TORONTO (Reuters) - Ina Matawapit was barely conscious - intoxicated and suffering from a blow to the head - when police drove her to the North Caribou Lake clinic in Ontario, Canada, one summer evening in 2012.
The nurse at the federal government-run clinic, the only source of emergency care in this remote indigenous community, told the officers the 37-year-old could sober up in jail, according to testimony at a 2018 inquest. Minutes after leaving the clinic, the police sped back. Matawapit had no pulse and could not be revived.
At the inquest, the nurse testified that in sending Matawapit on to jail, she had been following a standard protocol for intoxicated patients in the northern reserves. Government officials testified there was no such thing.
The coroner found that in the nearly six years between the death and the inquest, there was no evidence of any formal review of the case “or any learning from the events of that evening” akin to typical procedures in hospitals or emergency rooms. Matawapit’s death, attributed to heart disease, likely would have passed under the radar but for the fact that she died in police custody, which made the inquest mandatory.
Over at least nine years, the Canadian federal government has not consistently tracked, let alone investigated, poor outcomes at clinics on indigenous reserves, according to a Reuters analysis of documents, including internal reports and meeting notes obtained through public records requests.
Record-keeping on deaths and other critical incidents at the clinics, which provide basic and emergency care to about 115,000 people, has been erratic and fragmented, Reuters found. The incidents often are detailed in separate provincial computer systems, when they are tracked or reported at all.
As a result, there is no way for the federal government to know how often patients die or suffer injury at the clinics or how that compares to the rest of the Canadian health system.
The federal government’s First Nations and Inuit Health Branch (FNIHB), which funds 79 clinics and manages 50 of them, is hampered in identifying potentially harmful patterns and preventing future mistakes, documents and interviews with medical experts indicate.
Whether turning away apparently intoxicated patients in the northern reserves – described in the coroner’s verdict as the “northern protocol”- has been a widespread practice is difficult to say. Reuters was able to find one other similar death, detailed in Manitoba police records, that occurred five months after Matawapit’s. The federal government enacted a policy saying it was “not appropriate” to hold intoxicated patients in cells - but only after last year’s inquest brought the issue to light.
Reuters’ findings come as the country is in the midst of a public reckoning with the legacy of settler colonization, a hotter issue today than in nations such as the United States and Australia where European settlers also displaced local peoples.
With an indigenous population that is growing and gaining political clout, Prime Minster Justin Trudeau came to power in 2015 promising “reconciliation” with aboriginal people. Reduced to a minority government in this week’s election, he needs the support of other parties to govern and will face pressure from the left to address poverty, poor housing and health problems that are especially acute on remote reserves.
It will not be an easy task. Even reviewing critical health care incidents could be a challenge because of the multiple jurisdictions and providers involved, said Michael Green, a professor at Queen’s University who was once chief of staff at a small northern hospital that often received patients from clinics in indigenous communities.
But “without review, there’s no opportunity to learn and make the system safer for everybody,” he said.
Staff at FNIHB, part of Indigenous Services Canada, say they strive to provide the best possible care and have been working on a replacement reporting system, slated to roll out next year.
The effort, which documents show began in 2014, has been planned behind closed doors and has not previously been reported, although pilot programs are running in Manitoba and Alberta.
Documents reviewed by Reuters indicate the system is designed to provide national case tracking and a consistent process for investigating and following up on cases.
Robin Buckland, executive director of primary healthcare at FNIHB, said the current system is “not a bad policy” but the agency is working to build an environment in which staff members can learn.
“It’s taken a long time,” she said. “But we want it to be right, and we want to implement it well.”
Reuters was not able to reach the nurses involved in treatment described in this story.
“We truly believe that nurses are working hard to deliver the best health care possible, under difficult work conditions,” said Debi Daviau, president of the Professional Institute of the Public Service of Canada, which represents permanent staff nurses and other civil servants.
For years, indigenous communities have complained about poor treatment on remote reserves, which are often hundreds of miles from top-tier or specialized medical services in major cities. Matawapit died in a community more than 300 km (186 miles) from the nearest major highway.
For a map of reserves see: tmsnrt.rs/32uE3yk
These federally funded clinics, usually called nursing stations, struggle to retain nurses, often filling gaps with the help of private staffing agencies.
Services there need more government scrutiny, not less, some critics say.
“We are treating members of the First Nations communities as second-class citizens,” said Emily Hill, a senior staff lawyer with Aboriginal Legal Services, which represented the Matawapit family at the inquest. “This is a large government health service. You would expect there to be layers of oversight and accountability.”
Documents reviewed by Reuters show FNIHB staffers have repeatedly called for a modern reporting system for poor or unexpected outcomes.
The FNIHB started to track critical incidents in 2006. By 2010, however, a federal audit found that “monitoring and analysis at both the national and regional level is not occurring.”
Four years later, a FNIHB working group said that a common national policy was needed with “clear processes for reporting and tracking” incidents, according to meeting notes reviewed by Reuters.
In 2016, an internal report by a member of the working group looked at how other public organizations, including federal prisons, reviewed outcomes. Every policy was found to be more “robust” than the one at FNIHB.
The report, reviewed by Reuters, said that while some patient safety incidents had been recorded in a national database between 2006 and 2014, regions had stopped using it because of the difficulty in collecting data.
Federal policy focused mainly on nurses’ well-being, not patients’, the report said.
The nurse at the Matawapit inquest illustrated that point, testifying that a debriefing after the patient’s death was geared “more to how we were feeling as opposed to what we did.”
On November 28, 2012, the Royal Canadian Mounted Police in God’s Lake Narrows, Manitoba, responded to a report that Tracy Okemow, 31, was drinking and threatening suicide. Police found her next to two empty pill bottles labeled “metformin,” a diabetes drug, according to a police review of the incident seen by Reuters. She agreed to go to the local nursing station.
The nurses told officers they had consulted with a doctor off the reserve who felt her “consumption of medication was not of concern and she could be incarcerated until sober,” according to the police report.
Okemow spent the night in jail. A witness later told police that she seemed to be in agony. In the morning, she was flown to a Winnipeg hospital, where she died the next day of metformin toxicity, the report said.
There was no inquest or federal inquiry. “In the case of Ms. Okemow, the death occurred outside of a federally operated facility – therefore FNIHB did not undertake a formal review,” Indigenous Services Canada said in a statement.
Off reserve, healthcare is under provincial jurisdiction.
The federal government has reviewed some patient deaths, often after they draw media attention. Documents reviewed by Reuters show officials have found serious systemic problems, including nurses who are stretched thin and do not always appreciate the seriousness of patients’ symptoms.
After two children died from complications of strep infections in 2014, an internal review looked at a “sampling” of young people who had died, and called for better recruitment and retention of nurses, as well as more physician services.
A 2018 review looked at a 15-month-old toddler seen on a Saturday night for a seizure and infections. The nurse on duty did not consult a doctor, and the child died the next day. The report called for better oversight of nurses, as well as changes to shifts and staffing to address fatigue.
FNIHB’s Buckland said the agency is working to improve hiring and retention amid a global shortage of healthcare workers.
In Manitoba, the family of Tyson McKay is suing the federal government, alleging that the 32-year-old man died of a heart attack 31 hours after visiting a clinic complaining of chest pain in 2015. The suit alleges the nurse did not perform the appropriate tests that could have diagnosed his condition.
In a court filing, the government said a staffing agency was responsible for ensuring the nurse was qualified. The staffing agency defended its care and referred questions to the government.
Kelvin McKay, Tyson’s 41-year-old brother, has been going to the clinics since childhood. He said he sees a pattern.
“Nurses come in and out of our community, and they fail to take the time to get to know our people, and they think we come in with fake illnesses. They brush us off. And that’s not how it’s supposed to be.”
For a graphic on clinics on indigenous reserves often distant from major cities, click here
(This story refiles to add dropped word in paragraph nine)
Additional reporting by Rod Nickel in Winnipeg; Editing by Denny Thomas and Julie Marquis