A Nunavut coroner's inquest into the death of Julian Tologanak, the Cambridge Bay man who jumped out of a plane in mid-flight, heard Tuesday from an emergency room doctor and psychiatrist who examined him hours before the fatal trip.
The inquest panel in Cambridge Bay is hearing testimony this week into the death of Tologanak, 20, who was aboard an Adlair Aviation charter flight from Yellowknife to Cambridge Bay on April 15, 2009, when he forced open the twin-engine plane's door and jumped out from an altitude of about 7,000 metres.
Tologanak jumped somewhere near Umingmaktok, about 180 kilometres away from the Cambridge Bay airport. Despite a lengthy search, his body was never found.
The six inquest panellists have already heard that Tologanak was in Yellowknife for a hockey tournament when early in the morning of April 15, RCMP arrested him at a local hotel and took him to Stanton Territorial Hospital over concerns that he was suicidal.
Police had been called to the hotel around 1 a.m. MT, after Tologanak started yelling and grabbed a steak knife from the kitchenette of a friend's hotel room, the inquest was told.
On Tuesday, Dr. David Pontin testified that he was on duty in the hospital's emergency room when Tologanak was brought in around 2 a.m. The doctor examined Tologanak then and again at 6:30 a.m., in a lockable room for emergency patients in mental distress.
Pontin said Tologanak denied feeling suicidal, and no acute medical issues came up in the examination. Still, Pontin decided it was not safe to release Tologanak, and he ordered a psychiatric assessment to take place later that morning.
Concerns implied, doctor said
Under questioning by the Tologanak family's lawyer, Steven Cooper, Pontin said he did not communicate his concerns or those of the RCMP officers about Tologanak's mental state to the psychiatrist, saying such concerns would have been implied when he ordered the psychiatric assessment.
"The RCMP passed on some essential information that turned out to be unfortunately quite true about the suicidal tendencies, and the possibility of suicide, on the part of Julian. That seems to have been lost in the mix thus far," Cooper told CBC News.
Dr. Thomas Ripley, the psychiatrist who examined Tologanak around 11 a.m., determined that Tologanak was likely suffering from an adjustment disorder as the result of a break-up with his girlfriend.
Ripley said Tologanak did not show signs of depression or express a desire to commit suicide. But hours before, Tologanak had told police he didn't know if he wanted to kill himself, the inquest panel heard.
It was agreed that Tologanak could be released from hospital. Hours later, Tologanak boarded the Adlair Aviation charter flight back to Cambridge Bay, which his mother had arranged.
Earlier in the inquest, Helen Tologanak testified that her son had no history of mental illness. However, she said Julian was not acting normally when he called home early in the morning of April 15, only saying "Hi Mom" repeatedly over the phone.
Hospital policies changed
Stanton hospital officials said changes have since been made to the way patients with mental distress are handled.
"Dr. Pontin alluded to changes in policy that simply don't allow psychiatric assessments to take place in the emergency department anymore," said Jon Rossall, a representative for physicians at the hospital.
While it was not Pontin's decision to release Tologanak — that happened after the psychiatric assessment was completed — Cooper said there could have been a better flow of information about Tologanak's case early that morning.
"Leaving things that important, that essential, to assumptions and implications — hoping that the information gets passed on — is never good enough," he said.
Ripley testified that even if he had known about the RCMP's concerns about Tologanak's mental state, it likely would not have changed his diagnosis.
A total of a dozen witnesses are expected to testify during the inquest this week.