KINNGAIT/CAPE DORSET
Nunavut's chief coroner has rejected calls for a coroner's investigation into the death of Makibi Timilak.

Nunavut's chief coroner Padma Suramala has denied the request to do a discretionary inquest into the 2012 death of three-month-old Makibi Timilak in Cape Dorset. The death has been the subject of controversy. - NNSL file photo

Timilak died at three months old in his Cape Dorset home in 2012.

Gwen Slade, a nurse who raised the alarm about controversial circumstances surrounding the death, alleged that prior to the death the baby's mother was told by a health-centre nurse not to bring the baby in to be looked at when she called to ask about the baby's coughing, runny nose and peculiar breathing.

Last week, chief coroner Padma Suramala distributed an information release, citing the public's widespread desire for a factual account of the coroner's investigation into the case.

As the preliminary autopsy report showed no anatomical cause, the baby's death was attributed to sudden infant death syndrome (SIDS).

"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.

Her investigation also identified that the on-call nurse did not follow the Government of Nunavut's community health nursing procedures to treat children under one year of age.

Suramala's recommendations were sent to the nursing licensing board and Nunavut Department of Health in order for those bodies to review nursing standards and ensure that methods for infant care in and out of the health system are reviewed and followed.

An autopsy conducted by the Children's Hospital of Eastern Ontario in Ottawa showed "widespread pulmonary cytomegalovirus infection (CMV)," related to pneumonia, as the immediate cause of Timilak's death.

Suramala's office later consulted a forensic pathologist from Ottawa Hospital to review the autopsy results.

Dr. Christopher Milroy, director of forensic pathology at Ottawa Hospital, determined the lung tissue showed no evidence of infection and was negative for CMV.

Milroy also noted the sleeping environment was a known risk factor for SIDS.

Fatal CMV infection is typically seen in a child with a vulnerable immune system.

"The history in this case does not indicate any such state and there was no fever or other evidence the child was unwell," Milroy stated in his autopsy report. "There was evidence of bed sharing in this case, which is a known risk for sudden death of an infant."

Suramala stated that the evidence suggests to her that the cause of death should be classified as "undetermined."

"The coroner makes every effort to classify the death," stated Suramala. "In this case, there were initial indications of SIDS, as well as initial indications of CMV as the immediate cause of death."

She stated the classification of "undetermined" does not indicate negative findings of an investigation and follows a thorough and comprehensive investigation in which experts in the area were consulted.

"Coroner's investigations and inquests are fact-finding procedures and are not fault-finding exercises to assign blame to any particular individual or organization," she stated.

"The coroner examines the complete investigation and comes to a decision based on factual information. Coroners do not have a vested interest in the outcome of the death investigation and operate independently and at arms-length from the government to ensure the absence of bias in its findings."

She concluded Timilak's case does not qualify for a discretionary inquest.

Slade called Suramala's release "misleading, deceptive and disingenuous" in an e-mail response to Nunavut News/North.

She stated it sounded like a lawyer wrote the release.

"Everything after the fact (Timilak) wasn't seen is a moot point," stated Suramala. "He died. The inquest is needed to determine why he wasn't seen."

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