An Iqaluit woman who died after falling head-first down the stairs of a local hotel, then spending 14 hours in RCMP cells, did not receive the care and respect she deserved, an inquest jury says.

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Elisapee Michael, 52, died on Aug. 13, 2009, days after she fell head-first down the metal front stairs of the Nova Inn in Iqaluit. ((CBC))

The six-person inquest panel in Iqaluit issued 29 recommendations on Thursday based on testimony related to the death of Elisapee Michael, 52, who tumbled down the front stairs of the Nova Inn in the late hours of Aug. 8, 2009.

Following hours of deliberation Wednesday afternoon and evening, the inquest jury ruled that Michael's death was accidental.

But the jury also issued an apology to Michael's family, on behalf of society, for failing to provide Michael with the proper care, respect and dignity she deserved.

"Every member of society, no matter how they arrive in a given circumstance, deserves to be given proper care with the fullest respect and dignity that a member of this society deserves," the inquest jury stated in its report.

14 hours in RCMP cells

The 1½-week-long inquest heard that Michael had been drinking at the hotel's lounge in the hours before she fell head-first down the building's metal stairs shortly after 11 p.m. ET on Aug. 8.

Michael was taken to Qikiqtani General Hospital's emergency room, but within several hours hospital staff deemed her to be intoxicated and disruptive.

Michael was then arrested and transferred from the hospital to the local RCMP detachment's drunk tank, where she stayed for about 14 hours until officers noticed she was showing signs of brain damage.

After Michael was rushed back to the Iqaluit hospital, she was flown to an Ottawa hospital, where she died of head injuries on Aug. 13. An autopsy indicated that Michael's skull was fractured, while her brain was bruised and had a blood clot.

Hospital urged to get CT scanner

Among its 29 recommendations, the inquest jury called on Qikiqtani General Hospital to acquire a CT scanning machine and have its staff trained to operate it immediately.

The hospital — the largest health-care facility in Nunavut — currently does not have a CT scanner, which some witnesses said could have confirmed if Michael had a head injury in the first place.

The jury also said hospital staff should deal with disruptive patients at the hospital, rather than send those patients to police cells.

"The hospital shall implement a secure area for problematic patients who need medical care, instead of using the RCMP detachment to hold them in custody," the jury's report states.

The Iqaluit RCMP should make sure there are full-time video recordings of its detachment cells, and those videos should be kept for at least six months, the inquest jury recommended.

The jury also said RCMP officers and guards should check the responsiveness of intoxicated persons in cells every two hours.

Drug, alcohol treatment program needed

Safety concerns related to the Nova Inn's front stairs were mentioned in the inquest report, with the jury calling on Iqaluit building inspectors to ensure all public places comply with national building codes when it comes to outside stairs, railings and wheelchair ramps.

'My sister died. I don't care how much it costs for anybody to correct things.'—Eva Michael

The jury called on the Nunavut government to "implement a territory-wide drug and alcohol abuse treatment program immediately."

Finally, many of the recommendations urged the hospital, the RCMP and other agencies to improve the way they communicate with each other and with patients' family members.

While the inquest recommendations are non-binding, presiding coroner Garth Eggenberger said he believes most of them can be adopted.

"In some of the recommendations on this, we've already heard testimony that some of these recommendations are already in the works," Eggenberger said.

Michael's sister, Eva Michael, said she felt the inquest jury's recommendations are thorough and will hopefully prevent a similar death from happening in the future.

Eva Michael said she knows the recommendations could be expensive to implement, but she said cost should not be a barrier.

"My sister died. I don't care how much it costs for anybody to correct things," she tearfully told reporters.

Eggenberger said the Nunavut coroner's office will be following up with RCMP, the territorial government, the City of Iqaluit and Qikiqtani General Hospital within six months to see if they are addressing the recommendations.

Senior Mountie disturbed by incident

Many of the jury's recommendations were suggested by lawyers for the RCMP, hospital doctors and others in their final submissions on Wednesday.

Members of Michael's family yelled out their own comments that day, at one point howling over the lawyers' voices and crying out their regrets for leaving the hospital on the night Michael fell down the hotel stairs.

The inquest's final witness, Iqaluit RCMP Sgt. Peter Pilgrim, testified earlier on Wednesday that he found it "disturbing" nobody had checked Michael's responsiveness during the 14 hours she spent in the drunk tank.

Other witnesses had testified that Michael vomited as soon as she arrived, was in the fetal position on the floor of her cell, and later displayed visible signs that suggested she had brain damage.

Pilgrim told the inquest that nobody with a head injury should be placed in police cells.