Jury in Kugluktuk coroner's inquest rules death accidental, makes recommendations around prisoner protection

After a four day coroner's inquest into a man who died while in police custody, a jury handed down their recommendations for how Nunavut RCMP, the hamlet of Kugluktuk, and the Nunavut Government can prevent similar incidents in the future.

In 2018, 22-year-old Austin Maniyogena died while in police custody at Yellowknife's hospital as a result of a head injury he sustained after his detainment by a Kugluktuk bylaw officer.

The inquest jury found Maniyogena's death to have been accidental, and the result of severe head trauma likely caused by a fall.

The jury also made several non-binding recommendations. Among them are sensitivity training and body cameras for RCMP to document officers' actions and build trust with community members. The jury also recommended training police to seek medical attention for unresponsive prisoners, regardless of any level of intoxication. 

"Reduced consciousness due to intoxication does not affect the need for medical assessment," one juror said during the verdict hearing.

Conflicting testimonies

Maniyogena was first detained by Kugluktuk bylaw officer Matthew MacDonald who was responding to reports of Maniyogena driving an ATV while intoxicated. MacDonald told the coroner's inquest that he had never arrested anyone before Maniyogena. 

He said that he called RCMP and was told by Cpl. Tim Fiset to drive Maniyogena to the detachment. 

MacDonald testified that on the way, Maniyogena escaped through the bylaw vehicle's window and fell to the road. He said this left Maniyogena with blood around his nose and ear and a cut above his eye.

MacDonald said he phoned the hamlet's health centre and asked for an ambulance, and never saw Maniyogena regain consciousness.

He said he called RCMP again. Fiset arrived on scene and both officers put Maniyogena into the back of Fiset's vehicle. 

MacDonald testified he told Fiset what had happened and that an ambulance was on the way.

The bylaw officer's account differs from that of RCMP Cpl. Fiset's. 

Fiset testified that when he arrived at the scene of Maniyogena's fall, he was injured, "very intoxicated" and had a cut above his eye.

Unlike MacDonald, however, Fiset said Maniyogena was conscious and responded when he spoke to him. Fiset said he was never told that the health centre had already been called or that an ambulance was on its way. The community member driving the Kugluktuk ambulance that day testified that when she arrived, no one was on scene.

Fiset said that the community health nurse on duty told him to wait until Maniyogena was sober to bring him medical attention. The nurse testified that she took the RCMP officer's word that Maniyogena was "walking and talking" without seeing the patient. 

Among the jury's recommendations to the hamlet was to change its policies so that a call for medical assistance is considered active until a patient is assessed over the phone or in person, regardless of third-party information.

The jury also recommended that Kugluktuk's hamlet prohibit bylaw officers from arresting or transporting prisoners unless they are trained and equipped to RCMP standards, although details on RCMP standards of arrest and transportation were not mentioned.  

'Immediate attention for semi-conscious prisoners'

Earlier in the week, the inquest also heard from Dr. Harold O'Connor who is an expert in emergency medicine. He said Maniyogena needed medical attention immediately after falling out of the truck.

O'Connor also testified that law enforcement also should have given Maniyogena medical attention based on the level of consciousness Maniyogena reportedly showed after the fall and in the cells.

Surveillance video showed Maniyogena motionless in his cell with officers present. 

Officers called for medical attention five hours after taking Maniyogena into cells, and only after finding him unconscious and struggling to breathe. 

The jury recommended that RCMP be trained so that officers and civilian guards "have a solid understanding of the need to seek immediate medical attention for semiconscious prisoners." 

The non-binding jury recommendations include:

• RCMP will review and revise training of RCMP and civilian guards to ensure personnel seek medical care for unresponsive prisoners regardless of any level of intoxication.
• RCMP will revise operational manual 19.2 to require medical care in any case of actual or possible head injury in an arrest.
• RCMP in Nunavut wear body cams to build transparency and trust between police and the public.
• RCMP will take regular sensitivity training.
• The Government of Nunavut of review life support and trauma training for nurses in Nunavut.
• The Government of Nunavut will ensure calls for medical assistance remain active until a medical assessment is conducted either over the phone or in person with the client regardless of third-party information.
• The Hamlet of Kugluktuk will ensure bylaw officers do not engage in the arrest or transport of prisoners without policies, training and equipment that meet RCMP standards.
• The hamlet will generate standard operating and procedures and training for bylaw officers.
• The hamlet will seek legal advice regarding the authority of bylaw officers to make arrests.
• The hamlet and Government of Nunavut will ensure the ambulance is adequately staffed and equipped.