Inquest urges protocols for intoxicated patients
27 recommendations issued after Indigenous woman died in police custody
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 that nurses told police to bring Matawapit back for a medical assessment only after she had sobered up from a recent bout of drinking.
The 37-year-old died of heart failure hours after she was turned away.
Jurors at the coroner’s inquest in Sioux Lookout issued 27 recommendations after hearing testimony over five days. 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 nonhealth-care setting before they’ve stabilized. Indigenous Services Canada did not immediately respond to request for comment.
Emily Hill of Aboriginal Legal Services, who represented the Matawa- pit family at the inquest, said her death was probed only 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.
Hill said Matawapit’s ordeal began on June 7, 2012 when she was arrested by the Ontario Provincial Police for public intoxication.
While in police custody, Matawapit complained of chest pains and respiratory trouble, prompting police to take her to the community’s 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 at the in- quest, 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 should receive a full respiratory, neurological and cardiac evaluation.
Alvin Fiddler, Grand Chief of the Nishnawbe Aski Nation, attended part of the inquest and said he was deeply troubled to learn that impaired patients may routinely not be receiving care. “It’s something that is very disturbing and that’s something that we will definitely be following up on,” he said.
Many of the jury’s recommendations were specifically targeted at the North Caribou Lake nursing station, such as exploring options to have community paramedics on the reservation and ensuring more specialized equipment is on hand.
But other recommendations targeted the system as a whole. In addition to its suggestion on intoxicated patients, the jury urged Indigenous Services to consider adding an ombudsman office or liaison role for patients of nursing stations across the country.
They also encouraged more efforts to recruit and retain Indigenous nurses, cultural competency training for all health care practitioners, and a review of equipment such as stretchers and blood pressure cuffs to make sure that larger patients could be properly treated at nursing stations.