Quebec coroner slams botched rescue of burned Nunavik woman

A Quebec coroner says Nunavik authorities demonstrated a lack of common sense and compassion when they took 18 hours to rescue a badly burned Kangiqsujuaq woman.


MONTREAL — One year after a badly burned Kangiqsujuaq woman died, a Quebec coroner has found that a lack of common sense, planning and compassion severely hampered efforts to save her life.

Dr. Pierre Samson deemed the death of 79-year-old Sarah Ningiuruvik Paulusi as violent, but accidental, due to an explosion of gasoline at her cabin, which was located about 25 kilometers from Kangiqsujuaq.

But he said there were several other circumstances that contributed to her death.

“The speed of the emergency response from the moment she arrived in Kuujjuaq seems without reproach, but we can’t say the same about the time lapse between the explosion at Sarah Paulusi’s cabin, and her transport to the the hospital in Kuujjuaq,” says the coroner’s report.

It took 18 hours for authorities to pick her up and transport her over the short 25-kilometre distance between her cabin and the community of Kangiqsujuaq.

Sarah Ningiuruvik, as she was known in Kangiqsujuaq, had poor vision. As she attempted to light a camp stove around 6 p.m. on June 1, 1999, she mistakenly filled its reservoir with gasoline instead of kerosene.

The elderly woman’s feet were the only parts of her body that weren’t burned in the resulting explosion.

Her son, who was outside chopping wood when the blast occurred, looked up to see his mother’s face on fire through the window of her cabin.

After rescuing her from the flames, he left his mother at the camp while he travelled by skidoo to Kangiqsujuaq, some 25 kilometers away, to alert authorities.

But the two nurses stationed in Kangiqsujuaq told him they weren’t allowed to travel out of the community to help because of “internal regulations” that prevent nurses from leaving the village, even to respond to medical emergencies.

Ningiuruvik couldn’t be immediately medevaced to Kuujjuaq, either, because pilots at all the northern airlines based in the town said they’d already flown their legally allotted hours for that day.

According to the federal Civil Air Services Navigation Commercialization Act, pilots are limited to only a 14-hour duty shift.

“The lack of internal planning in such a situation needs to be the subject of an urgent and thorough review by public authorities, so well-organized services are available in any emergency or disaster that may arise,” reads the coroner’s report.

Finally, a group of local Canadian Rangers and a police constable arrived at the scene of the explosion seven hours later. They didn’t arrive back in Kangiqsujuaq until 3 a.m.

At daybreak, a helicopter was finally able to leave Kuujjuaq to fetch the burned woman. Eighteen hours after the accident, when Ningiuruvik arrived at Kuujjuaq’s Tulattavik Health Centre, she was suffering from hypothermia and low blood pressure in addition to her burns, On June 3, she died a few hours after her arrival at a Quebec City hospital burn unit.

“Any emergency procedure should reflect a concern for the well-being of patients or injured individuals involved in an emergency or disaster. Any internal constraints, such as a fixed period of work, restrictions regarding work-load, etc., should not override common sense or compassion when the life of a person hangs in the balance due to a possible administrative or organizational delay,” concludes the coroner’s report.

The coroner also said different colours should be used to identify fuel containers. “There is certainly reason to use set and predetermined colours to safely identify different inflammable products. While red for snowmobile gasoline appears to be satisfactory, we would suggest using yellow or another colour for kerosene,” his report says.

Since Ningiuruvik’s death — and due to lobbying from Makivik Corporation and the Kativik Regional Government — Nunavik-based airlines such as Air Inuit have been given more flexibility for medevac flights, and flight crew may now work for up to 17 hours in a day. According to Air Inuit operations manager Pierre Laplante, a medevac will not be aborted after 17 hours if there is a “moral case” to proceed, and no risk to safety.

Air Inuit has also stationed another flight crew in Puvirnituq to provide a 24-hour response time for medevacs.

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