pronounced dead at Iqaluit’s Baffin Regional Hospital within an hour of collapsing.

Oshutsiaq was serving a six-month sentence for assault when he died.

Inmates who die while in custody of the department of justice are subject to an inquest under the Coroner’s Act.

A six-person coroner’s jury based their Dec. 14 verdict on autopsy results and witness’ testimony. Forensic pathologist Dr. Graeme Dowling, who conducted the autopsy, offered what was perhaps the most compelling testimony.

“The blood clot formed quickly and he died rapidly – not leaving a lot of time to prevent the death,” Dowling testified via phone from his Edmonton office.

An inquest is not a trial, but a simple fact-finding exercise. No one was accused of a crime. Nor were their any findings of guilt.

The jury recommended improved administration, communication and follow-up between the jail and the hospital. A second recommendation called for interpreters for Inuktitut-speaking offenders under medical care.

Tim Neily, administrative coroner for the department of justice, presided over what was the first coroner’s inquest since division.

“It went very well. We had a serious jury that asked some good questions. And counsel did a very thorough job,” Neily said.

Chief coroner Elizabeth Copland will now forward the findings to the department of justice and the department of health and social services. However, the government is not under legal obligation to implement the recommendations.

Evidence regarding Oshutsiaq’s medical history was raised. Ten months earlier, he’d been seen at BRH for numbness on his right side.

Doctors said Oshutsiaq was never tested for heart disease or given an electrocardiogram (EKG) because his symptoms were indicative of a stroke-like episode, not a heart attack. Nor was he referred to a specialist.

“Given his young age and symptoms (previous numbness), I’m not sure if a diagnosis would have been made and then prevented (his death),” Dowling said.

Medical records from BCC suggested Oshutsiaq was symptom-free in the 10 months preceding his death.

No one from the John Howard Society — the national watchdog group for prison inmates — attended the inquest.

Flight delays prevented Oshutsiaq’s mother from attending the inquest.

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