Eagle inquest recommends communication changes

A Northwest Territories coroner's inquest into the death of Raymond Eagle has called on RCMP and health-care officials to find a way to share medical information about patients who are transferred into police custody.

Eagle, a 48-year-old homeless man in Yellowknife, slipped into a coma after spending time at Stanton Territorial Hospital and at the local RCMP drunk tank on Aug. 3, 2006.

The weeklong inquest, which concluded late Friday afternoon, heard that Eagle had been treated in hospital for a head injury before he was transferred to RCMP custody.

Eagle stayed in RCMP cells for about 10 hours until he started vomiting blood and he lost consciousness.

He was then flown to the University of Alberta Hospital in Edmonton, where he was treated for an acute subdural hematoma, or a blood clot in the brain.

Eagle was brought back to Yellowknife, where he remained in a comatose state in hospital until he died on Jan. 5, 2010.

Information not passed on

The six-person inquest jury concluded that Eagle ultimately died of natural causes due to coronary artery disease, but the panel said the head trauma was a "significant condition" that contributed to his death.

The jury said there were major communication gaps between the RCMP officers and the doctors and nurses who handled Eagle on Aug. 3, 2006.

"The RCMP might have said, 'Well, he has an injury,' and that information — or no information — is passed on to the [emergency medical technician]. It snowballed from there," Margaret Eagle, Raymond's sister, told reporters.

Among its 16 recommendations, the inquest jury suggested that:

• Hospital officials and the RCMP develop guidelines — "within ethical boundaries and applicable legislation" — on what personal medical information can be shared when a patient is being transferred from hospital into police custody.
• Hospital staff try to obtain a patient's consent for relevant medical information to be shared if that patient is being transferred to the RCMP. If the patient is unable to give that consent before the transfer, staff should make "reasonable attempts" to contact next of kin.
• The RCMP put up posters by its holding cells with information on how to identify symptoms of head trauma, blood poisoning, drug overdoses and other common medical concerns.
• RCMP detachment guards make sure they closely observe and record any prisoner movements and conditions.

Establish rehab facility: jury

The inquest jury also called on the N.W.T. Health and Social Services Department to set up a drug and alcohol rehabilitation centre in Yellowknife.

The department should meet with members of the medical community, the RCMP, the Salvation Army and other agencies to "explore the possibility" of creating a rehabilitation centre or a halfway house for homeless people with substance abuse issues, according to the jury.

While the inquest jury's recommendations are not legally binding, chief coroner Cathy Menard said she believes they will be taken seriously.

"A lot of what the jury has done has looked at the root issues of a lot of the social issues that are in the Northwest Territories. A lot of it's asking for action to be done," Menard said.

Margaret Eagle said the results of last week's inquest will not bring her brother back, but she hopes that other intoxicated persons who end up in Yellowknife RCMP custody every year will receive better care.