First Nations man had ‘quite good’ chance of survival if taken to hospital instead of cell, inquest told


WARNING: This story describes distressing particulars about deaths in custody.

Don Mamakwa of Kasabonika Lake First Nation had a 97 per cent chance of surviving the evening if he had been introduced to hospital instead of a Thunder Bay, Ont., police cell in August 2014, an emergency-room doctor told a coroner’s inquest Tuesday.

Instead, the Oji-Cree man, 44, died alone in custody on the Thunder Bay police headquarters after he was arrested on suspicion of public intoxication, his pleas for assist and medical consideration ignored for hours, in accordance to proof offered up to now throughout the inquest.

Dr. Alim Pardhan testified Tuesday throughout the second week of the inquest, which is investigating the circumstances surrounding the 2014 demise of Mamakwa and the 2017 demise of his uncle, Roland McKay, 50, of Kitchenuhmaykoosib Inninuwug. Each man was discovered with out very important indicators whereas in a police cell.

Ina Kakekayash, Mamakwa’s mom, beforehand testified the saddest half for her is realizing he told police he wanted medical consideration, however was introduced to the police station instead.

“Don was an individual. He was our brother. We liked him and took care of him finest we may. I need to inform the police to deal with him with respect. I’m simply unhappy he had to die alone in that place,” Mamakwa’s sister, Rachel, stated throughout her testimony.

Mamakwa’s demise ‘utterly preventable’

Mamakwa was discovered with out very important indicators within the early hours of Aug. 3, 2014. No private checks have been finished on him for upwards of 5 hours, in accordance to an investigation report by the Special Investigations Unit (SIU), a police watchdog.

During a very emotional interval of the inquest, video from the police cells confirmed Mamakwa reaching out for assist, rocking backwards and forwards, holding his chest and struggling to transfer and stand earlier than misleading down and not shifting.

He died from ketoacidosis, a severe complication of Type 2 diabetes, alcohol use dysfunction and sepsis (when the physique’s response to an an infection damages its personal tissues), stated the post-mortem report.

“All three of these situations are fairly treatable, and so the survivability possibilities” would have been “fairly good” if he had been introduced to hospital, stated Pardhan in his testimony.

Most of the witnesses and proof offered up to now to the five-member civilian jury have targeted on the demise of Mamakwa, who was homeless and residing with alcohol use dysfunction and different bodily and psychological well being points.

Rachel Mamakwa, left, is proven beside her lawyer, Asha James, throughout the coroner’s inquest into the 2014 demise of Rachel’s brother, Don Mamakwa. (Logan Turner/CBC)

The proof has demonstrated clear failures on the half of the whole emergency response, health-care and justice techniques to take care of a susceptible particular person, stated Asha James, a lawyer representing each the Mamakwa and McKay households.

“As we have heard, the demise was utterly preventable and it is a guilt that [Mamakwa] fell via the cracks. But he fell via many cracks,” she told CBC News

Hand up interpreted as ‘wave-off’

The issues with Mamakwa’s remedy by police and paramedics started virtually instantly, the inquest has heard.

Police and paramedics obtained a name a couple of “man down” on the steps of a south-side downtown church, a location that first responders testified is frequented by individuals ingesting alcohol.

When paramedics arrived, police have been already speaking to one man, later recognized to be Mamakwa, who was standing on his personal two ft, testified Heather Gilbert, one of two responding paramedics. 

Gilbert stated one of the officers put a hand up, in a transfer she interpreted as a “wave-off,” a typical observe amongst police, paramedics and firefighters — who typically reply to the identical incidents — to inform the opposite companies the scenario is beneath management and so they aren’t wanted. Ryan Krupa and Jeny Bailot, the police constables who have been testifying,  stated it wasn’t a wave-off, however instead was acknowledging the arrival of paramedics.

That miscommunication performed a key function within the choice by paramedics to not conduct a medical evaluation of Mamakwa.

Gilbert stated wave-offs are nonetheless frequent observe, however there isn’t any coverage or protocol among the many companies, which may proceed to create miscommunication, Gilbert acknowledged.

Mamakwa requested to go to hospital

During the communication between Mamakwa and police, Mamakwa complained of issue respiration in addition to ache from earlier accidents, and requested not less than twice to go to the hospital, the officers testified.

Krupa stated it was his understanding Mamakwa solely needed to go to the hospital for a sandwich, and he told him that was not a great motive to be taken there. Neither Krupa nor Bailot told the paramedics about Mamakwa’s issue respiration, in accordance to the testimony of the 2 officers.

When paramedic Rob Corbeil arrived to the scene a couple of minutes later, he heard Mamakwa ask to go to the hospital and complain once more that he could not breathe, in accordance to an audio recording of Corbeil recounting the scenario as half of an Ontario Ministry of Health investigation in 2015.

Mamakwa did not have any shortness of breath, was talking usually and in no obvious misery, Corbeil stated throughout the 2015 investigation, so he didn’t full any bodily assessments earlier than leaving.

When the paramedics left, Krupa and Bailot stated of their testimony, they believed the paramedics had “medically cleared” Mamakwa, so that they arrested him for public intoxication and introduced him to the police station to “sober up.”

Paramedics should take affected person to hospital: knowledgeable

But paramedics do not need the authority to “medically clear” anybody, in accordance to testimony from Pardhan, additionally an affiliate professor of emergency medication at McMaster University in Hamilton.

The solely time a paramedic can decline bringing a affected person to the hospital when referred to as to a scene is if the affected person would not need to go, Pardhan stated.

Dr. Alim Pardhan, an emergency-room doctor and affiliate professor at McMaster University in Hamilton, told the inquest Mamakwa had a 97 per cent chance of surviving the evening if he had been introduced to hospital and obtained remedy instead of being left alone in a police cell.

If a affected person requests it, that particular person ought to at all times be introduced to the hospital, Pardhan stated, including it’s troublesome for anybody with out medical coaching to decide whether or not somebody wants remedy within the discipline.

But that is not at all times the case, Const. Neal Soltys told the inquest.

Soltys was testifying about his interactions with a 3rd First Nations man, Dino Kwandibens, who was seen, in movies proven to the inquest, being dragged via the police station. Kwandibens was additionally arrested for public intoxication on the identical day as Mamakwa.

To see the unique movies of Kwandibens in Thunder Bay police custody, comply with this hyperlink (WARNING: The movies include disturbing pictures).

Soltys stated that when he was referred to as to the scene, he decided Kwandibens had been ingesting sufficient that he should not be left alone, but additionally determined his situation did not warrant going to hospital, so he took Kwandibens to the police station instead.

Part of the rationale, Soltys stated in his testimony, is that hospital employees “typically give us flack” if they convey people who find themselves intoxicated to the hospital.

There have been some adjustments in observe since 2014, Soltys stated, together with that police have a tendency to defer to paramedics because the lead on the scene when there’s a “man-down” name.

Examining the function of racism, unconscious bias

One of the central questions being thought of throughout this inquest is “how racism, bias and stereotyping might have been an element within the Thunder Bay paramedics’ and law enforcement officials’ interactions” with Mamakwa and McKay, in accordance to a doc from the coroner.

Everyone has unconscious bias, which impacts their every day interactions and decision-making processes, Dr. Suzanne Shoush stated in testimony. Shoush is a household doctor and the Indigenous well being college lead on the University of Toronto’s division of household and group medication.

In emergency response and well being care, these unconscious biases can manifest in a “malignant narrative,” the place preconceived notions about somebody primarily based on components like gender, race or financial standing can affect cognitive decision-making and lead health-care professionals “on a runaway practice to a catastrophic consequence,” Shoush stated.

After reviewing the accessible proof and offering her testimony, Shoush told CBC that “on this case, actually from starting to finish, most likely the main contribution to the demise of these two gents [Mamakwa and McKay] was the truth that they have been First Nations males.” She added their requests for assist have been downplayed or ignored.

LISTEN | Dr. Suzanne Shoush describes unconscious bias in well being care:

Up North8:44Mamakwa-McKay inquest hears from knowledgeable medical witness Dr. Suzanne Shoush

Dr. Suzanne Shoush, a household physician and knowledgeable witness, testified on the inquest into the police custody deaths of two First Nations males in Thunder Bay. She spoke to visitor host Bridget Yard about racism and bias in healthcare and justice, how that impacts Indigenous individuals shifting via these techniques, and the pressing want for change.

“We’ve had a centuries-long course of of devaluing Indigenous individuals and devaluing Indigenous life … and we even have these longstanding tropes and stereotypes which might be related to drunkenness or vagrancy,” she stated.

“If, as health-care suppliers, we aren’t conscious of that insidious and that pervasive bias, that permeates all elements of our society, together with our personal judgments.”

However, when requested, all of the primary responders who have testified up to now stated they don’t imagine unconscious bias affected their judgment or interactions with Mamakwa.

“Education is one thing that Dr. Shoush pressured is essential, and finally, it is the jury’s accountability to provide you with suggestions on the finish of this course of, and that’ll be one thing for them to decide in phrases of what could also be wanted,” stated Kate Forget, a lawyer representing the coroner throughout the inquest.

The inquest is predicted to final 17 days and embrace 31 witnesses.

At the top of the method, all authorized events could have the chance to submit suggestions they imagine will assist forestall different deaths comparable to what occurred to Mamakwa and McKay. The jury will determine what suggestions needs to be adopted and offered to the organizations concerned within the inquest.


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