Kugluktuk Coroner’s Inquest Jury Judges Accidental Death, Makes Recommendations on Prisoner Protection


After a four-day coroner’s inquest into a man who died while in police custody, a jury has released its recommendations on how the Nunavut RCMP, the Hamlet of Kugluktuk and the Government of Nunavut can prevent similar incidents at the coming.

In 2018, 22-year-old Austin Maniyogena died while in police custody at a Yellowknife hospital following a head injury he sustained after being detained by a Kugluktuk bylaws officer.

The inquest jury concluded that Maniyogena’s death was accidental and the result of severe head trauma likely caused by a fall.

The jury also made several non-binding recommendations. Among them is sensitivity training and body cameras for the RCMP to document officers’ actions and build trust with community members. The jury also recommended training police to seek medical attention for unresponsive prisoners, regardless of their level of intoxication.

“The reduction in consciousness due to intoxication does not affect the need for a medical evaluation,” a juror said during the verdict hearing.

Conflicting testimonies

Maniyogena was first detained by Kugluktuk Settlement Officer Matthew MacDonald, who was responding to reports that Maniyogena was driving an ATV while intoxicated. MacDonald told the coroner’s inquest that he had never arrested anyone before Maniyogena.

He said he called the RCMP and Cpl. Tim Fiset to drive Maniyogena to the detachment.

MacDonald testified that on the way, Maniyogena escaped through the window of the regulation vehicle and fell on the road. He said it left Maniyogena with blood around his nose and ear and a cut above his eye.

MacDonald said he phoned the Hamlet Health Center and requested an ambulance, and never saw Maniyogena regain consciousness.

He said he called the RCMP again. Fiset arrived at the scene and the two officers put Maniyogena in the back of Fiset’s vehicle.

MacDonald testified that he told Fiset what had happened and that an ambulance was on the way.

The by-laws officer’s story differs from that of the RCMP corporal. that of Fiset.

Fiset testified that when he arrived at the scene of Maniyogena’s fall he was injured, “very drunk” and had a cut above his eye.

Unlike MacDonald, however, Fiset said Maniyogena was conscious and responded when he spoke to her. Fiset said he was never told that the health center had already been called or that an ambulance was on the way. The community member who was driving the Kugluktuk ambulance that day testified that when she arrived, no one was at the scene.

Fiset said the community health nurse on duty told her to wait until Maniyogena was sober to get medical attention. The nurse testified that she believed the RCMP officer’s word that Maniyogena “walked and talked” without seeing the patient.

One of the jury’s recommendations to Hamlet was to change its policies so that a call for medical assistance would be considered active until a patient was assessed over the phone or in person, regardless of medical information. third.

The jury also recommended that the Hamlet of Kugluktuk prohibit by-law officers from arresting or transporting prisoners unless they are trained and equipped to RCMP standards, although details on the standards of RCMP arrest and transportation were not mentioned.

“Immediate attention for semi-conscious prisoners”

The RCMP detachment in Kugluktuk, Nunavut. After sustaining a head injury earlier in the day, Austin Maniyogena was taken into RCMP custody. He was placed in a cell where, four hours later, officers found him struggling to breathe. They took him to the health center where he was then medically evacuated to Yellowknife. He died later that night. (Hilary Bird/CBC)

Earlier in the week the inquest also heard from emergency medicine expert Dr Harold O’Connor. He said Maniyogena needed medical attention immediately after falling from the truck.

O’Connor also testified that law enforcement also should have given medical attention to Maniyogena based on the level of consciousness Maniyogena would have shown after the fall and in the cells.

Surveillance video showed Maniyogena motionless in his cell with officers present.

Officers called for medical attention five hours after taking Maniyogena to the cells, and only after finding him unconscious and struggling to breathe.

The jury recommended that the RCMP be trained so that officers and Civil Guards “have a solid understanding of the need for immediate medical attention for semi-conscious prisoners.”

The non-binding recommendations of the jury include:

  • The RCMP will review and revise training for RCMP officers and Civil Guards to ensure staff seek medical attention for unresponsive prisoners, regardless of level of intoxication.
  • The RCMP will revise Operational Manual 19.2 to require medical attention in the event of actual or potential head injury during an arrest.
  • The RCMP in Nunavut uses body cameras to build transparency and trust between the police and the public.
  • The RCMP will undergo regular sensitivity training.
  • The Government of Nunavut is reviewing resuscitation and trauma training for nurses in Nunavut.
  • The Government of Nunavut will ensure that medical assistance calls remain active until a medical assessment is completed over the phone or in person with the client, regardless of third party information.
  • The Hamlet of Kugluktuk will ensure that by-law officers do not engage in the arrest or transportation of prisoners without policies, training and equipment that meet RCMP standards.
  • The Hamlet will produce operating standards and procedures as well as training for by-law officers.
  • The Hamlet will seek legal advice regarding the authority of by-law officers to make arrests.
  • The Hamlet and the Government of Nunavut will ensure that the ambulance is properly staffed and equipped.