APTN National News
A Nunavut coroner’s report has left the family of Annie Kootoo with a map of how the Nunavut Health system failed her.
The report, given to the family on Feb. 14, outlines 11 different recommendations for Inuit patients suffering from tuberculosis (TB).
Kootoo was being treated for TB, and died in Ottawa of liver failure, after complaining to three different parts of the health care system of unusual pain. She had TB before and knew this pain wasn’t usual.
Bernice Clarke is Kootoo’s daughter and said her mother’s symptoms weren’t noted by Nunavut’s healthcare workers.
“She started getting ill, and she was telling the nurses, ‘I feel sick,'” said Clarke. “She had TB years before, so she was telling nurses, ‘I don’t feel normal, like a TB” like how she remembered.”
The Coroner’s report outlines how Kootoo was bounced around between departments. When diagnosed, there was no room in the isolation ward, so she was treated at home by home care nurses.
One month later, she went to the emergency room complaining about unusual pain. She was sent home, without an assessment or her pain being noted in her chart.
Two days later, her home care nurse heard the same complaints of pain from Kootoo. The nurse didn’t write the complaint on their chart.
The doctor treating her TB was on vacation.
Four days later, Kootoo was back in hospital.
Five days after that, she was dead from liver failure.
Clarke is sharing the story in hopes that Nunavut will do better.
“We have a system in place that is broken. It is very broken. And not just this, I have other, myself, I’ve had problems with the Health system here,” said Clarke.
Two of the Coroner’s recommendations are about Inuktitut, the language of the Inuit. Services are supposed to be available in Inuktitut in Nunavut. It is one of the reasons Inuit fought to have the territory established. Through tears, Clarke says Inuktitut may have been a difference maker for her mother.
“If there was an Inuk, she would have been able to say, ‘Listen to me! I’m Sick!” But it was such an accepted or normal, for her to be fearful, or didn’t feel comfortable with a non-Inuk,” said Clarke.
The coroner’s report outlines exactly how the system failed Kootoo.
She didn’t receive service in Inuktitut. Her home care nurses, emergency room doctor and TB doctor didn’t communicate well enough. Things she told one doctor were not written in her file, leaving the next doctor at a disadvantage.
Clarke said things have to change.
“Inuktitut, first of all, make sure your doctors and nurses are qualified. I don’t know if these nurses who ignored my mother are qualified, I don’t know. More documentation, so if you call in to the hospital with ‘I don’t feel good’, like, tell them to come in. Too many times [Inuit] are told to go home, take Tylenol, Advil. Too many times, they’re just sent home. Too many people go home sick,” she said.
Nunavut’s Health Department has received the recommendations of the Coroner’s Office, and are reviewing them now, according to a department spokesperson contacted by APTN.