Inquest needed into death of Indigenous woman who fell down laundry chute, forensic pathologist says

A high-profile forensic pathologist has concluded that the case of an Aboriginal woman who fell to her death down a hotel laundry chute "needs to go to an inquest."

At the request of CBC's iTeam, Dr. John Butt reviewed the details of the investigation into the death of Nadine Machiskinic, a 29-year-old mother of four who fell to her death at Regina's Delta Hotel in January 2015. He considered a range of documents including autopsy reports, a report from the Public Complaints Commission and the chief coroner's report.

"There's definitely so many questions in this case," said Butt. "I would have thought that it would have been a perfect case for [whoever] makes these recommendations to have an inquest."

In Saskatchewan, inquests can be called by the chief coroner. An inquest is a public fact-finding hearing held before a six-member jury.

Butt brings a wealth of expertise to his analysis. He's a British Columbia doctor who consults on sudden death investigations and is an expert in forensic pathology. He served as chief medical examiner in Alberta and Nova Scotia and was president of the U.S. National Association of Medical Examiners.

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He said recent revelations about this case have raised serious questions about Saskatchewan's death investigation system.

"This is just a system that needs revision, in my opinion," Butt said.

No hard conclusions

In May 2016, Saskatchewan's Chief Coroner Kent Stewart issued his report into Machiskinic's death, concluding the "manner of death is accidental." Stewart said the autopsy was just one factor among several he considered. He said one of the main reasons for finding the death accidental was that police found no evidence of foul play.

After reviewing the documents, Butt saidhe was surprised Stewart arrived at such a definitive conclusion.

"The manner of death would best have been left at 'undetermined,' because of the fact that there are really no hard conclusions."

Butt said that overallit appears there are too many unanswered questions for authorities to conclude the death was accidental.

Delayed response to death

Butt is also concerned with how long it took the coroner's office to notify police about the questionable nature of Machiskinic's death. It took 60 hours before the coroner called police to investigate.

Hotel staff discovered Machiskinic at the bottom of the laundry chute at 4 a.m. CST on Saturday, Jan. 10, 2015.

Emergency Medical Services responded to the 911 call, but police weren't sent to the hotel.

Machiskinic was taken to hospital unconscious with cracked ribs. She diedabout 6:30 a.m. CST.

The coroner didn't call in police at that time.

Stewart saidthe coroner on call that weekend wasn't informed of "the circumstances surrounding what brought [Machiskinic] to hospital." He said usually police respond to calls like this one and pass on that sort of information, but "this didn't happen in this particular situation."

Butt responded, "Well then, she should have called the police," arguing that unanswered questions should provoke some research. In his view, this situation has exposed a problem with how the system responds to emergency calls like this.

"That's something that needs to be worked out," Butt said. "You could have a three-hour meeting and work all this stuff out. Bring all the problems to the table and work out the communication protocols."

Butt said he was surprised to see that the chief coroner's report made recommendations about things the hotel should change in order to prevent this sort of tragedy.

"It's a bit cheeky when you consider that somebody probably should be making recommendations to the chief coroner about what went wrong in this case," said Butt.

Autopsy report altered

Butt is also concerned with revelations that the original autopsy report into Machiskinic's death was altered, though the report doesn't acknowledge that fact or explain why.

The original autopsy report was completed by Saskatoon forensic pathologist Shaun Ladham. He found Machiskinic was severely intoxicated from a cocktail of drugs in her system, which "would make it unlikely that she would have been able to climb into a laundry chute on her own."

He concluded the ""manner of her death should be listed as undetermined."

Obviously there's an issue here that needs to be addressed, which is I would say part of the reason for an inquest.- John Butt, forensic pathologist

The coroner's office sought a second opinion from Alberta-based toxicologist Dr. Graham Jones. In an email, the coroner's office explained "questions were raised particularly given the evidence indicating the deceased was up and mobile prior to her death."

Jones cast some doubt on Ladham's findings. He wrote that "given Ms. Machiskinic's history of chronic alcohol and drug abuse and the fact she was prescribed relatively high doses of methadone, I do not believe that there is sufficient evidence to conclude that she would have been incapable of climbing into the laundry chute without assistance."

It's what happened next that bothers Butt.

Ladham's original autopsy report was altered. His opinion about the manner of death was replaced with the opinion ofJones. The final report doesn't say it was altered. It also doesn't provide Ladham's original opinion, or explain why it was changed.

"When there's no acknowledgement of why the report was changed in the hands of Dr. Ladham or Kent Stewart, I mean obviously there's an issue here that needs to be addressed, which is I would say part of the reason for an inquest," Butt said.

CBC asked the coroner's office why the alterations were made without noting that fact, or explaining why they were made. Those questions weren't addressed. But the coroner's office did say thatLadham is the one who altered his own report, replacing his opinion with that ofJones.

Butt said the most transparent way to handle this would have been to leave Ladham's report unaltered and include Jones's report separately.

"An addendum report appending Dr. Graham Jones' report; that was the way to go in this, rather than masking the issue by taking Dr. Jones' report and putting it into Dr. Ladham's report," said Butt.

CBC's iTeam put all of these concerns to the Office of the Chief Coroner. In an email, he responded by noting that his report had been made public. He added that "should additional evidence be discovered, the Office of the Chief Coroner could consider reopening the investigation."