In a span of just two weeks, two different coroner's inquests in Nunavut heard that two different men were delayed getting proper medical care because police or a doctor assumed they'd been drinking.

A coroner's jury examining the 2013 death of Victor Kaludjak, 50, released 24 recommendations to help the territorial government prevent similar deaths in the future. 

The jurors heard last week that when Kaludjak visited the Rankin Inlet health centre seeking medical help on March 20, 2013, he was treated for alcohol poisoning even though he told nurses he hadn't had a drink in four days.

The inquest ran from July 31 to Aug. 3, just a week after an inquest in Baker Lake looked at the death of Paul Kayuryuk in 2012. The jury in that case heard that medical care was delayed because RCMP had assumed Kayuryuk was drunk. 

In Kaludjak's case, his nephew brought him to the health centre in the morning because he was having trouble walking, and had double vision and muscle weakness. He was seen by nurses and the doctor on duty. Three-and-half hours passed before he was admitted for observation. 

Victor Kaludjak

Kaludjak's nephew brought him to the health centre because he was experiencing an unstable gait, double vision and muscle weakness. (Submitted by Chelsea St. John)

His blood pressure and breathing rate fluctuated throughout the day. Three nurses suggested he be flown to a hospital in Winnipeg for further testing.

"It was obvious he needed to get to a hospital with the proper medical equipment to help him," Kaludjak's older brother, Noel Kaludjak, told CBC in Inuktitut.

"The nurses said many times he needed to go on a medevac and the doctor said he was fine to get on the [scheduled] flight the next day."

Padma Suramala​, Nunavut's chief coroner, confirmed the doctor on duty believed alcohol was the cause of Kaludjak's condition. 

"The MD suspected Wernicke's encephalopathy and it commonly affects people with the history of alcohol use and she was observing the symptoms and gave the treatment for acute alcohol intoxication," Suramala told CBC News.

 'A lot of miscommunication'

Kaludjak went into cardiac arrest around midnight and staff performed CPR until he was put on a medevac flight at 3:30 a.m. He arrived in Winnipeg around 9 a.m. and died just after 11 a.m. after being taken off life-support.

The autopsy found he died from a lack of oxygen to the brain. The jury agreed the death was natural.

But the family believes more could have been done — and sooner.

"There was a lot of miscommunication between the nurses and doctors and some of the communication was obstructed by assumptions," Noel Kaludjak told CBC.

A similar case in Aklavik, N.W.T., last summer prompted the territory's Department of Health and Social Services to order an external investigation, after a woman complained her uncle's stroke was mistaken for drunkenness.

24 recommendations

At the top of the Kaludjak jury's list of recommendations is for the territory and its Health Department to develop a policy to prevent and deal with conflict between nurses and doctors.

Other recommendations include documenting disputes, reviewing the scope of nurses' responsibilities and instituting a "non-punitive process of reviewing the appropriateness of the transfer of any patient from a health centre via scheduled flight or medevac." 

Victor Kaludjuk

Kaludjak died in hospital in Winnipeg on March 21, 2013.

The jury also wants to see a policy that requires patients with abnormal vital signs or unexplained neurological symptoms that do not improve be sent to a health facility where they can be better investigated and monitored.

It recommends finding ways to improve recruitment and retention of health-care staff and developing improved cultural competency programs with mandatory staff participation.

"The entire inquest highlighted the need for proper policies, proper procedures and proper orientation for health-care professionals who come to work in the North," Suramala said.

All of the recommendations are directed to the government of Nunavut and its Department of Health. The latter says it has received the recommendations and will develop a corrective action plan.

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