Jurors issue 11 recommendations in Tuk inquest

Jurors have issued 11 recommendations for RCMP and the NWT government following a coroner’s inquest into the 2021 death of Sylvia Panaktalok in Tuktoyaktuk.

Over the past three days, six jurors in Inuvik heard details of the night RCMP took Panaktalok, who was highly intoxicated, to the Tuktoyaktuk detachment to provide her a secure place to spend the night.

Around an hour after she arrived at the detachment, at 11:24pm, a guard found Sylvia unresponsive in her cell and notified officers.

Police attempted to load Sylvia into the back of an RCMP vehicle, but, after struggling to do so and being informed that nurses could not leave the health centre, they began performing CPR.

The officers then transported Sylvia to the health centre where, following efforts at life-saving treatment, she was pronounced dead shortly before midnight on July 31, 2021.

At the inquiry on Thursday afternoon, jurors delivered their verdict – finding that the cause of Panaktalok’s death was alcohol poisoning and the manner of her death was accidental.

With the aim of preventing future similar deaths, they recommended that:

• Tuktoyaktuk’s RCMP detachment ensure all officers and guards review and discuss all cell block policies every six months as required;
• the detachment conduct an audit of cell block operations within six months;
• the detachment ensure all officers and guards receive rousability assessment training within one year;
• all NWT RCMP detachments in communities without emergency medical services make best efforts to ensure they have procedures in place to deal with medical emergencies and conduct quarterly drills on those procedures;
• NWT RCMP change the wording on a section of their prisoner report form from “consciousness” to “alertness;”
• NWT RCMP make best efforts to ensure all staff, including dispatchers, are aware of an NWT Health and Social Services policy that nurses not respond to calls outside of health centres and hospitals;
• the NWT government and relevant community stakeholders make best efforts to establish ambulance and emergency medical services in Tuktoyaktuk;
• the NWT government and relevant community stakeholders make best efforts to establish a sobering centre or alternative safe housing for intoxicated people, as well as culturally relevant addictions and harm reduction services, in Tuktoyaktuk;
• NWT RCMP ensure all officers and guards understand and follow all steps of the rousability model;
• all NWT health centres have breathalyzers for voluntary use; and
• NWT RCMP ensure all officers and guards are trained in recognizing abnormal and palliative breathing patterns to recognize when medical services may be needed.

‘She was loved and cared for’

Sylvia was 54 years old, a mother to eight and grandmother of six. She was described by family members as a “friendly, nice grandmother” and hard worker who was outgoing and loved spending time on the land.

“She was loved and cared for by a large family,” Jessi Casebeer, the lawyer for the coroner, said.

Lawyers for the coroner, RCMP and NWT government had jointly suggested many of the recommendations that the jury ultimately issued.

Casebeer said those recommendations would ensure that people in RCMP custody, particularly those who have not committed a crime, are treated with dignity and respect and are afforded proper medical care. She said they would also ensure that RCMP are following policies that are already in place and taking Sylvia’s death seriously.

Jurors heard from several of Sylvia’s family members, RCMP officers, a jail guard, healthcare providers, and one of the detectives who investigated Sylvia’s death during the three-day inquest.

Several witnesses testified about the lack of emergency medical services in Tuktoyaktuk and alternative safe places for people who are intoxicated to spend the night other than RCMP cells. Police testified that they are required to provide a wide range of services in the community including ambulance, helping with CPR at the health centre, and assisting with child and family services and bylaw enforcement.

Medical experts testify

Jurors also heard from two medical experts who testified during the final day of the inquest on Thursday.

Dr Tara Dixon, a forensic pathologist in Alberta who performed the autopsy on Sylvia, said she determined Sylvia’s cause of death was alcohol poisoning. She pointed to a toxicology report that found Sylvia’s blood alcohol level would have been 3.35 grams of alcohol per litre of blood at the time of her death.

“It’s a very high blood alcohol level,” Dixon said, adding that would be expected to cause unconsciousness and coma.

“Alcohol is a very toxic substance. It might be legal but it’s really a horrible, horrible substance.”

Dixon also noted Sylvia had bruises to her scalp and some injuries due to CPR, such as fractures to her sternum and ribs, but said they would not have been fatal.

Medical monitoring

Dr Evan Wood, an expert on addictions and internal medicine based in Vancouver, said alcohol poisoning can cause a range of effects, from slurred speech and difficulty walking to heart attack and coma.

Wood said someone who is highly intoxicated should be monitored by medical professionals. If they are experiencing erratic heart rhythms or heart attack, he said they should be taken to an intensive care unit where they can be provided extreme life-saving care such as intubation and dialysis.

“It’s a five-alarm fire,” he said.

Watching video footage and reviewing police statements of the night Sylvia was taken into custody, Wood said it would have been helpful for someone in her condition to be medically assessed. He added that when someone is highly intoxicated, responders may not know when they will reach their peak intoxication level.

Video footage from the Tuktoyaktuk detachment indicated that 10 minutes after Sylvia was placed in a cell, she began gasping for breath followed by shallow breathing. Wood said that is a typical breathing pattern for someone with severe alcohol poisoning or who is in palliative care.

There was some disagreement among the lawyers for the coroner and RCMP about whether or not Sylvia began breathing normally before the guard found her unresponsive.

Wood said while he’s not an expert in rural and remote care, there is expertise available on providing care in those settings. He also highlighted the importance of culturally appropriate addictions care.

Wood said in all communities across Canada, it is “disappointing” there is a high prevalence of alcohol addiction and inadequate treatment services.