Lack of answers after baby's death left parents angry, confused

The family of Makibi Timilak had to go to the police to get the local coroner in Cape Dorset to hand over an autopsy report looking into the death of their three-month-old son.

Timilak's parents testified Tuesday on the first day of a corner's inquest aimed at determining how he died and make recommendations to prevent similar deaths from happening.

His mother and father said no one from the Government of Nunavut nor the office of the chief coroner have ever explained to them what happened the night their son died or why his cause of death changed. It's left them confused, angry and scared.

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Timilak was their first-born. Both parents regularly attended hospital check ups during and after pregnancy. After their son died, the couple adopted a baby girl from Ottawa.

"We would get up every hour just to see how the baby was doing. We were scared it could happen again," Timilak's father, Luutaaq Qaumagiaq, testified.

Territory to look into all deaths of children under 5

Nunavut's chief coroner Padma Suramala is not attending the inquest in person but did write an opening statement read in court. Qaumagiaq has called on the territory to fire her.

Suramala wrote the territory has made changes to the way it handles infant deaths in light of the circumstances surrounding Timilak's death. She said she has made a point not to release any preliminary autopsy reports and the territory is now in the process of forming a Paediatric Death Review Committee, modelled after an Ontario process.

"All deaths of children under five will be reviewed for trends, risk factors, cause and manner of death," Suramala wrote.
It will also be her office contacting the family of any deceased to provide updates on the death investigation.

Timilak's death was first ruled Sudden Infant Death Syndrome (SIDS).

The parent's were asked on Tuesday to recall a conference call following the death informing them of the cause.

They testified it left them feeling responsible for their son's death.

It was only after Timilak's mother, Neevee Akesuk, was contacted by a former Cape Dorset nurse the family knew the cause of death had been changed from SIDS to a viral infection.

When the family asked the local coroner for a copy of the autopsy report, they say they were told they wouldn't understand it.

"I had to get the police involved in order to get the autopsy," Qaumagiaq testified.

The family contacted the police and, a day later, the local coroner gave the family the report and an apology.

Timilak's cause of death was eventually changed again and is now listed as undetermined.

'Just like any other baby'

Timilak was born at full-term and other then being a loud crier, was healthy.

"He was just like any other baby," Akesuk said.

Then, he started to develop a runny nose.

A nurse made a note of it on his patient record a few weeks after he was born. Less than three months later, one night in April 2012, he was unusually cranky, crying all day and not sleeping.

"He was having trouble breathing while nursing," his mother testified. She called the health centre.

It was after hours but the nurse on call, Debbie McKeown, picked up. Akesuk says she told her about what was happening. McKeown suggested bathing the child and coming to the health centre in the morning.

McKeown's notes from the phone call show no indication about the baby having trouble breathing, something the family says was communicated during the phone call.

Attempts to summon the former Cape Dorset nurse to the inquest failed. A lawyer for the coroner tried to reach her, including contacting a health facility in Guelph where it's thought McKeown is staying.

Another former nurse testifies

The inquest heard testimony Tuesday from another former Cape Dorset nurse, Laura Easton, who provide pre and postnatal care to Timilak.

Her charting notes indicated the first-time parents were fatigued dealing with a newborn and both parents smoked during and after the pregnancy. 

After Timilak died, the couple came to see her in her office at the health centre.

She recalled Timilak's mother saying she informed McKeown the baby was having a hard time breathing. Easton said if she had taken the call she would have had the parents bring the child in. "If you're under one, bring 'em on down. Period," she said.

Easton spoke with Registered Nurses Association for NWT and Nunavut about how she could help the family, rather then contacting her director at the time, Heather Hackney.

"There was a nurse who would frequently try to empower community members if they were dissatisfied with the health care they were receiving to write letters of complaint," said Easton. "That nurse was reprimanded and condemned and eventually was one of the reasons that she was let go - fired from working in the North as a community health nurse."

The nurse was Gwen Slade, the same nurse who, a couple years later, would inform the family about the change to Timilak's cause of death.

Prior to the death, Slade filed a workplace grievance against Hackney for abusing her authority by covering up complaints. Months later, Hackney filed a complaint with the nurses association against Slade.

The timing of the complaint was criticized by an independent report looking into the circumstances of Timilak's death.

The inquest continues today. Officials with the RCMP and Government of Nunavut are expected to testify.