Coroner’s inquest into death of Rankin man doctor mistakenly thought was drunk releases recommendations

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An inquest into the March 21, 2013 death of Victor Kaludjak in Rankin Inlet has led to 24 recommendations from a coroner’s jury on how to prevent similar deaths in the future.

The inquest, which ran from July 31 to Aug. 3, heard testimony Kaludjak visited the Rankin Inlet Kivalliq Health Facility prior to his death. He was walking unsteadily, had muscle weakness and was experiencing double vision. He was seen by two nurses and a physician, but was not medevac’d out despite recommendations from the nurses.

He was finally medevac’d to the Health Sciences Centre in Winnipeg, Man., at 2 a.m. the morning of March 21, two hours after he had gone into cardiac arrest. He arrived the next morning and died shortly after. An autopsy found his heart was enlarged.

All 24 recommendations from the coroner’s jury are directed at the territorial government, specifically the Department of Health, as well as at nurses and physicians.

Chief among those recommendations is for the Nunavut government and the Department of Health to develop a policy for disagreements between nurses and physicians at the Kivalliq Health Facility.

Other recommendations for the Department of Health include making sure physicians can demonstrate “ongoing continuing medical education” in regard to acute care and having a policy where patients with abnormal vitals or unexplained neurological symptoms are sent to a better-equipped facility.

The jury also recommends all nurses and physicians complete cultural competency and decolonization training.