IKALUKTUTIAK/CAMBRIDGE BAY - The lawyer for the family of Julian Tologanak-Labrie said a lawsuit is likely to be filed against an unnamed party after a coroner's inquest wrapped up in Cambridge Bay on April 15, exactly one year after his death.

The lawyer for the family of Julian Tologanak-Labrie said a lawsuit is likely to be filed against an unnamed party after a coroner's inquest wrapped up in Cambridge Bay on April 15, exactly one year after his death. - NNSL file photo

"We need some time to digest what has happened and really just switch gears," Steven Cooper, the lawyer representing Tologanak-Labrie's family, told Nunavut News/North on Friday. "The question now becomes if one or more people should be sued."

It was ruled the 20 year old committed suicide after jumping 7,000 metres to his death from an Adlair Air King Air 200 plane on April 15, 2009. Tologanak-Labrie was on a flight home to Cambridge Bay from Yellowknife.

His body was never found.

Cooper said the family is "completely" satisfied with the conclusions of the inquest. He said the most important thing he and the family learned from the process was that there was a serious lack of information during the ordeal.

"The essence of my submissions to the jury was that Julian died because the people that needed to know things didn't know them and what they knew was discounted by the people that knew it," said Cooper.

As an example, he said there was confusion over how Tologanak-Labrie was brought into Stanton Territorial Hospital by Yellowknife RCMP. Those at the inquest were told he arrived in handcuffs at the hospital involuntarily under the Mental Health Act.On April 14, 2009. He had been in Yellowknife for a hockey tournament and police took him to the hospital from a hotel after his friends reported he was behaving unusually and had a knife.

Cooper said with a careful reading of the Mental Health Act, he realized Tologanak-Labrie had never been fully admitted as a patient to the hospital. If he had been fully admitted, more information from Tologanak-Labrie would have been collected and he probably would have had some communication with his family, said Cooper.

With the inquest concluded, Cooper said he now knows, based on the evidence and testimonies of witnesses, that once a doctor and a psychiatrist conducted assessments at the hospital, Tologanak-Labrie was told he could leave.

NWT chief coroner Garth Eggenberger presided over the inquest, which started on April 12. The six-member inquest panel made five recommendations as to how similar deaths could be prevented in the future. Targeting government and health-care officials, the jury recommended both the governments of Nunavut and the NWT should review their mental health legislation to ensure it is focused on patient care. The second recommendation advised Stanton Territorial Hospital to develop a way to record information from the time patients are admitted to a hospital until they are discharged, including any notes or relevant details from the RCMP.

Other recommendations are:

--Stanton Territorial Hospital should have an on-call psychiatrist on staff for emergency calls

--Transport Canada should review locking mechanisms on aircraft doors and look at getting emergency locks that can only be activated by the crew on the aircraft

--Adlair Aviation should have an on-flight nurse on all medical flights, and that rear-view mirrors should be installed on its aircraft