Tragic lessons
Coroners inquests give citizens final say

by Richard Gleeson
Northern News Services

NNSL (May 05/97) - Coroner's inquests studied the untimely deaths of 11 Northerners last year. Each inquest resolved questions that otherwise may have been left to echo forever in the minds of families and loved ones of those who died.

But those answers sometimes came at a high price, both financially and politically.

Two weeks ago, for example, the family of Honorine Norn served notice of a $310,000 lawsuit they've filed against Yellowknife's Stanton Regional Hospital for alleged negligence causing death.

The lawsuit followed by four and a half months an inquest into Norn's death. The inquest concluded she died as a result of complications due to surgery.

Norn was admitted to hospital in April 1994 to have her gall bladder removed. According to the statement of claim, shortly after the operation, Norn showed signs of infection.

Her condition continued to deteriorate. Three days after the operation Norn was moved to Edmonton's Royal Alexandra Hospital, where staff discovered a dangerous amount of bile and blood in her abdomen. Doctors there operated on her three times in an attempt to save her, to no avail.

After listing its recommendations to avoid a repeat of the events that led to Norn's death, the inquest jury made a statement on the importance of inquests:

"We as the jury would like to thank Madame Coroner for initiating this inquest ... we advocate the use of inquests to encourage community responsibility for the lives and safety of others."

The Coroner's Act requires that a coroner investigate all deaths that occur as a result of apparent violence, suicide, accident, negligence, malpractice or any cause other than sickness or old age. Deaths that occur in police custody or jail must also be investigated.

To allow proper investigation, coroners have the authority to examine the scene of death, seize evidence, secure the scene for up to 48 hours, recruit the help of a doctor, even order the buried to be exhumed.

After an investigation, coroners must call a public inquest to look further into deaths where they believe some public good would be served.

"As coroners, we're not interested at all in fault. We deal only in facts," explained Iqaluit coroner Tim Neily.

"That's particularly important during inquests, that we stay only with the facts, and ensure no questions are leading toward finger pointing or assignations of blame."

Either a local coroner or the chief coroner of the NWT presides over an inquest. Through questioning of witnesses -- questioning often conducted by lawyers -- the facts surrounding the death are exposed.

The information is heard by a panel of six randomly selected jurors. The jurors are responsible for determining the manner of death and making recommendations to help avoid such a death in the future.

"They're not legally binding," noted Heather Chang, Stanton Regional Hospital's liaison with the coroner's office. "But in the best interests of the community most agencies will ensure that recommendations are addressed."


1996 inquests

February


Inuvik
Circumstances: Man dies Oct. 23, 1993, after blows to abdomen while being forcibly ejected from bar

Manner of death: Homicide

Recommendations: Liquor board require thorough screening of bouncers; bars establish guidelines for situations requiring physical contact; police train bouncers

Inuvik


Circumstances: Three people die after consuming methanol at an Oct. 29, 1994, drinking party. Jury concludes third victim, who died four days after party, would have survived if treatment started immediately.

Recommendations: Inuvik hospital improve diagnosis and treatment procedures for methanol ingestion.


June
Yellowknife
Circumstances: Two weeks after attempting suicide in Cambridge Bay, woman hangs self while lodged in jail cell.

Verdict: Suicide

Recommendations: List of 21 recommendations to improve treatment, follow-up and support for sexual abuse victims, care for those who have attempted suicide


August
Yellowknife
Circumstances: Infant dies 24 hours after being brought to hospital for vomiting July 19, 1995, sent to clinic, then brought back to hospital.

Manner of death: Natural causes

Recommendations: Ensure rigorous application of diagnostic procedures; Stanton Hospital ensure emergency room doctors assess all patients prior to discharge; establish protocols to increase effectiveness of emergency specialist services.


December
Yellowknife
Circumstances: Infant dies as a result of complications due to surgery at Stanton, May 31, 1994.

Manner of death: Homicide

Recommendations: Stanton address communication problems; ensure medical staff has responsibility to request a second opinion when complications arise; establish system to notify staff of blood tests showing "panic" levels, requiring signed acknowledgement from doctor of having seen results; GNWT provide funds for ultrasound, radiology technicians; interpreters available at all times