A coroner’s inquest has found a Tuktoyaktuk woman accidentally died of alcohol poisoning while in RCMP custody in 2021.
The jury at the hearing in Inuvik this week also made 11 recommendations for the RCMP, territorial government and NGOs.
Shortly before 10 p.m. on July 31, 2021, a call was made to the Tuktoyaktuk RCMP to pick up an individual who appeared to be highly intoxicated in the community of about 900 people.
RCMP came to the house where the call was made and picked up Sylvia Panaktalok, who was on the steps of the residence, reads the report.
The sign outside of Tuktoyaktuk. (Photo courtesy of Wikimedia Commons)
Two RCMP members, as well as a family member of Panaktalok ‘s assisted the intoxicated woman into the back of the RCMP truck.
Panaktalok was aided in walking up the ramp towards the cells by the RCMP members, but became “dead weight” halfway up the ramp, the inquest heard.
One member brought a mat to the ramp and Panaktalok was laid on it and dragged into the cells building.
The officers lay Panaktalok in a recovery position on the mat, and left the cell.
The cell guard made an initial check on Panaktalok at 10:25 a.m., and three more times after that.
Then, at a fifth check at 11:27 p.m. the guard “did not see any visual breathing,” and notified detachment members.
Officers initiated CPR on Panaktalok, along with use of an AED device, as they struggled to load her into the back of the patrol truck.
In addition to the more routine calls for training upgrades and procedures reviews, this week’s Coroner’s Inquest called for the NWT RCMP to ensure all regular members and civilian guards be educated in recognizing palliative breathing patterns and other abnormal breathing patterns, also called “rousability assessment training.” to identify when medical services may be needed.
Another recommendation called for all NWT health centres to have breathalyzers for voluntary usage in order to determine blood alcohol levels and to ensure due diligence for health and safety measures.
In 2021, Panaktalok was placed in the bed of the truck and transported to the health centre at 11:35 p.m.
Upon arrival to the health centre, CPR was continued on the woman by a rotation of RCMP members while nurses took direction from a doctor via telephone.
Territorial regulations prohibit nursing staff from leaving the health centre to attend to, or transport, a sick or injured person.
Medical care and CPR was administered on Panaktalok until the doctor gave orders to stop.
The time of death listed was 11:59 p.m.
The Coroner’s Inquest also called on all relevant GNWT departments and other groups mandated with the provision of health and emergency medical services in the Hamlet of Tuktoyaktuk should try harder to establish more robust ambulance and emergency medical services.
And that a sobering centre or other alternative housing for intoxicated persons be established, as well as culturally relevant addictions and harm reduction services within the entire NWT.
