Doctors spread thin in remote Ontario communities, inquest for First Nation woman told

The inquest for Ruthann Quequish from Kingfisher Lake First Nation in northwestern Ontario has shed light on health-care challenges in remote areas, and as it wraps up, her community's chief says it's clear to him that the "second-tier" health-care system failed the 31-year-old.

Quequish died of ketoacidosis, a complication of diabetes, at her home in the Oji-Cree community in April 2017. She had visited Kingfisher's nursing station multiple times in the days leading up to her death.

Since the start of the inquest in Thunder Bay in late July, a five-person jury has heard from more than a dozen witnesses. 

"Medical professionals at the inquest have described that the health-care system in Kingfisher Lake and other First Nations communities in our area is second tier," said Kingfisher's Chief Eddie Mamakwa in an emailed statement to CBC News.

"The second-tier system is one which our community members experience every day. It is the system which failed Ruthann Quequish and her family," he said. "Health care is a treaty right and our people deserve health care that meets our needs."

The jury is expected to hear closing submissions from the parties with standing in the proceedings on Thursday before being tasked with answering five questions: identifying who died, when and where they died, their medical cause of death and by what means they died (classified as either natural causes, accident, homicide, suicide or undetermined).

Jurors then have the option to make recommendations on how to prevent future, similar deaths. 

Kate Forget and Carolyn Leach, who are with the Indigenous justice division of Ontario's Ministry of the Attorney General, are serving as inquest counsel.

"We've heard from a number of very interesting witnesses who I think have provided a clear and nuanced picture of the delivery of health-care services in remote northern Ontario First Nations communities," Leach said in an interview with CBC News.

"We have a very engaged jury who's clearly listening attentively and have been asking some excellent questions." 

'The north is a different place'

Dr. Usne Josiah Butt, a remote and rural locum physician, primarily serves Sandy Lake First Nation's nursing station. He was called as a witness because he interpreted Quequish's lab results.

Physician services for northern communities in the region are flowed through Sioux Lookout Regional Physicians' Services Inc., which was formed in 2010.

Many nursing stations are operated by Indigenous Services Canada, but Kingfisher Lake runs its own nursing station. While a physician travels to the community five days a month, Butt said two of those days are largely taken up by travel, which means they're essentially "trying to see a month's worth of patients in three days."

Recruiting and retaining physicians has become harder, impacting the continuity of care. Butt said physicians serving the north haven't had a new contract with the province since 2010. While their workload has increased, "the financial compensation has not remained competitive."

The north is a different place. It's the wilderness. Access is a challenge. Preparation for the isolation, for the travel dynamics, is a challenge.- Dr. Usne Josiah Butt

"They haven't really evaluated the way the service is being delivered and how we'd like to improve the service delivery. The old model doesn't work," Butt said. "We need funding in different areas so that we can increase our community days."

Meanwhile, communities have grown, as have the health-care issues they're facing, including addictions, mental illness and diabetes, he said. 

"The north is a different place. It's the wilderness. Access is a challenge. Preparation for the isolation, for the travel dynamics, is a challenge," Butt said.

There's also the problem of balancing the needs of in-person patients and those accessing services over the phone.

"It's acquiring information without seeing the patient, without touching the patient, and you're trying to sift through all of that," he said. "I'm an experienced provider and I still find it overwhelming."

While he's had a rewarding career, Butt said it's important to provide remote health-care workers with support to cope with the emotional burdens of the job.

His suggestions to improve the system include a new contract for remote physicians and what he calls "doctor pods." These would consist of small groups of physicians dedicated to specific communities who could better share the workload and maintain a continuum of care.

Stress for patients, health-care providers 

Communication and access to information, such as medical records, are two themes that came up numerous times during the inquest.

"The jury has heard a lot of information about the challenges with the systems that are currently in place that can hinder communication between health-care professionals, and what that means in terms of providing care on the ground," Forget said.

With an inquest focused on health care, it's been important for the jury to hear from a wide range of people, so they have context about Kingfisher Lake, diabetes and how different bodies interact within the health-care system.

"I think the jury has heard certainly about limitations in resources, about the stress for health-care providers in practising in this context, and on the flip side, the challenges for community members in accessing health care that will meet extensive health-care needs," Leach said.

As the inquest nears its conclusion, Leach said preparing the jury for the task at hand has been a collaborative process.

"I feel like we're going to be well positioned as a group to collectively assist them."

Quequish's inquest is being held at 189 Red River Rd. The proceedings are also being streamed online in both English and Oji-Cree.