Nunatsiaq Online
NEWS: Nunavut August 08, 2017 - 1:10 pm

Inquest into Nunavut man’s death exposes emergency care shortfalls

Jury heard about disagreements between nurses and doctors at Kivalliq Health Centre

An inquest looking into the 2013 death of Victor Kaludjak found a disagreement between nurses and doctors at the Kivalliq Health Centre may have delayed his transport to a Winnipeg hospital, where he died hours later. (PHOTO BY SARAH ROGERS)
An inquest looking into the 2013 death of Victor Kaludjak found a disagreement between nurses and doctors at the Kivalliq Health Centre may have delayed his transport to a Winnipeg hospital, where he died hours later. (PHOTO BY SARAH ROGERS)

A coroner’s jury that last week examined the medical treatment and subsequent death of a Rankin Inlet man says the incident should serve as a lesson for Nunavut’s health care system.

They said the Nunavut health department must develop stronger guidelines for emergency treatment, documentation of care and proper training for practitioners, according to recommendations released Aug. 4 from the Chief Coroner of Nunavut.

Victor Kaludjak was admitted to the Kivalliq Health Centre at 10:30 a.m. on March 20, 2013, suffering from double vision, muscle weakness and an unstable gait.

After he suffered a cardiac arrest at around midnight, staff at the centre gave him CPR and called for a medevac, which took him to Winnipeg at around 2 a.m. March 21. He died at the Winnipeg Health Sciences Centre at 11:02 a.m. that day.

Complaints from family members about the circumstances around Kaludjak’s death prompted the Chief Coroner of Nunavut to convene an inquest, held in Rankin Inlet between July 31 and Aug. 3.

The six-member jury released 24 recommendations, which touched on the treatment of patients in Nunavut, and the responsibilities and capabilities of health care workers

The jury called on the Government of Nunavut and its Department of Health to develop guidelines and policies to handle disagreements or “communication issues” between nurses and physicians, and to maintain a “conflict log book” for disputes.

According to a statement of facts provided by the coroner, nurses treating Kaludjak said he should have been sent to a southern facility for more testing, but Kaludjak remained in Rankin Inlet until he went into cardiac arrest.

The jury recommended that Nunavut’s health department create policies requiring that any patients exhibiting abnormal signs or unexplained neurological symptoms—without showing improvement—be sent to a centre “where more investigation and high level of monitoring is available.”

That would take some of responsibility for emergency transport away from the discretion of the most responsible physician on duty at the time of an incident.

All orders to transfer patients via medevac or scheduled flight should be reviewed in a “non-punitive process” to determine their appropriateness, another recommendation said.

Nurses across Nunavut should be given mandatory training, as well as clear guidelines for intravenous and other forms of care leading up to “code blue” emergencies.

The Department of Health was also asked to finalize and implement an orientation handbook for nurses throughout Nunavut by the end of the year, and that nurses be provided with additional cultural orientation.

Any end-of-life care provided by Nunavut physicians or nurses should be established under legislated guidelines and policies to assist caregivers in contacting next-of-kin if a patient is incapable, the jury recommended.

And all medical treatment at community facilities should be rigorously documented, so that critical care can be examined by the centre’s staff after the event for debriefing exercises, the jury said.

The coroner’s inquest into Kaludjak’s death followed another inquest in Baker Lake over the 2012 death of Paul Kayuryuk.

The jury in that inquest demanded that Nunavut RCMP officers challenge their assumptions about intoxication and alcohol abuse among Inuit, after Kayuryuk died from complications of diabetes after the police mistakenly identified him for being drunk.

The recommendations from the Rankin Inlet inquest echoes many of the same themes outlined by the Auditor General of Canada during its audit of Nunavut’s Department of Health in March.

That report called for increased support of nurses working in community health centres, who the report concluded were not being given enough training or oversight from the Department of Health.

Coroner’s inquests are not fault-finding exercises.

Their purpose is to determine the cause of a person’s death where the cause of death is in doubt and to make recommendations for avoiding similar deaths in the future. Coroner’s jury recommendations are not binding on government.


Email this story to a friend... Print this page... Bookmark and Share Comment on this story...

(21) Comments:

#1. Posted by Concerned Inuk on August 08, 2017

So many problems with Nunavut’s health system!  Nobody is looking ahead.  Top officials only wait for people to die and their health irreparably harmed before fixing anything!!!

Nunavut’s health system lacks leadership, including the Minister and Deputy Minister who only protect the status quo!!!

#2. Posted by Marina F Graham on August 08, 2017

A licenced Paramedic in community would provide a measure of safety, mobile emergency care competence and create a bridge of care between persons in care of the RCMP, the Nursing resources and tertiary care hospitals to the south.

#3. Posted by Well Said on August 08, 2017

Well said Concerned Inuk. I would add that this Government is very inexperienced in dealing with a number of issues.  It would seem that this Government has no value in its own people. I complete firing of ADM’s & DM’s needs to happen across the board.

#4. Posted by Northerner on August 08, 2017

Our healthcare has been this way for a very long time and it seems to be getting worse.
I am not sure if the nurses are getting the right training but the last 10-15 years I have seen a steady decline in our healthcare.

This should be a strong reminder that this incident and many others over the years that our healthcare needs much improvement.
But I have her little confidence in our health department to make those improvements.
Just don’t get sick in Nunavut.

#5. Posted by Supporter? on August 08, 2017

sometimes it is very scary to go to the health centre here…the staff and nurses are getting less caring and more grumpy or grumbly…no one cares anymore…so take care of your health no one else will…

#6. Posted by Witheld on August 08, 2017

No one will care about us until WE start to care about ourselves and care about our fellow nieghbours.  The problem is nobody cares about anything up here.

#7. Posted by Marina F Graham on August 08, 2017

It makes me sad to read the feelings of despair that exist in community. Please know there are many who care. I believe that by working with community members and perhaps enhancing the skills set you already have, a new patient centered and healthy culture of caring can be fostered. I am a Paramedic who serves many Nunavut workers in industrial work camps. I am always troubled by the feelings of not feeling valued or heard that they express. It is also why they get the very best I can provide as a health care provider and to send them home in the best shape possible.

#8. Posted by sled dog on August 08, 2017

Just wondering how additional cultural training fits into the recommendation. This situation appears to be a medical procedural issue, not a cultural issue.

#9. Posted by Bbf on August 09, 2017

It’s only about money and trying to save a buck- cheap doctors and cheap nurses, they don’t care about us just their budgets!

#10. Posted by Marina F Graham on August 09, 2017

Regardless of motivations what’s happening isn’t working. Time to rethink and include all stakeholders in the process. It is not for one group to determine the needs of another. There is a unique opportunity here to rebuild a pt centered model of care delivery here. It will take flexibility, open mindedness to innovate standards that meet cultural, medical and complex geographical parameters. The alternative is more of the same, and I believe we can do better collectively.

#11. Posted by Concerned Inuk on August 09, 2017

#8 when racial prejudism exists medical practitioners may not give their full attention and may not apply the correct medical procedures as they would when treating people who they care about.  Cultural training tries to make racially prejudice medical practitioners to see Inuit as human, worthy of their highly skilled medical training.

However, many people do not want to live in the north, and a lot of professionals who work in the north are not the most competent, no matter the profession.  They come here because of the money and decision-making authority they get.  Many are second and third rate professionals, and the term “professional” may not correctly apply to them.

There are a few people from the south who move north because they want to live in the north, and you will not be seeing these people only hanging out with other people from the south, but they will be mixing with people from the north during their free time.  The people who don’t do this are obvious.

#12. Posted by sled dog on August 09, 2017

sorry Concerned Inuk, but how many professional groups can you insult at one time.

For you to state that medical professionals are prejudice against Inuit is simple race baiting at its worst. For you to suggest and state as fact that medical professionals ( and others lawyer, accountants, engineers) are second and third rate is complete caribou droppings.

If they are accredited, then who the heck are you to question competency and motivation.

Get over yourself

#13. Posted by Concerned Inuk on August 09, 2017

#12 you asked the question, I gave you an answer.  If you don’t want an answer, why even ask a question?

You overstate what I said in my answer, either because you don’t know what a qualifying statement is (“when” is the qualifier), or you’re simply one of those people who get defensive when talking about racial discrimination and you take it personally, either because you don’t understand what’s being said, or you think what’s being said is applicable to you.

If the medical practitioners who were treating this person were competent, he might not have died.  Argue that away!

#14. Posted by Uvaga on August 09, 2017

So what was the drs finding?

#15. Posted by sled dog on August 09, 2017

Perhaps I have a dangling modifier in my sentences. Big deal. You slander the competency of medical practitioners without proof. No wonder you need a qualifier.  Please show me a finding, a citation, professional misconduct hearing minutes, anything to show they were not competent. You can’t. Can you.

#16. Posted by Marina F Graham on August 09, 2017

Again whatever the motivation, the fact remains that the people whom we as health care providers are here to serve, do not feel a genuine investment in their well being. At the end of the day, that’s what it boils down to. If the trust and respect isn’t there, not much will change. What I hear Concerned Inuk saying (and correct me if I’m wrong please!) is that community members value and want care providers that are genuine, who make the effort to build rapport and relationships with their patients and whom are diligent in maintaining their skills / competencies in a challenging environment. North or south, I would expect nothing less myself.

#17. Posted by Observer on August 10, 2017

Yes, there are competent health care providers in Nunavut, both full time and part times.

But there are also some whose work is not acceptable, whether it be due to fatigue, laziness, ignorance, or incompetence.

I recently saw a patient prescribed a big bottle of laxative because she had not pooped in 2 weeks.  But her failure to poop was due to her having eaten almost nothing in more than 3 weeks. 

Her lack of appetite was ignored, rather than treated and rather than being considered a symptom indicating a serious underlying condition.

Ooops!  How many years of medical school does one need to understand this?

#18. Posted by tuktuborel on August 11, 2017

This government needs to be sued. It has to wake up and maybe a law suit would help move things ahead. Too many people have died from poor health services in Nunavut. Enough is enough.

#19. Posted by zed on August 12, 2017

I attended The Corner’s Inquest at Rankin Inlet. It became very clear to me that there is a lot of tension between the Inuk nurse and the non Inuk medical staff. The Inuk nurse was totally on her own, ignored during most of the time of crisis. Without the support of her colleagues it isn’t any wonder why she had a complete shut down. While she was tending to the emergency at hand, other medical staff were casually passing by without any offering to get involved until it was much too late. It was very obvious to me that racism is alive and well at the Rankin Inlet Health Center on Inuit patients and staff; or else a medivac would of been arranged when first suggested.

#20. Posted by Marina F Graham on August 13, 2017

@Zed…This is very troubling to read. Thank you for sharing.

#21. Posted by Johns on August 17, 2017

Racism seems to be coming out under the rocks more and more, the US and in Canada, what is going on? Why is it getting worse? How can we fix it?

Remember my personal information

Notify me of follow-up comments?