OCC Inquest - Matawapit 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Matawapit
Given name(s): Ina
Age: 37

Held at: Days Inn – 3 Sturgeon River Road , Sioux Lookout
From: Feb. 12
To: Feb. 16, 2018
By: Dr. Michael Wilson
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ina Matawapit
Date and time of death: June 7, 2012, at 9:10 p.m.
Place of death: Nursing station of  the North Caribou Lake First Nation
Cause of death: Hypertensive and obesity associated heart disease
By what means: Natural

(Original signed by: Foreperson)


The verdict was received on the 16 of Feb., 2018
Coroner's name: Dr. Michael Wilson
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Ina Matawapit


Jury Recommendations

To the Ministry of Community Safety and Correctional Services and the Ontario Provincial Police (OPP)

  1. Investigate the options for larger space in the rear seating area of police vehicles.
  2. Investigate the possibility of outfitting police vehicles with Automated External Defibrillators (AED)

To North Caribou Lake First Nation (NCLFN)

  1. Consider formally adopting the OPP Prisoner Care and Control policies.
  2. Consider ways to improve communications when notifying community members to assist with emergencies.

To Indigenous Services Canada, NCLFN, OPP

  1. Develop a protocol for the transfer of care for individuals in custody between the police and nurses in NCLFN.
  2. Develop training for medical situations in NCLFN where the police and nurses are jointly responding.

To Indigenous Services Canada, NCLFN, Province of Ontario

  1. Investigate the options for a suitably equipped medical transport vehicle.
  2. Explore options for the provision of community paramedics in NCLFN, including the possibility of training NCLFN community members for the community paramedic positions.
  3. Explore ways to provide and maintain CPR and First Aid training to community members, including adding this training into the school curriculum.

To Indigenous Services Canada and NCLFN

  1. Explore different ways of providing community orientation, including the dynamics of the community; to nurses coming into NCLFN. Explore the possibility of accomplishing this through the use of a website.
  2. Develop a process by which the family and community can learn about what happened following a critical incident.
  3. Create a joint working group to develop policies or practices aimed at increasing the involvement of NCLFN as a partner in health care delivery.  The working group will look at increased opportunities for collaboration, communication and education with members of NCLFN. It will also examine ways to ensure that healthcare providers are accountable to NCLFN and ways for NCLFN to encourage community members to give feedback on their healthcare. Examples include: shared staff meetings and patient satisfaction surveys.
  4. Explore ways to involve NCLFN in the hiring, orientation and retention of nurses.

To Indigenous Services Canada

  1. Should review equipment, including stretchers and blood pressure cuffs in their nursing stations to ensure accessibility for larger people.
  2. Consider the development of a patient ombudsman office or community liaison for patients of Indigenous Services Canada nursing stations.
  3. Supply a height adjustable medical transport gurney to the nursing station to facilitate transfer of patients from trucks etc. into the nursing station.
  4. Ensure that intoxicated, unconscious individuals are never discharged from health care to a non-health care setting until the individual is stable.
  5. Develop a nursing station specific protocol or algorithm for the assessment and management of intoxicated, unconscious patients.
  6. Consider equipping nursing stations with a portable AED as a back-up for the crash cart defibrillator.
  7. Ensure that nursing stations are equipped with at least two portable oxygen tanks.
  8. Implement an education rounds program to facilitate the review, analysis and learning from deaths or serious patient outcomes where the provision of health care is in issue.
  9. Conduct root-cause analyses with the involvement of family members and the community in a timely manner in any death where there are broader systemic issues or at the request of the family and/or the community.
  10. Make best efforts to recruit and retain Indigenous nurses.
  11. In consultation with First Nation communities, identify strategies to address barriers to retention of nurses.
  12. In order to ensure the cultural safety of Indigenous patients:

Explore the development or use of practical tools (such as flashcards) to help healthcare providers, including nurses, conduct assessments in a way that minimizes bias and improves the collection of accurate information.

  1. Ensure that all health care practitioners receive mandatory Indigenous Cultural Competency Training which includes Cultural Safety. This training should include:
  1. The history of First Nations in Canada, including how policies emanating from the Indian Act have affected the wellbeing of First Nations people,
  2. Education about conscious and unconscious bias;
  3. Opportunities to consider how practitioners own exposure to stereotypes and assumptions may influence their practice and actively seek to counter those,
  4. Evidence related to those stereotypes,
  5. The specific history of the community with which they are working, including the history of colonial harms, the contemporary sociopolitical and economic context.
  1. Indigenous Service Canada is encouraged, where necessary and appropriate, to report healthcare professionals to the appropriate regulatory college.