A coroner's inquest in Cambridge Bay, Nunavut, has concluded that the death of Julian Tologanak, 20, who jumped from an airplane in mid-flight one year ago Thursday, was a suicide.
The inquest panel also issued five recommendations on how to prevent similar deaths in the future — aimed mostly at government and health-care officials.
The panel released its report late Thursday afternoon, hours after hearing final statements from lawyers and presiding coroner Garth Eggenberger.
On April 15, 2009, Tologanak was on a charter flight from Yellowknife to his hometown of Cambridge Bay when around 4:35 p.m. MT, he opened the small plane's door and leapt out. At the time, the plane was flying at an altitude of about 7,000 metres and was 114 nautical miles (about 211 kilometres) southwest of Cambridge Bay.
Tologanak's body has never been found. The six-member inquest panel cited "multiple blunt injuries" as the main cause of death.
Prior to the inquest, authorities had not conclusively described Tologanak's death as a suicide.
Since the inquest began on Monday, the panel heard that Tologanak was in Yellowknife for a hockey tournament when he was arrested at the Nova Court hotel in the early-morning hours of April 15, 2009.
Yellowknife RCMP officers found Tologanak in a friend's hotel room, holding a knife but not threatening anyone. The officers took him to Stanton Territorial Hospital because of concerns that he was suicidal.
A psychiatric assessment concluded that Tologanak was likely dealing with a break-up with his girlfriend, but he did not show signs of depression or express a desire to commit suicide.
Tologanak was released from hospital, and he boarded an Adlair Aviation charter flight that his mother had arranged for him from Cambridge Bay.
The inquest panel was told that Tologanak tried twice to force open the twin-engine aircraft's door, but the plane's two pilots intervened both times.
It was shortly after Capt. Craig George tried to subdue Tologanak by reducing the cabin pressure that Tologanak successfully opened the door and jumped out of the aircraft.
In its recommendations, the panel called on the Northwest Territories and Nunavut governments to review their mental health legislation and focus more on patient care.
The panel also suggested that the two territorial governments, as well as Stanton Territorial Hospital, in particular, develop a system that would record relevant information about a patient on one document that would follow the patient from hospital admittance to discharge and contain any relevant information from the RCMP.
The other recommendations are: