Inquest results en route
Beth Brown
Northern News Services
Monday, November 28, 2016
KINNGAIT/CAPE DORSET
An inquest into the death of Cape Dorset infant Makibi Timilak took place Nov. 22 to 25.
Coroner Garth Eggenberger of Yellowknife presided over the inquest.
"Our hope in holding the inquest is that it will provide both the family and the community some level of closure, in having important answers about what happened to Baby Makibi," stated the coroner's lawyer Amy Groothuis.
Makibi died on April 5, 2012, after allegedly being refused care by a community health nurse, Deborah McKeown. Territorial regulation is that children under one year of age must be seen after hours.
Nunavut News/North discussed the inquest with Groothuis before the inquest's conclusion, as it continued after the press deadline.
"This week we expect to hear from the family, nurses who provided care to Makibi during well-baby visits and who responded the night of his death, RCMP officers who conducted an initial investigation, an infectious disease specialist, pathologists involved in the post mortem examination, and an expert witness on identifying cause and manner of death in infants," she wrote.
"The coroner's inquest is a non-adversarial, fact-finding hearing that's meant to provide a full explanation for why the deceased died."
Eggenberger held a community meeting the day prior to the inquest. South Baffin MLA David Joanasie, the family of the deceased and few community members attended the meeting, she said.
In June 2015, Nunavut chief coroner Padma Suramala said an inquest was not needed. The decision was challenged by the child's parents, Neevee Akesuk and Luutaaq Quamagiaq.
The inquest opened with a written statement by Suramala, who was not present.
"The death of Baby Makibi has provided an opportunity for me to reflect on how and where improvements may be made in the Coroner's Office," she wrote. "I acknowledge there were miscommunications between myself and baby Makibi's parents. I know this caused them distress in an already unimaginable situation, and I apologize for adding to their sorrow."
The miscommunications were related in part to the child's cause of death.
"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," retired lawyer Katherine Peterson said last December.
Conflicting autopsy and pathology reports suggested that the child had died of either cytomegalovirus infection, which is related to pneumonia, or from sudden infant death syndrome.
Peterson authored a review of the death, providing 50 recommendations to the Department of Health. MLAs critiqued the department at the time for the review's lack of scope. Suramala noted three changes made within the office following the events since the child's death.
"A direct change instituted in the Office of the Chief Coroner is to always contact families directly to inform families the cause of death and provide updates on the death investigation," wrote Suramala.
Should the family not have a phone, they may use one at the RCMP or health centre. The office will not rely on nurses or community health officers to explain the cause of death. Also, preliminary autopsy reports will not be released when if additional testing is being done. In addition, "The Office of the Chief Coroner is currently in the process of instituting a pediatric death review committee."
The committee will be modeled after an Ontario process to comprehensively review circumstances surrounding the deaths of children under the age of five.
Nurse Debbie McKeown faces a number of other allegations brought forward by the territorial nurses association.
"McKeown is still technically an employee of the Government of Nunavut, on long term medical leave," wrote Gwen Slade, the community nurse who put her career on the line to accuse McKeown of negligence, in a Nov. 20 e-mail to Nunavut News/North.
The jury is tasked with answering five questions, including the identity of the deceased, the date, time and place of death, the cause of death, the manner of death and the circumstances surrounding the death. The jury report will also make recommendations for preventing similar deaths in the future.
