Report into baby Makibi Timilak's death calls for coroner's inquest

A report examining the circumstances surrounding the 2012 death of a three-month-old baby in Cape Dorset is calling for a formal coroner's inquest.

• Parents relieved report into baby Makibi Timilak's death will be released
• Lawyer finishes report into death of Makibi Timilak

Makibi Timilak died hours after a nurse at the local health centre allegedly refused to see him. The report says there are varying accounts of what led to the baby's death. The nurse, Debbie McKeown, was later promoted to the community's top nursing position. 

The government's review was prompted by a CBC News investigation into the circumstances of the infant's death.

The 82-page report was scheduled to be released in Cape Dorset today by Health Minister Paul Okalik and the report's author, Katherine Peterson. Due to weather issues, the charter flight was cancelled and the report was released in Iqaluit at the Department of Health offices this afternoon.

"A formal inquest will assist the parents, the community of Cape Dorset and Nunavut residents generally in better understanding these tragic events," states the report.

The report says an inquest is desirable, "given the remaining unanswered issues, the degree of concern, and the existence of factual discrepancies and the presence at times of misinformation."

Cape Dorset Health Centre: a troubled work environment

Nunavut Chief Coroner Padma Suramala initially attributed Makibi's death to Sudden Infant Death Syndrome, which affects otherwise healthy infants. Suramala later signed off on an autopsy report by an Ottawa pathologist who concluded that the baby had died of a widespread viral infection in both lungs.

After a second Ottawa pathologist reviewed the original autopsy results and tissue samples and found no evidence of a viral infection, Suramala classified the death as "undetermined."

"The parents of baby Makibi deserve to know why these differing opinions exist and what prompted medical professionals to have different views of the cause of death," states the report.

The report also states that "the Cape Dorset Health Centre was a troubled work environment long before the death of Baby Makibi," and that "complaints had been made orally, in writing, by formal grievance, to supervisors and union officials well before the fatality occurred."

The report highlights that these concerns were not fully investigated and those who raised the issues were marginalized.

"It should be noted that a culture of fear has developed within the Government of Nunavut, from the very base of employees and work environments through the hierarchical ladder of authority which now represents government function and process," states the report.

The report states some health care practitioners did not want to be identified when interviewed for fear of reprisal by their employers.

Key recommendations

The report includes 47 recommendations dealing with a number of issues, such as government process, education, training, and staff management. Six of the key recommendations include:

• holding an inquest into the death of baby Makibi
• making structural changes at the Department of Health, such as reporting through the chain of command, ensuring that the department assumes the responsibility of discipline and termination of employees, and entrenching the position of chief nursing officer
• the implementation of a complaints procedure at health centres
• reassessing personnel requirements at health centres and regional offices to meet community needs and alleviate overwhelming workloads 
• culturally appropriate orientation and peer-to-peer mentoring for nursing staff 
• requesting that any nurse applying for a job sign a consent form allowing the nurses union to release any information regarding their past disciplinary history and information regarding complaints received from their past work placements

CBC's John Van Dusen and Jordan Konek were at the news conference. Follow their tweets here.