A coroner's inquest into the death of a Kugluktuk, Nunavut, man who died in RCMP custody heard conflicting testimony this week about who specifically decided Austin Maniyogena did not need immediate medical care after he fell and sustained a head injury.
The 22-year-old died on Sept. 19, 2018, of the head injury he sustained shortly before police took him into custody. Four hours after police put him in a cell at the community's detachment, officers found him unconscious and struggling to breathe. They brought him to the health centre where he was later medevaced to Yellowknife. He died later that night.
On Monday, the inquest heard from community bylaw officer, Matthew MacDonald. He testified that around 8:30 a.m on Sept. 19, he was told that Maniyogena was driving an ATV around Kugluktuk while intoxicated. MacDonald said he called police twice but they told him there was only one officer on duty.
MacDonald said he found Maniyogena standing near a parked ATV behind a residence in the community. He told him he was under arrest and they had a physical struggle. MacDonald said he overpowered Maniyogena and put him in handcuffs. He said he put Maniyogena in the back of his bylaw truck and it was apparent that Maniyogena was intoxicated.
His "speech was almost completely incoherent … eyes were very glossy, almost completely closed when we could actually see his face. So I would describe it as a very high level of intoxication. He needed almost complete help to move around," MacDonald told the inquest.
MacDonald was questioned on whether it was common for him to arrest people in his role. He said no and that it was his first time doing so but that he believed it was a "life or death situation" since Maniyogena was driving intoxicated.
Crawled out of the back window, landing on the ground
MacDonald said he then called the RCMP again and was told by Cpl. Tim Fiset to drive Maniyogena to the detachment about a kilometre away.
"When I contacted the detachment, I was advised there was only one member working on that day today and requested to transport him over to the RCMP," MacDonald said.
He said as he started driving he noticed Maniyogena was moving around in the back seat. He said he heard the back window go down. As he pulled over, MacDonald said Maniyogena crawled out of the back window, landing on the ground.
MacDonald said when he got out of the truck he saw Maniyogena lying unconscious with a cut above his eye and blood around his nose and ear.
Called health centre and RCMP
MacDonald said he called the community's health centre and spoke to nurse Byron Bussey. MacDonald said he told Bussey that Maniyogena was unconscious and needed an ambulance.
Bussey testified that he then called to have the ambulance dispatched.
MacDonald said he contacted the RCMP again. Several minutes later, when Cpl. Fiset arrived, Maniyogena was lying unconscious.
Fiset and MacDonald put Maniyogena into the back of Fiset's police vehicle. MacDonald testified he told Fiset what had happened and that an ambulance was on its way.
But in his testimony, Fiset said he was never told that the health centre had been called or that an ambulance had been dispatched. He also testified that Maniyogena was conscious and responsive, though very intoxicated.
Both Fiset and MacDonald said they then drove Maniyogena to the detachment and placed him in a cell.
'He was fine'
On Thursday, the inquest heard from Shannon Case, a community member who volunteered to drive the community's ambulance that day.
Case said she first drove to where MacDonald's truck had been but didn't see anyone. She said she then called Bussey to find out where she needed to go.
Bussey said he then called Fiset who told him Maniyogena had been brought to the detachment and placed in a cell. Bussey said he asked about his condition and whether he needed treatment. He said Fiset told him, "he was fine."
"My main concern was whether or not he was conscious. [Fiset] said he was walking and talking," Bussey said.
Bussey said Fiset told him Maniyogena didn't need to be seen by a nurse right away.
When questioned on why he didn't argue with Fiset, after having been told by MacDonald that Maniyogena was unconscious, Bussey said he assumed the bylaw officer was just new and inexperienced. Fiset, on the other hand, was a very experienced police officer, Bussey said
"[MacDonald] was panicked, he was new … I accepted [Fiset's] experience. I trusted his assessment," he testified.
But Fiset gave a very different recollection of events. He testified that he was the one who called Bussey about Maniyogena's condition. He told the inquest that it was Bussey who determined that Maniyogena did not need immediate medical intervention.
Fiset said he never knew about Maniyogena's head injury and was only worried about the cut above his eye. He said Bussey told him to wait until Maniyogena "sobered up" before bringing him into the health centre.
"They're the medical experts," Fiset said. "I'm not."
But Bussey testified that waiting until someone sobered up to examine them was not "best practice" and he didn't believe it ever happened in his seven years working as a nurse in Nunavut.
In his testimony, Fiset said Maniyogena was responsive while being brought into cells. MacDonald, on the other hand, said he never saw Maniyogena regain consciousness after he jumped out of the vehicle window.
Surveillance video from the Kugluktuk RCMP detachment shown to the inquest showed Maniyogena lying motionless on the floor of the cell while officers removed his clothing and wiped blood from above his eye.
Needed immediate medical attention
On Thursday, the inquest also heard from expert witness, Dr. Harold O'Connor, who is a specialist in emergency medicine.
O'Connor testified that Maniyogena needed to receive medical attention immediately after his fall from the truck, which elicited a round of applause from members of the public attending the inquest.
O'Connor said the level of consciousness Maniyogena was reported to have shown immediately after his fall, and while being placed in a cell, should have prompted law enforcement to get him medical care.
O'Connor also recommended that vehicles used to transport prisoners be outfitted to ensure the prisoners are secure and cannot get out on their own.
The jury is expected to begin its deliberations Friday to develop non-binding recommendations on how to prevent similar deaths in the future.