IQALUIT - Eva Michael said her family is relieved the nine-day inquest into the death of her sister Elisapee Michael is over and hopes the recommendations of the jury are taken seriously by all parties.

The nine-day inquest to determine what circumstances led to the death of Elisapee Michael ended at the Nunavut Court of Justice in Iqaluit on April 14 after the jury came up with 29 recommendations. Eva Michael, left, Elisapee's sister, speaks to reporters while the family's lawyer Scott Wheildon looks on. - Emily Ridlington/NNSL photo

"My sister died and I don't care how much it costs for anybody to correct things," said Eva Michael after the six-person jury in the inquest investigating her death ended at the Nunavut Court of Justice in Iqaluit on April 14.

Eva said the most important thing is communication in emergency situations.

Elisapee Michael died as a the result of a head injury on Aug. 13, 2009 at Ottawa Hospital after being medevaced from Iqaluit. On Aug. 8 she had been drinking at the bar in the Nova Inn. She was asked to leave and was seen falling down the stairs of hotel. After being sent by ambulance to Qikiqtani General Hospital and examined, she was deemed to be disruptive by hospital staff, who called the RCMP.

On Aug. 9, she was found in her RCMP cell unresponsive in a pool of vomit and taken back to the hospital in Iqaluit. She was medevaced to Ottawa on Aug. 10.

Scott Wheildon, the lawyer for the family of Elisapee Michael, told the jury prior to their deliberations, that Michael's death was caused by a "tragic fabric of errors," and asked the jury members if they felt "the minimum standards of human decency were met."

The jury produced 29 recommendations and ruled Michael's death was caused by a head injury and accidental.

"We express our deepest and serious condolences on behalf of society for society failing to provide Elisapee Michael with the care, dignity and respect she deserved," said the foreman of the jury before he read the recommendations.

They focused on the themes of communications, safety and consistency.

The jury requested the city's building inspectors ensure all licensed establishments have proper stairways, lighting and railings up to the National Building Code. They also want the city's emergency medical responders to have a log form available upon patient transfer when a patient arrives by hospital via ambulance.

According to the jury, guards working at the RCMP cells should receive full and complete training which should be updated semi-annually with the training materials being available at the guard station.

Guards should have visibility of all cell blocks and emergency numbers should be put on speed dial on the telephone at the guard station.

The rousability test, as found in the RCMP manual, should be conducted by guards every two hours to all prisoners and video recordings from cells should be kept at least six months.

They also recommended translation services be available at the RCMP station.

"Especially in a community like this where the majority of people are Inuit," said Eva.

If a patient is released to the RCMP, the jury recommended a form be drafted stating what precautions need to be taken as well as follow-up care. This form would be signed by a doctor and go with the patient and another copy would remain in their medical file.

The majority of the recommendations were geared towards Qikiqtani General Hospital and the Department of Health and Social Services. Priority number one to get the facility get a CT scanner and personnel to run the machine immediately which would "improve health care for all the citizens of Nunavut."

Upon each hospital visit, the jury would like to see the contact information for the next of kin of each patient updated and it the information be put on each patient's wristband.

Hospital needs secure area

The jury recommended that under no circumstances should a patient with a head injury be released to the RCMP.

If a patient needs a medevac, they be sent out promptly instead of having to wait almost a day as did Michael before she was sent to Ottawa. If a patient is unconscious and not accompanied on the medevac, the next of kin should be called and a medical consent form with the family's wishes should be sent with them before the patient leaves the North.

The jury asked for a secure area to be created at the hospital for "problematic or intoxicated" patients instead of transferring them to the RCMP cells. This mean the hiring or more security guards at the hospital. It was also felt if there should be more medical staff.

The jury also said translation services should be available to patients at all times.

The last recommendation to the hospital was that new staff should be made aware of policies and procedures especially when it comes to the transfer of patients south and to the cells.

Meghan O'Brien, the lawyer for the three doctors involved in the inquest, had suggested to the jury Wednesday 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.

The jury also reccomended the Department of Health and Social Services "must implement a territory-wide drug and alcohol treatment program immediately."

Coroner Garth Eggenberger presided over the inquest. He said while the recommendations are not binding under law, in most cases the recommendations can be achieved.

As for how the organizations will be held accountable he said: "We are relying on their commitment to the citizens of Nunavut."

He said organizations are given up to six months to respond to the recommendations.

Eggenberger said if the Michael family wanted to sue any of the parties that would be up to them.

As for Eva and the rest of the family, she said they are hoping something like this doesn't happen again.

"As Mom put it, 'it's time to carry on and move forward.'"

We welcome your opinions. Click here to e-mail a letter to the editor.