Cause of death still not clear after
inquest into infant death
Jury provides seven recommendations for territorial health-care providers
Beth Brown
Northern News Services
Monday, December 5, 2016
KINNGAIT/CAPE DORSET
The cause and manner of death of a three-month-old Cape Dorset infant remain undetermined, according to the Nov. 25 verdict of a coroner's jury following a four-day inquest.
An inquest into the death of a Cape Dorset infant who died in April 2012 led to seven recommendations by a coroner's jury. The child's cause and manner of death remain undetermined. - NNSL file photo |
"To the people attending the inquest it wasn't a surprise," said presiding coroner Garth Eggenberger.
The verdict found that the child, Makibi Timilak, died on April 5, 2012 between 3:45 and 3:50 a.m. at the Cape Dorset Health Centre.
The baby died after being refused care by a community health nurse, Deborah McKeown, despite territorial regulation that children under one year of age must be seen after hours.
"Baby Makibi was a healthy, well taken (care) of and well-loved child," stated the verdict.
"On the day of April 4, 2012 baby Makibi was not well. He had a runny nose, was coughing, had trouble breathing and wasn't sleeping well. He was bed-sharing with a parent and placed on his tummy to sleep."
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 (SIDS).
"There is a cause of death, but the cause of death is undetermined," said coroner's counsel Amy Groothuis. "The evidence that came out is that cytomegalovirus is a common type of infection, but there is a big difference between infection and disease."
Doctors said the virus is commonly carried by adults, but not active, she said.
"The baby had the infection but what we learned from the pathologist is that it was not symptomatic, and cytomegalovirus did not cause his death."
As for SIDS, she said the factors were there, such as bed-sharing, but specialists could not call these factors a cause.
Nurse McKeown was not present at the inquest, but the notes she made were read from the child's medical file.
"Between that and having some of the witnesses speak to their conversations with her, there was still evidence that spoke to her involvement," said Groothuis.
Medical records did show that the child had continuity of care, she said.
The jury provided seven recommendations to help the territory avoid similar incidents in future.
"What the jury came up with was greater support for new parents, early education on risk factors, and increased training and orientation with a cultural component and with cultural sensitives for health care providers in communities," she said.
The recommendations also included enforcing the telephone triage policy (specifically for infants under the age of one), creating a way for patients to reach out if they are unsatisfied with the care they are receiving, and providing resident doctors to each community.
"Given the miscommunication and misinformation in this particular case, we recommend all post-mortem examinations for children under five years old receive mandatory peer review within a reasonable time frame," stated the final recommendation.
Coroner Eggenberger also provided recommendations for how to strengthen coroner services in the territory.
"They need to get more local coroners, but they need more money to do that for training," he said.
"I did a review five to seven years ago. This is just another review to see where they are at."
He said the recommendations from his previous review were implemented.
"This is just going to the next level."
 | Chief coroner said inquest not necessary | 
|
Nunavut chief coroner Padma Suramala said in June of 2015 that an inquest was not required. The decision was challenged by the child's parents, Neevee Akesuk and Luutaaq Quamagiaq. The inquest was later requested by the minister of Health, following an independent review into the case.
"The family was definitely not happy with the chief coroner," said Eggenberger, "so we brought someone else in for a different view."
As of Dec. 1, Suramala was preparing to comment on the inquest and recommendations.
"I wanted this inquest to be as independent as possible, that's why I handed it over to him."
She was also working on an inquest in Iglulik at the time – so said the choice was in part a matter of stretched resources.
The coroner's office had Inuktitut-speaking counselors visit the community during the inquest.
"My sense is that they were utilized and that it was beneficial for the family and the community," said Groothuis. "It was an emotional week."
