911 issued complaint over handling of emergency call about unresponsive baby at Yellowknife hotel

After the death of a Nunavut infant while in mandatory isolation at a Yellowknife hotel, Northwest Territories 911 issued a formal complaint to the City of Yellowknife over how the city's emergency dispatch centre handled the father's call for help.

Jackson Quince Agligoetok of Kugluktuk, Nunavut, died while in mandatory isolation with his father, Jason Agligoetok, at the Explorer Hotel in April 2020. At the time, all Nunavut residents who left the territory were required to isolate for 14 days in a designated hub before returning home. 

Agligoetok was 15 weeks old at the time of his death.

According to a Northwest Territories coroner's report released to CBC News last Thursday, Agligoetok's father called Emergency Medical Services about his son and city dispatch told him to call 911 for further assistance while they sent out an ambulance.

But a June 8, 2020, complaint from N.W.T. 911's manager to Yellowknife's then-director of Public Safety, obtained by CBC News, says 911 got no such call.

The complaint indicates that city dispatchers should have transferred the father's call to 911, where he could have gotten instructions for infant CPR while he waited for the ambulance to arrive.

In the event of an emergency in Yellowknife, there's more than one number people can call.

They can dial 911, which is equipped to provide over-the-phone instructions for thousands of medical and fire situations before first responders arrive, or they can call the local prefixes plus 2222 to reach fire or ambulance dispatchers directly.

In a statement issued Tuesday, the city and territory said they wanted to "jointly assure the residents of Yellowknife" that in an emergency, they can call either 911 or 2222.

When asked about Agligoetok's death, the city said it can't comment on specific incidents. 

In an emailed statement, a city spokesperson said "life critical" medical calls to city dispatchers are forwarded to 911, "as per protocols confirmed between N.W.T. 911 and the City."

Baby died from 'undetermined cause'

According to the coroner's report, there were no signs of foul play or visible trauma to the baby. 

An autopsy showed "a normally formed, well-cared-for male infant with no injuries or fractures" and no evidence of asphyxia. 

Coroner Garth Eggenberger concluded that Agligoetok died of an "undetermined cause," or what previously would have been called "sudden infant death syndrome."

Agligoetok had been in Edmonton for treatment of pneumonia caused by Haemophilus influenza, reads the June 9 coroner report. Upon recovery, he was transferred to Stanton Territorial Hospital in Yellowknife to be weaned off his medication.

"He did very well and was discharged from Stanton on April 4, 2020," the report states. 

The baby and his father were moved to the Explorer Hotel to complete 14 days of required isolation before returning to Kugluktuk. 

CBC News's attempts to reach Jason were unsuccessful. Posts to his Facebook account show a grieving father who loves and misses his baby boy.

"I think about him everyday, continue to rest my baby daddy misses you a lot," reads a post on Jason's Facebook page on Dec. 23, 2020, what would have been his son's first birthday.

The coroner's report says Agligoetok and his father had been sleeping in a king-size bed, with Jason on one side and the baby on the other.

At 9 a.m. on April 10, Jason Agligoetok awoke to find his son unresponsive. "His head and chest were cold but his stomach was warm," says the report.

It says Jason Agligoetok called EMS and the City of Yellowknife dispatch told him they were sending an ambulance. They said he should call 911 for more assistance while he waited for the ambulance. 

When EMS arrived at the Explorer, they noted that Agligoetok was cyanotic (bluish in colour) and that he didn't have a pulse. He was put on a stretcher and paramedics performed CPR until they got to the hospital. Agligoetok was pronounced deceased at 9:47 a.m.

Unknown whether 911 connection would have made a difference

But N.W.T. 911 suggests efforts to revive the baby could have started before paramedics got to the hotel.

In the complaint, N.W.T. 911 manager Ashley Geraghty says that on the day of the baby's death, 911 got a call from Yellowknife's dispatch centre asking whether 911 had received a call from a male at the Explorer Hotel about an infant who wasn't breathing. 

"The father did not contact N.W.T. 911 for dispatch life support," reads the complaint.

Geraghty goes on to ask that the city dispatch centre directly transfer callers needing dispatch life support to 911 once city dispatchers get all the information they need.

A spokesperson for the territorial Department of Municipal and Community Affairs, which oversees 911, said it wouldn't comment on the complaint "due to the sensitive nature and privacy concerns related to this case."

The coroner said it's difficult to say whether Jason calling 911 immediately, or getting his call transferred to 911, would have saved his son's life.

Cases like this rely on "interpretations of all the results of the investigation and the results of the autopsy," Eggenberger told CBC News in an email. 

"Given the lack of any evidence at autopsy of cause of death, we just have no way of knowing the answer."