A coroner's inquest held in Baker Lake, Nunavut, last week has recommended police "challenge assumptions" about intoxication in Inuit communities.
The inquest investigated the October 2012 death of Paul Kayuryuk. The jury determined that he died of natural causes after medical care was delayed, because he was held in jail overnight on the assumption he was drunk.
Coroner's inquests do not determine who was at fault for a death, but they can make recommendations to prevent similar deaths in the future.
Kayuryuk was found unconscious at the landfill in Baker Lake and was taken into custody by RCMP, "based on some level of assumption and some evidence he was intoxicated," the jury's written verdict said.
Over the course of the night, the verdict said three guards monitored Kayuryuk more frequently than normal, "each with an increasing level of concern," because of his unconscious state.
By midday the next day, a medical examination was ordered based on information received from the family and concern from the guards.
Kayuryuk was diabetic and the doctor and nursing staff at the local health centre quickly determined he was experiencing a serious stroke.
He was medevaced to Winnipeg, where the prognosis was not good. He died in Winnipeg two weeks later from complications of the stroke.
More training for RCMP
Of the jury's 17 recommendations, 16 target Nunavut RCMP, most suggesting that officers should receive more training before the end of this year.
Using Kayuryuk's case as an example, it says RCMP should follow up with family and community members when people are suspected to be intoxicated and, when in doubt, err on the side of seeking medical attention.
It also recommends that cells be checked every 15 minutes, and prisoners should be physically checked for responsiveness within eight hours of being placed in a cell.
Cultural sensitivity training and giving prisoners access to Inuktitut translators were also recommended.
The jury also suggested that the Government of Nunavut promote the use of medic alert bracelets for individuals who require ongoing care for conditions like diabetes.
Nunavut's Chief Coroner Padma Suramala will present the recommendations to the RCMP and the appropriate government departments.