CORONERS COURT, NUNAVUT D?d?'bx'rm?bd? A?bb?bDAa?P?, .003? VERDICT OF JURY ?LLcn?lur iLc?L?Lc 4mm: ?rpm-DP?- Fore man/ Fore Person We the undersigned members of the Jury: d?L?D?br?Lx'dc Quin-3": "damaged; 1. IDENTITY OF DECEASED: mm Victor Kaludjak 2. DATE AND TIME OF DEATH: March 21. 2013 @11:02 am nnqu 9 FORM 9 FORMULE 9 d?hr?Lo'q?L 9 SECTION 9 ARTICLE 9 CORONERS COURT, NUNAVUT A?bb?bIJA??l'?, no.9: IVERDICT 0F JURY D?d?b?rn?hd? 3. PLACE OF sweepers-Wow: Health Sciences Centre, Winnipeg. Manitoba 4. CAUSE or Severe Acute Hypoxic Ischemic Brain Damage 5. MANNER OF DEATH: ?tm?i" ammo-seams; Natural 6. CIRCUMSTANCES UNDER WHICH DEATH OCCURRED: ?has? Victor Kaludjak arrived at the Rankin Inlet Kivalliq Health Facility at 10: 30 am March 20. 2013. He was seen by both nurses and the physician on duty. He presented with an unstable gait, double vision. and muscle weakness. At 13:55 he was admitted upstairs to the inpatient unit for observation. The patient?s blood pressure remained low and respiratory rate was high at times. These vital signs ?uctuated throughout the day. Concerns about his condition were brought forth by nurses that he should be medevaced for further testing. The patient went into cardiac arrest around midnight and staff performed many rounds of CPR until around 2am when medevac transported him to Health SciencesCentre in Winnipeg, MB. He arrived there around 3:50 and passed at 11:02 am, March 21. 2013 after being removed from the supports. The autopsy ?ndings state that he had a mildly enlarged heart WE. THE JURY WISH TO MAKE THE FOLLOWING TO PREVENT SIMILAR DEATHS IN NUNAVUT (SEE was gunned: d??da9d? CAL?bbldide?o_C mseacwterc ALanr?LdC) 1. The Government of Nunavut, Department of Health, will develop a policy for disagreements or communication issues that an'se between the nurses and physicians caring for patients in the Kivaliiq Health Centre. The nurse is to contact the nurse manager to intervene and make note of the discussion. The nurse manager will follow up with both parties for a resolution. 2. The Department bf Health will implement a conflict resolution log book for disputes on care to be reconded when discussed with date and time included and initialed by the parties involved to be followed up on. 9 FORM 9 POW 9 ds?t?r?Lo-?L 9 SECTION 9 ARTICLE 9 10. 11. CORONERS COURT, . D?d?bsrn?hd? .0119: VERDICT 0F JURY The Department of Health will provide mandatory training opportunities for the physicians and nurses upon hire to review the nursing scope of practice and transfer of responsibility policies within all Health Centres in Nunavut. It is recommended that this training be incorporated into the orientation program for all new hires. The Department of Health will ensure physicians working in Nunavut are able to demonstrate ongoing continuing medical education in acute care medicine and experience in emergency medicine as a requirement to work in the Territory. The Government of Nunavut, Department of Health, develop a policy requiring that any patients with abnormal vital signs or unexplained neurological and do not improve with interventions. be sent to a centre where more investigation and higher level of monitoring is available. The Department of Health will update community health nursing standards, policies. guidelines, and procedures manual for immediate reference to improve skills and knowledge of health care professionals to manage emergencies effectively. The Department of Health will institute a policy that addresses the process to be followed after a critical incident at a Health Centre. This policy would include requiring a debriefing meeting of all health care professionals involved in the care and treatment provided to the patient while at the Health Centre. Support resources will also be available for the staff. The Department of Health will institute an on-going, non-punitive process of reviewing (auditing) the appropriateness of the transfer of any patient from a Health Centre via scheduled flight or medevac and utilize the information collected if applicable, to improve upon the care and treatrnent provided to patients at Health Centres The Government of Nunavut continue to commit additional resources to enhance orientation and cultural competency programs for use in training all front line medical staff. This should be available both online and through in-services. All nurses and physicians complete online or in-person cultural competency training and decolonisation training as part of a standardized orientation. The Department of Health will develop clear guidelines, protocols. or algorithms to guide intravenous initiation and titration, use of supplemental oxygen, use of AED, and procedures to activate and respond to medical codes in the hospital including ?code menu.? 9 FORM 9 9 9 SECTION 9 ARTICLE 9 CORONERS COURT, NUNAVUT D?d?bs?c?nhbd? Aqbb?bDAa?l?, no.9: VERDICT OF JURY iL?n?P?o' blue". The guidelines should clarify roles and responsibilities and medical codes should be practiced on a regular basis via mock scenarios. 12. The Government of Nunavut. Department of Health. continue to research. refine. and evaluate recruitment and retention initiatives to ensure a full. stable workforce of professionals is in place. This should include partnering with academic institutions, job sharing, and encouraging and supporting Nunavurnmiut to enter into heaith care careers. 13. The Government of Nunavut, Department of Health, continue to evaluate and revise criteria for admission into the inpatient unit at the Kivalliq Health Facility. At any time a patient's condition becomes more serious than admission criteria. this should require communication with the most responsible physician and rectuest a re-evaluation of the patient. 14. The Department of Health will ensure all nurses and physicians are orientated on all crash carts and available equipment for emergency situations. All crash carts within a facility. both inpatient and outpatient. must be standardized and stocked adequately with the supplies and medications to support the need of emergency care and that resuscitative equipment he store on the unit and be functional. The crash carts must be checked daily. . 15. All nurses and physicians should be familiar with the supplies and equipment on both the inpatient and outpatient units, regardless of the area they are employed. to. The Department of Health will ensure proper documentation on any and all patients is kept in all Health Centres in Nunavut. Regular chart audits will be conducted to ensure charting practices meet nursing standards. 17. The Department of Health will develop guidelines to fensure that physicians chart thoroughly and that entries include date and time. 18. The Government of Nunavut, Department of Justice, and the Department of Health, will develop legislation and/or standard policies to guide physicians and nurses in Nunavut regarding substitute decision making and the appropriate persons to be contacted to make end of life decisions where the patient is incapable. 9 FORM 9 FORMULE 9 9 SECTION 9 ARTICLE 9 CORONERS COURT, D?d?b?ira?bd? 430.9? VERDICT 0F JURY um??ihcwwib D?d?bdc?nebd" dccn?P?o" 19. Health care providers should engage in end of life discussions with patients and, where appropriate, their next of kin. Where the patient is capable this should occur with the patient?s consent. 20. The Department of Health shall develop and provide, as part of any contractual agreement with a receiving medical facility, information explaining that extra time for medical decisions may be required and provided in communication with family members. The extra time may be required due to distance, necessity for translation or interpretation, issues with electronic/telephone communication, and the need for support persons. 21. The Department of Health will provide a Nurse Educator at all Regional Health Centres in Nunavut, to provide standard orientation and educate nurses to deliver high quality of nursing to all Nunavummiut. This position would also be available to the other communities of the region for support and training. 22. The Department of Health wilL within the noxt year, ?nalize and implement an orientation handbook for nurses throughout Nunavut, building on the draft prepared for the Kivalliq Health Centre inpatient Unit after March 2013. 23. Family members are to be well informed on treatment decisions and the prognosis of a patient?s condition, subject to patient consent. The communication should be from the physician or assigned nurse providing care. 24. A debrie?ng with familyr following a critical incident take place within a respectable timeframe. This includes nurses, physicians. support staff, and translation if requested. Explanations of all circumstances will be available as well as contact information if the family still needs assistance. s. a: Qt? Padma Suramala :33; s; . 95th:? Presiding Coroner Chief Ceroner of Nunavut r?CLr. D?d?bs'rrt? d?r?l?lm' _oo_9>Ll? 9 FORM 9 FORMULE 9 9 SECTION 9 ARTICLE 9 CORONERS COURT, NUNA U'l' D?d?bs'rnebd? 430.9? VERDICT 0F JURY D?d?bx'rnehd? The Of?ce of the Chief Coroner is conducted a mandatory inquest in the death of Late MR Victor Kaludjak, who died in Winnipeg. Manitoba on 21March 2013. Before: Presiding Coroner: Mrs. Padma Suremala. Chief Coroner of Nunavut K?b?o' stems-rte? Her. Counsel to the Coroner: Mr. Sheidon Toner Lem-rte D?d?bs'rnedeOC: in Representatives of the parties with standing: Phenom? dev?b: - 1. 2. Mr. Mark Christie Lawyer representing the Family Mr. Andrew W. McKenna Lawyer representing Dr. Jessica Otte Ms. P. Burt Lawyer representing Dr. Alexander Nyirabu Mrs. Sandra MacKenzie Mr. Mark Bridgeman - Lawyer representing the Government of Nunavut A5 A RESULT OF AN INQUEST INTO THE DEATH OF Wk HELD ON AT Rankin inlet. NUNAVUT eetncnebwuc 110.9%" MANDATORY CORONERS INQUESTS AS PER CORONERS A CT A MADE THE FOLLOWING ism? maestro-b amt: . 0' 0.30.3?? 9&3: s.