Nunavut coroner’s office launches pediatric death review committee

Former coroner planned same committee two years ago

Nunavut’s coroner is working with the RCMP, the Government of Nunavut and other medical experts in child health to review, through a new pediatric death review committee, all deaths in the territory of children below the age of five. This photo shows the GN’s baby boxes, which were introduced in 2016 to help lower Nunavut’s high infant mortality rate. (FILE PHOTO)

By Beth Brown

Starting in January, a special committee chaired by Nunavut’s chief coroner will review all deaths in the territory of children below the age of five.

That’s after Nunavut’s Office of the Chief Coroner announced on Wednesday, Dec. 19, a new pediatric death review committee for Nunavut.

“The committee will help identify risk factors, trends and patterns from cases reviewed to make recommendations towards the development of effective intervention, awareness and prevention strategies,” Nunavut’s new chief Coroner, Khen Sagadraca, said in a news release.

The committee will also “make recommendations that prevent deaths in similar circumstances,” he said.

Child mortality rates are high in Nunavut, especially for infants, according to Statistics Canada.

Since the beginning of January 2018, the Coroner’s office initiated 18 investigations into the deaths of children under the age of five,” Sagadraca told Nunatsiaq News.

This committee was planned by the chief coroner’s office, the Government of Nunavut’s Department of Health and the Nunavut RCMP, along with neonatal and intensive care medical experts and a pediatrician—a doctor who specializes in child health care.

The committee’s workings will be confidential, and will help the coroner’s office understand what situations might lead to a child’s death in Nunavut.

Ontario has had a similar pediatric death review committee for over 10 years.

But this isn’t the first time such a committee has been talked about in Nunavut.

In fact, almost the same announcement was made two years ago by then Nunavut Chief Coroner Padma Suramala.

That was directly following an inquest into the 2012 death of baby Makibi Olayuk Akesuk in Cape Dorset.

Suramala is no longer Nunavut’s chief coroner.

“This was mentioned in 2016 by the previous chief coroner, however, I’m unable to comment on whether this committee happened, occurred or not in the past as I was not in the position as chief coroner at that time,” Sagadraca said in an email.

Sagadraca previously filled roles as administrative coroner and deputy coroner in Nunavut.

Now that the child death review committee has been launched, its expert members will help the coroner’s office understand when and if child deaths are avoidable, and make recommendations that could help prevent future deaths. The committee will also help the coroner identify the “presence or absence of systemic issues, problems, (or) gaps” in related government and front-line services, Sagadraca said.

An April coroner’s inquest into the 2015 death of Iqaluit infant Amelia Keyookta found her cause of death was undetermined. At the inquest, a coroner’s jury made recommendations that the GN’s social service office employ more Inuktut-speaking social workers and translators, that foster parents be trained in safe sleeping practices for babies, and that parents be given more information about the health effects of cannabis smoke on young children.

But the coroner only holds inquests when a child dies in government care, as four-month-old Keyookta did the day after she was apprehended from her family.

Now the coroner’s office will have access to an in-depth review following the death of any Nunavut toddler or baby.

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(6) Comments:

  1. Posted by Sled dog on

    Something is not right here ” comittes working is confidential, and will help the Coroners-office understand what situations might lead to a child’s death in Nunavut.Unfortunately , Each year there should be a annual report published of all deaths reviewed at the committee, tabled and publicly available on the Coroners website the summary of all deaths reviewed by the committee and recommendations of each case for public education and to prevent similar deaths.
    The media release stats on making the chief coroner understand “ its experts will help Coroners office understand when and if child deaths are avoidable” ? Is this committee for the coroner to understand?? What a joke of incompetence. Ha ha

  2. Posted by pauliq ema on

    I am pretty sure padma had started this anf now someone else is getting the credit for it which is completely unfair to the GN department of justice. I know that khen was completely trained under Padma supervison and he is carrying forward her work which is stupid.

  3. Posted by stephen coleen on

    Padma has worked for few years with research On Sudden infant deaths below 5 years along with health , NTI and police put forward the recommendations to prevent with safe sleeping pattern. Find attached link from PAediatic medical journals . See the extent of study and efforts put in by the previous chief coroner.We all are aware that she was working on this Committee and there was a push back .

  4. Posted by lori on

    The real question here is why now and not 2 yrs ago when Padma initiated this committee.

  5. Posted by John on

    The previous chief coroner brought up the Coroners office to the high standards and she was a passionate women providing support to grieving families. What I am learning from this article that she worked hard to bring changes in Nunavut.
    Looking at the BMC paediatrics research paper from 1999 to 2011 study clearly indicates the causes, risk factors of deaths under 5 years. The extent of study indicates CPT1 variant in sudden deaths, which indicates the depth of deligience in death investigations. Looks like she worked hard to educate safe sleeping practices and 2016 baby box’s were introduced.
    Why is the new chief coroner wanted to learn from department of health and experts how to prevent these deaths? And why now? May be he does not know what he is doing?

  6. Posted by Sour Grapes on

    These comments are disgraceful! Rather than looking at this as a positive and congratulating the new coroner for having the insight and the ability to make this happen, this is what he gets ! Think of the good that will come out of this. The previous coroner talked the talk, he is walking the walk ! I wish you all the best with this, I know you are doing this to help the people of the Territory!

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