Intoxicated patient rules needed, inquiry finds

Woman turned away from clinic had heart attack

An inquest probing the circumstances surrounding the 2012 death of an Ontario Indigenous woman is recommending stricter protocols for handling intoxicated patients.

Jurors at the inquest heard that Ina Matawapit died in police custody after being turned away from the nursing station in her home community of North Caribou Lake First Nation in northwestern Ontario.

Jurors heard nurses told police to bring Matawapit back for a medical assessment only after she had sobered up. The 37-year-old died of heart failure hours after she was turned away.

Jurors at the coroner’s inquest in Sioux Lookout, Ont., issued 27 recommendations.

Among them was a recommendation to Indigenous Services Canada, the federal ministry responsible for nursing stations in Indigenous communities, to ensure that health care facilities never discharge intoxicated, unconscious patients into a non-health care setting before they’ve stabilized. The ministry says it’s reviewing the recommendations.

Emily Hill of Aboriginal Legal Services, who represented the Matawapit family at the inquest, said her death was only probed because of rules mandating that inquiries be made whenever someone dies in police custody.

“Had she been brought to the nursing station by a friend and the exact same things happened, there would be no opportunity to scrutinize what happened,” Hill said.

Matawapit’s ordeal began on June 7, 2012 when she was arrested by the police for public intoxication. While in police custody, Matawapit complained of chest pains and respiratory trouble, prompting police to take her to the nursing station.

The inquest heard that a nurse on duty assessed Matawapit while she lay, semi-conscious, in the back of the cruiser.

After an examination that Hill described as “cursory,” jurors heard the nurse told police to take Matawapit away and bring her back for a full medical assessment only once she was sober.

As part of her testimony, the nurse said she was following “northern protocol” by sending Matawapit away, according to Hill.

Hill said the treatment provided to Matawapit fell well short of clinical standards, which dictate that patients in such circumstances receive a full evaluation.

Other nurses and a government witness all told the inquest that Matawapit did not receive typical treatment, Hill said, but added that the government expert also testified that Indigenous Services did not have a clear protocol in place for treating intoxicated, unconscious patients.

Hill said the reference to a “northern protocol” suggests denying treatment to patients in Matawapit’s condition had become an informal yet accepted practice.