SOMBA K'E/YELLOWKNIFE - A coroner's inquest jury returned Friday night with 16 recommendations aimed at addressing alcoholism and enhancing information flow between Stanton Territorial Hospital and RCMP, among other things.

A jury came back with 16 recommendations at the coroner's inquest Friday regarding the 2010 death of Raymond Eagle. In this 2009 photo, Eagle's father, Tom, stands at Raymond's bedside. Tom Eagle passed away later that year. - NNSL file photo Key recommendations The Department of Health and Social Services should create a community group to explore the possibility of establishing a drug, alcohol and substance rehabilitation centre and a half-way house in Yellowknife. Stanton Territorial Hosptial establish protocols regarding what medical information can be shared to outside agencies regarding patient care. RCMP and Stanton Territorial Hospital should develop a protocol that meets "ethical boundaries" regarding the sharing of information about individuals being transferred. Guards at the RCMP detachment should perform a physical cell check and review of forms and reports during shift changes; and log prisoner movements and observations in a log book. RCMP and guards should have written guidelines and large information posters on the walls near cells regarding head trauma symptoms, blood alcohol poisoning, drug overdoses as well as a prisoner responsiveness chart.

After nearly seven hours of deliberation, the four-woman, two-man jury urged the Department of Health and Social Services to "explore the possibility" of establishing a drug, alcohol and substance rehabilitation centre and a "half-way house" in Yellowknife. As well, they recommended improved safety checks for intoxicated prisoners in RCMP cells and better communication between the police and hospital staff.

The inquest was launched following the death of Raymond Eagle, whom a taxi driver found lying in the middle of a downtown street in a pool of blood from a head wound on the evening of Aug. 3, 2006.

Eagle, heavily intoxicated at the time, was taken to Stanton Territorial Hospital, treated and released into police custody by hospital staff. After vomiting in jail a few times and becoming unresponsive, the RCMP took Eagle back to the hospital. He was then placed on a medevac to Edmonton close to 18 hours flight after being initially treated.

A doctor in Edmonton discovered Eagle had bleeding in his brain and he underwent surgery for a blood clot the next day.

Eagle slipped into a coma and never regained consciousness. On Jan. 5, 2010, after spending more than three years in a coma, Eagle passed away at the age of 48 from the effects of heart disease.

"Raymond went from a patient to a prisoner to a victim within an 18-hour period," said Margaret Eagle, Raymond Eagle's sister, speaking to the jury before they left for deliberation. "My brother slipped through the cracks on this one."

Mark Raven-Jackson, a lawyer representing Stanton Territorial Hospital, expressed concerns to the jury regarding draft recommendations involving the release of medical information to the RCMP. His concerns were that this would violate doctor-patient privacy rules. Raven-Jackson added that if private medical information was disclosed to the RCMP in similar situations, that could deter individuals from seeking medical attention.

The jury recommended the information should be shared within "ethical boundaries."

Matt Young, a lawyer for the Yellowknife RCMP, told the jury that since the incident, the RCMP has changed its procedures for dealing with "highly intoxicated" prisoners, including random observations of prisoners every eight to 10 minutes and waking up highly intoxicated prisoners every hour.

Prior to being assigned to the task of forming the recommendations, the lawyer for the GNWT coroner's office had some sombre advice for the jury: "You can't bring Raymond Eagle back, but you can change the future of people like him," said Paul Smith, referring to Eagle's issues with alcohol and homelessness.

Cathy Menard, chief coroner for the GNWT, said the coroner's office will check on the progress of the recommendations after three months. However, she added the recommendations are only for consideration and are not legally binding.

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