Makibi Timilak's cause of death undetermined inquest rules

Makibi Timilak's cause of death is undetermined, a jury in a coroner's inquest ruled Friday night in Cape Dorset, Nunavut.

The parents wept and consoled one another after the inquest looking into the death of their three-month-old son wrapped up, capping a week of emotional, technical and complicated testimony.

"There really is no closure once you lose someone," said the presiding coroner Garth Eggenberger afterwards.

"I think everybody felt for the family. They wanted the answers for the family.

"Hopefully, they've got the answers they need."

An undetermined cause of death results when there is no conclusive evidence pointing to one, single cause why a person died.

"Baby Makibi was a healthy, well taken care of and well loved child," read the jury's findings into the circumstances surrounding the death.

"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, placed on his tummy to sleep."

That may have been one of the potential risk factors, but there is no clear answer as to what caused his death, the lawyer representing the presiding coroner told the jury in her closing statements.

"We do not know why Baby Makibi stopped breathing," Amy Groothuis said.

The six-member jury made up of two men and four women from the hamlet of roughly 1,350 deliberated for about four hours Friday night inside Cape Dorset's community hall.

7 recommendations

The jury made seven recommendations to help prevent future similar deaths from occurring.

It recommended the territory enforce its telephone triage policy, specifically that all infants under the age of 1 be seen in the clinic as a priority.

Debbie McKeown, the nurse who took the phone call from Timilak's mother the night before he died, did not follow that policy. McKeown was deemed unfit to testify at the inquest by a doctor in Ontario.

• Former Nunavut nurse Debbie McKeown may be no-show at inquest into baby's death

Timely post mortems

Given the miscommunication and misinformation in this case, the jury called for all post mortem examinations of children under 5 years old to receive a mandatory peer review within a reasonable timeframe.

It was three years before the Timilak's autopsy was reviewed, leading to a change in the cause of death.

• Doctor says he erred in concluding Makibi Timilak died of a lung infection

Other recommendations from the jury include:

• the department of health acquire resident doctors for all Nunavut communities
• more education for expectant parents on safe sleep practices, as well as what to expect for first time parents
• culturally relevant, standardized orientation and mentorship for new nurses, to be delivered within the first few weeks of arriving in a community
• an avenue for patients to use if they are unhappy with the care, treatment or advice they receive at a health centre
• a review of nurses' schedules to allow them to get enough rest to avoid fatigue.

Review needed of chief coroner's office

The presiding coroner told CBC following the inquest he will be offering some recommendations of his own to Nunavut's Office of the Chief Coroner.

Eggenberger suggests more training be provided to local coroners in the territory's 25 communities.

He also recommended a review of the chief coroner's office, which has come under fire from the family and in an earlier independent report that examined the circumstances surrounding Timilik's death.

"You'll always remember this case of Baby Timilak," Eggenberger said after the inquest wrapped up and the tables and chairs were being put away to make room for a youth dance.

"For the parents, they're going to need support from their family the rest of their life. It will get better for them.

"But it's going to take time."