IQALUIT - The lawyer for the family of Elisapee Michael said her death was caused by a "tragic fabric of errors."

Scott Wheildon and the other lawyers involved in the inquest involved Michael gave their final submissions at the Nunavut Court of Justice in front of coroner Garth Eggenberger on April 13 in Iqaluit.

The inquest began April 4 and is going over what led to the death of Michael, 52, in August 2009. Michael had been drinking Aug. 8 at a bar in the Nova Inn in Iqaluit. She was asked to leave and was seen falling down the stairs of the hotel. She was found unresponsive and sent by ambulance to the hospital. She was deemed to be disruptive by hospital staff and was handed over to the RCMP, spending the rest of the night and most of the following day in a detachment cell.

On Aug. 9, she was found in the cell unresponsive in a pool of vomit and was taken back to the hospital. She was diagnosed with a head injury, and medevaced to Ottawa where she later died.

Wheildon asked the jury members if they felt "the minimum standards of human decency were met."

On behalf of Michael's family, he proposed the jury take up several recommendations including that Iqaluit get a CT scanner, the Nova Inn stairs be reconstructed and be lit at all times, the emergency medical responders make written documentation available to staff at the hospital when they arrive with a patient and that doctors do not transfer citizens with suspected head injuries to cells.

He then said the next of kin or family of the patient should be contacted.

Michael's family sat in the gallery Wednesday as they have for the entirety of the inquest.

"We should have never left the hospital," said Eva, her sister, as she was crying while Wheildon continued.

This was followed up by other recommendations that the hospital have properly trained security guards, the new RCMP detachment keep video recordings of cells for a longer period of time than the couple weeks as is currently done, translation at the hospital and RCMP be at least on call or available in some form 24 hours a day, seven days a week and drug and alcohol abuse counselling be available in the community.

"No one asked for 14 hours if she was OK ... she should have been medevaced immediately," Wheildon said.

Hospital needs more staff: lawyer

Meghan O'Brien, the lawyer for the three doctors involved in the inquest, also recommended the hospital get a CT scanner. She added the hospital needs more staff including more and better trained security guards to handle what she called "difficult patients in emergencies."

Michael was hospitalized during a H1N1 epidemic and two babies were in the emergency room with one of them on a ventilator.

"Hospital staff were under enormous pressure," O'Brien said.

A medevac plane needs to be on hand at all times to fly patients such as Michael out of the community, she said, because Michael had to wait until the morning of Aug. 10 to be transferred to Ottawa.

It was noted that the Department of Health and Social Services has since switched medevac providers and there are supposed to be medevac teams on the ground and based out of Iqaluit.

As suggested by her fellow lawyers, she said having an interpreter at the hospital and getting EMRs to hand over written documentation at the hospital would be crucial.

In addition she suggested the hospital should develop a "clear and and written policy to handle difficult patients and particularly those who are to be transferred to RCMP custody."

Two guards didn't know policies

Before the lawyers began their final submissions, the court heard from Sgt. Peter Pilgrim, who in 2009 was the operations non-commissioned officer in Iqaluit.

Pilgrim was responsible for screening the guards, ensuring they were trained and had read the required manuals.

While Michael spent time in RCMP cells, she was under the supervision of three guards in total, one guard on each shift.

Wheidon asked Pilgrim if the three guards had signed the Iqaluit cell block operations manual. It turned out only one guard had signed it.

Pilgrim was then asked if any of the guards had attended a session how to assess a prisoner's responsiveness.

"I've never heard of it before," he said.

The manual and the session include the four Rs – rousability, response to questions, response to commands and remember. A tour of the cells revealed a poster with the four Rs was on the wall next to the door of the cell block.

"The guards never assessed responsiveness in 14 hours," Wheildon said.

The court heard there is no specific amount of time guards have to be trained for before they report for duty. This was confirmed by guard Jonathan Dailey who worked the 1 a.m. to 9 a.m. shift on Aug. 9.

He said the training mainly consisted of on-the-job shadowing.

That night when Michael was in the cells, he checked on her and the other prisoners to see if she was still breathing. If there was no response he said he kicked or banged on the door.

Dailey said he was unsure if there was a policy on guard work and does not remember reading it.

RCMP wants holding area at hospital

RCMP lawyer Rohan Brown started his submission with what one of the RCMP members overheard Dr. Shahin Shirzard say at the hospital when they took Michael back to the facility.

"Why was she sent to jail and not left here?," he had said.

Brown said RCMP members did not know Michael had a head injury and no one at the hospital signed a C13 form stating she had to come back to the hospital.

He said while the new detachment facilities have made a difference, a provision will be added to the manual stating intoxicated prisoners should be checked on every hour fours.

Brown also said a holding area should be created at the Qikiqtani General Hospital so patients who are intoxicated can be safely monitored instead of always sending them to the cells. Only those who are dangerous would then be transfered.

Once submissions were complete, Eggenberger reminded the jury the inquest is not a case and no one stands accused. He said they have to figure out how the deceased died and by what means. He added they do not have to come to a majority decision or accept any of the proposed recommendations.

Eggenberger reminded jury members before they were dismissed: "You can effect change to prevent similar deaths in the future."

The jury continues its deliberations.

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