Wrong medication given, single-use syringes reused at Nunavut home where 2 youth died: report

Nunavut RCMP say they have found no criminality in the deaths of two young people at Naja Isabelle Home in Chesterfield Inlet, while a third-party review of the home reveals the home wasn't meeting required standards. 

In a news release in early 2024, Margaret Nakashuk, Nunavut's minister of family services, said three people were hospitalized as a result of "critical incidents" at the care home.

The Nunavut coroner's office later confirmed a 12-year-old died on Jan. 6, 2024, in Nunavut, and a 19-year-old died on Oct. 17, 2023, outside the territory.

In a news release Friday evening, the RCMP said the investigation into those deaths is now complete. 

"As a result of the investigation, no evidence was found to suggest any criminality in the deaths of two clients who were in the care of the Naja Isabelle Home," the release said. 

A third-party review contracted by the Department of Family Services after the deaths found major deficiencies in medical care, staffing and record-keeping at the home. 

In one example, it found nurses were reusing single-use syringes. In another, a staff member gave the wrong medication to a child. 

The review also found that medical charts weren't kept up to date and documents were missing or incomplete. 

"We found multiple instances where information presented in the chart contradicted the medical intervention that occurred," the report says. 

Delayed access to care, missing medical charts 

The Naja Isabelle Home cared for children and adults under the age of 40 from across Nunavut with specialized medical needs, and until last March was operated by Pimakslirvik Corporation under contract with the territory's Department of Family Services.

At the time, territorial officials said they were working to move all residents out of the home. 

The report found that when a resident was in acute medical crisis, the provider failed to follow its own policy to contact the health centre and transport the resident there immediately. 

"The lack of adherence to this policy is a cause for concern as delays in treatment at the community health centre resulted in several medevacs in 2023."

The report also found evidence of delayed access to medical care and "inappropriate medical interventions for respiratory issues when health conditions were escalating."

"We also found that in some instances when vital signs were abnormal or grossly abnormal, appropriate interventions were not evident."

It also said there was no organized mental, educational, physical or cultural programming for residents.

The reviewers also learned that licensed nurses were prohibited from taking residents in need of care to the health centre with authorization from the director of care.

The report makes 26 recommendations to the Department of Family Services. In an email to CBC News, a spokesperson for the department said they need time to respond to those recommendations. 

The contract with Pimakslirvik expired March 31, 2024, and was not renewed.