Jury delivers 22 recommendations at Iqaluit baby's death inquest

The jury of the coroner's inquest into the death of Amelia Keyookta made 22 recommendations on Friday to prevent similar deaths in future.

The six jurors decided her cause of death was undetermined and occurred on July 29, 2015 at the Qikiqtani General Hospital in Iqaluit.

They agreed that the four-month-old was found limp and not breathing, when the social worker assigned to her case went to an unlicensed day home, where she'd been temporarily placed by social services, to pick her up to return her to her parents.

The day home worker started CPR and when they arrived emergency services took over. Resuscitation efforts continued at the hospital, but Amelia was pronounced dead at 3:30 p.m.

• Inquest begins into death of Iqaluit baby in protective care

The main theme of the recommendations was to shift child services work from crisis intervention to prevention and the first recommendation deals with that issue.

It suggests a way to formalize communication between medical professionals with the territorial Department of Health to alert social workers to families of children under five who could use more support.

This recommendation stems from testimony where it appeared Amelia's mother made an effort to get her daughter to the doctor for regular check-ups, but the burden of other factors — including family violence, uncertain living arrangements and other stressors — may have led to things reaching a crisis point.

Training for Family Services staff about how to provide preventive support was also recommended, as was a formal discussion about creating a resource centre for families to access learning materials and relief.

A government-run daycare for kids in care was another recommendation. These institutions would operate as alternatives to the significant action of taking kids away from their parents.

Family Services welcomes recommendations

The director of Family Services, Jo-Anne Henderson White, testified Thursday that the department had already made some changes as a result of Amelia's death and was open to the recommendations.

In fact, she said the jury's recommendations would help her advocate for the funding and support the department needs to make larger changes.

Henderson White created an incident report in the wake of the death that ranked the department's priorities — the first of which was staffing.

She said the child services unit in Iqaluit now has two supervisors, as the sole supervisor in 2015 testified that she felt overworked and went on sick leave due to burnout.

• PREVIOUS STORY | Overworked and burnt-out: Social worker testifies at inquest into baby's death

The unit also now has two family resource workers, who are employed to work with families with at-risk children to help prevent the children from being taken away from their parents and into protective care.

Pathologist suggests safe sleep training

The pathologist, Dr. Christopher Milroy, who oversaw Amelia's autopsy found the cause of death to be undetermined.

He explained that Sudden Infant Death Syndrome is a collection of risk factors and not in itself a cause of death, as many infants exposed to the same factors do not die.

Amelia, however, was exposed to at least two significant risk factors for infant death including exposure to secondhand smoke and she was left to nap on her stomach while in the care of a day home worker.

Milroy said education for all parties in contact with children, including Family Services staff, foster families, day home workers and others, may help reduce infant death. The jury made this one of their recommendations.

Milroy said education campaigns in the United Kingdom on safe sleep practices significantly decreased the incidence of infant death. He also said Nunavut has a higher rate of infant death than other Canadian jurisdictions.

The recommendations include having the government of Nunavut conduct a study into why Nunavut's population is vulnerable to infant death so that campaigns to reduce it have a baseline to start from.

In the lead up to legalization, a study into the effects of cannabis use around children was also recommended, as was a review by the government of Nunavut on the effectiveness of its campaign to educate Nunavummiut on the risks of secondhand smoke, including cannabis smoke. 

The jury began deliberating on their verdict report around 3:30 p.m. on Thursday. They delivered their verdict just after 2 p.m. Friday.

The jury publicly released their recommendations on Monday, May 30. Read them below: