The Office of the Chief Coroner held an inquest from July 29 to August 16, 2024, into the death of Ruthann Quequish. Ruthann was an Indigenous woman who lived in the community of Kingfisher Lake First Nation (KLFN). Beginning March 22, 2017, Ruthann visited the nursing station in KLFNmultiple times before she died in the morning of April 1, 2017. Ruthann was 31 years old; she was a mother and beloved by many members of her family. ALS senior staff lawyers, Caitlyn Kasper and Emily Hill, represented the family at the Inquest. The jury found that Ruthann’s cause of death was undiagnosed and untreated diabetic ketoacidosis. The jury ruled that the means of Ruthann’s cause of death was undetermined, and not from an accident, natural causes, homicide, or suicide.
Witnesses testified about the events leading up to Ruthann’s death and the impact of her death. Ruthann’s mother, Edna Quequish, strongly advocated for Ruthann to receive proper medical care in her final days. Members of the community, nurses, doctors, and expert witnesses testified about health care in remote First Nations and the challenges Indigenous peoples have accessing health care. The quality of health care in KLFN and other remote First Nation communities continues to be impacted by colonialism, systemic racism, underfunding from the federal government, issues with cultural training for nurses and rotating staff, and technical and logistical issues that hamper administration of records and continuity of care. Witnesses also testified about the unique challenges of managing and treating diabetes in remote communities.
The jury made 42 recommendations to improve health care in KLFN and other remote First Nations. The jury’s recommendations include changing how nursing staff and physicians are trained to work in remote Indigenous communities, and improving the administration of electronic records, virtual tools, and continuity of care. Other recommendations include: facilitating consultation and collaboration between the Ministry of Health, Indigenous Services Canada, and health care facilities serving KLFN; making changes to glucose checks and diabetes screening; and supporting the development of a patient advocacy position in Kingfisher Lake First Nation. The family is hopeful that these recommendations will assist in improving health care for all Indigenous patients.
Nathan Kenna