Government, health care system failed Baby Makibi
'Cycle of division between community members
and service providers' should be addressed, says lawyer
Michele LeTourneau
Northern News Services
Monday, December 7, 2015
KINNGAIT/CAPE DORSET
A Journey Through Heartache is the title of long-awaited review into the 2012 death of an infant in Cape Dorset.
Retired lawyer Kathrine Peterson, author of A Journey Through Heartache, left, Health and Justice Minister Paul Okalik and South Baffin MLA David Joanasie release the long-awaited review into the 2012 death of an infant in Cape Dorset on Dec. 1. - photo courtesy of the Department of Health, GN |
Author and retired lawyer Katherine Peterson said she titled the document to acknowledge the pain of mom Neevee Akesuk and dad Luutaaq Qaumaqiaq who lost their child under circumstances that remain largely unknown, despite three pathology reports.
The report is about more than the death of one child. It speaks of a government bureaucracy that failed time and time again.
"Two policies in the Community Health Administration Manual mandate an in-person assessment of infants under the age of one year," states Peterson in the review. "These policies were not followed by Nurse (Debbie) McKeown at the time the mother of Baby Makibi contacted the Health Centre on April, 4, 2012. This report is not mandated to conclude, nor does the author have the expertise to conclude whether this would or would not have resulted in the survival of Baby Makibi."
Makibi is said to have died of sudden infant death syndrome (SIDS) or a respiratory infection depending on which of three reports is to be believed.
Peterson also states an investigation into the regional office in Cape Dorset, which took place in 2013, "was in response to a further harassment complaint regarding McKeown. It was not in response to the death of Baby Makibi and that fatality received only a peripheral mention at the time this investigation occurred."
Health and Justice Minister Paul Okalik released the document Dec. 1, along with Peterson and Cape Dorset MLA David Joanasie.
Okalik publicly apologized to the family in a news conference after his flight failed to land in Cape Dorset. Okalik intended to share the information in the report with Akesuk and Qaumaqiaq but weather prevented him. Department of Health officials say he did manage that visit the next day.
"On behalf of the Government of Nunavut and the Department of Health, I apologize to Baby Makibi Timilak's family. In particular, I apologize to Makibi's parents, Neevee Akesuk and Luutaaq Qaumaqiaq, for the heartache and suffering they experienced following their son's untimely death in 2012," said Okalik at the news conference. "I also extend apologies to the people of Cape Dorset for any uncertainties they have experienced about the quality of health-care service delivery in their community, and assure them of our commitment to a higher standard."
The parents did not respond to Nunavut News/North's requests to tell their story.
The report, which contains almost 50 recommendations aimed at the Department of Health, is essentially a history of a bureaucracy gone wrong. It's an excoriating review of health care in one community, Cape Dorset, but suggests that community is likely not the only one to experience system failures.
"This atmosphere is not only current in Cape Dorset but has existed over many years. Action which hopes to address this dynamic must be more broadly based than this current review," states Peterson. "It must focus on those factors, such as historical trauma, and current individual and family dysfunction. It is a long and arduous road, not easily undertaken or achieved. However, if the cycle of division between community members and service providers is to be addressed, this effort must occur."
Peterson tackles the difficulties of nursing in Nunavut, demonstrating a practical understanding.
But she is clear the system has failed Inuit.
Peterson writes: "The failure to conduct a timely and appropriate investigation regarding the death of Baby Makibi likely arises as a result of: The failure by responsible bureaucrats to properly report/investigate the death in accordance with the Community Health Administration Guidelines; the failure of communication between the district supervisor, South Baffin and regional office; the failure to respond to known difficulties existing in the operation of the Cape Dorset Health Centre, which facts were known by the regional office and district supervisor, South Baffin in 2012 prior to the death of Baby Makibi."
As Peterson notes, McKeown, the nurse at the heart of this infant death, declined to speak with her for the review.
"One person, namely Debbie McKeown, attending nurse at the Cape Dorset Health Centre at the time of this fatality, declined to be interviewed or participate in this review. Reasons cited were the existence of litigation initiated by Ms.McKeown respecting professional disciplinary proceedings."
McKeown is seeking reparation from the Registered Nurses Association of the Northwest Territories and Nunavut through a legal process and is scheduled at the Nunavut Court of Justice in Iqaluit later this month.
Peterson also addresses the toll on the nurse now known as the whistleblower, Gwen Slade.
"The credibility of Ms. Slade was treated as suspect from the outset," stated Peterson. "Complaints had been made orally, in writing, by formal grievance, to supervisors and union officials well before the fatality occurred. These concerns were not fully investigated and in some cases, the credibility of the complainants was entirely marginalized without investigation."
Peterson also states in the report that the parents deserve to have a full inquest carried out surrounding the death of their child.
"The varying reports of the chief coroner as to the cause of death of Baby Makibi has left the community of Cape Dorset uncertain as to the facts, medical opinions, distrustful and angry," she said.
"Various versions of events at the time have emerged leaving a situation of conflicting facts. These conflicting facts and medical opinions are best addressed by a formal inquest in the community regarding the death of Baby Makibi."
Nunavut's chief coroner Padma Suramala denied requests for an inquest in June of this year.
"Evidence observed at the scene and information collected through witness statements revealed that the infant was sleeping in an unsafe sleeping environment, which is a known risk factor for SIDS," Suramala stated at the time.
This was despite the fact that a pathology report earlier stated the infant died of a respiratory illness.
