2nd coroner's inquest this summer hears Inuit man in need of medical care was presumed drunk

In a span of just two weeks, two different coroner's inquests inNunavutheard that two different men were delayed getting proper medical carebecause police or a doctor assumed they'd been drinking.

A coroner's jury examining the 2013 death ofVictorKaludjak, 50, released 24 recommendationsto help the territorial government prevent similar deaths in the future.

The jurors heard last week that when Kaludjakvisited theRankinInlet health centre seeking medical help on March 20, 2013, he was treated for alcohol poisoning even though hetold nurses he hadn't had a drink in fourdays.

The inquest ran from July 31 to Aug. 3, just a week afteran inquest in Baker Lakelooked atthe death ofPaulKayuryukin 2012. The jury in that case heard that medical care was delayed becauseRCMPhad assumedKayuryukwas drunk.

• Assumed drunk: Inquest intoNunavutman's death recommends cultural training forRCMP

In Kaludjak'scase, his nephew brought himto the health centre in the morning because he was having trouble walking, and had double vision and muscle weakness.He was seen by nurses and the doctor on duty. Three-and-half hours passed before he was admitted for observation.

His blood pressure and breathing rate fluctuated throughout the day. Three nurses suggested he beflownto a hospital in Winnipegfor further testing.

"It was obvious he needed to get to a hospital with the proper medical equipment to help him,"Kaludjak'solder brother, NoelKaludjak,told CBC inInuktitut.

"The nurses said many times he needed to go on amedevacand the doctor said he was fine to get on the [scheduled] flight the next day."

PadmaSuramala,Nunavut'schief coroner,confirmed the doctor on duty believed alcohol was the cause ofKaludjak'scondition.

"The MD suspectedWernicke'sencephalopathyand it commonly affects people with the history of alcohol use and she was observing the symptoms and gave the treatment for acute alcohol intoxication,"Suramalatold CBC News.

'Alot of miscommunication'

Kaludjakwent into cardiac arrestaround midnight and staff performed CPR until he wasput on a medevac flight at 3:30 a.m. He arrived in Winnipeg around 9 a.m. and died just after 11 a.m. after being taken off life-support.

The autopsy found he died from a lack of oxygen to the brain.The jury agreed the death was natural.

But the family believes more could have been done and sooner.

"There was a lot of miscommunication between the nurses and doctors and some of the communication was obstructed by assumptions," NoelKaludjaktold CBC.

A similar case inAklavik, N.W.T., last summer prompted the territory's Department of Health and Social Services to order an external investigation, after a woman complained her uncle's stroke was mistaken for drunkenness.

24 recommendations

At the top of theKaludjakjury's list of recommendations is forthe territory and its Health Department to develop a policytopreventand dealwith conflict between nurses and doctors.

Otherrecommendations includedocumentingdisputes, reviewing the scope of nurses' responsibilitiesand instituting a "non-punitive process of reviewing the appropriateness of the transfer of any patient from a health centre via scheduled flight or medevac."

The jury also wants to seea policy that requirespatients with abnormal vital signs or unexplained neurological symptoms that do not improve be sent to a health facility where they can be better investigated and monitored.

Itrecommendsfinding ways to improve recruitment and retention of health-care staff and developing improvedculturalcompetency programs with mandatory staff participation.

"The entire inquest highlighted the need for proper policies, proper procedures and proper orientation for health-care professionals who come to work in the North," Suramala said.

All of the recommendations are directed to the government of Nunavut and its Department of Health. The latter says it has received the recommendations and will develop a corrective action plan.

• Read the jury's full recommendations