a= VERDICT OF CORONER'S JURY ‘AS A RESULT OF AN INQUEST INTO THE DEATH OF CLYDE AKUMALIK HELD ON _25/09/2015__AT_Igaluit_ IN NUNAVUT THE JURORS HAVE CONSIDERED THE EVIDENCE AND MAKE THE FOLLOWING DETERMINATIONS: L. IDENTITY OF DECEASED: CLYDE AKUMALIK 2. DATE AND TIME OF DEATH: October 13, 2013. Between midnight and 13:00. 3. PLACE OF DEATH: House 2716, unit 1 4. CAUSE OF DEATH: Suicide 5. MANNER OF DEATH: Death by hanging 6. CIRCUMSTANCES UNDER WHICH DEATH OCCURRED: Clyde was found in the bedroom closet hanging from the rod. Ligature markings were noticed on his neck with no other signs of trauma. RECOMMENDATIONS OF JURY: (SEE ATTACHED) DATED AT Iqaluit Justice Centre ON 25/09/2015 NAMES OF ALL JURORS: SIGNATURES OF ALI. JURORS: ansas 9 FORM9 FORMUI Arlo 9 SECTION 9 ARTICLEa i) VERDICT OF CORONER’S JURY AS A RESULT OF AN INQUEST INTO THE DEATH OF Antonio “Rex” Uttak HELD ON _ 25/09/2015 AT __IQALUIT IN NUNAVUT THE JURORS HAVE CONSIDERED THE EVIDENCE AND MAKE THE, FOLLOWING DETERMINATIONS: 1. IDENTITY OF DECEASED: Antonio “Rex” Uttak 2. DATE AND TIME OF DEATH: August 10, 2013. between midnight and 0900. 3. PLACE OF DEATH: House 161, Naujaat (Then Repulse Bay, Nunavut) 4, CAUSE OF DEATH: Suicide 5. MANNER OF DEAT! eath by hanging 6. CIRCUMSTANCES UNDER WHICH DEATH OCCURRED: Rex was found in the bedroom closer, hanging from a nylon cord. Ligature markings were noticed on his neck with no other signs of trauma, RECOMMENDATIONS OF JURY: (SEE ATTACHED) DATED AT Iqaluit Justice Centre ON 25/09/2015. NAMES OF ALL JURORS: SIGNATURES OF ALL JURORS: nase 9 FORM9 FORMULE 9 Le 9 SECTION 9 ARTICLE 9VERDICT OF CORONER'S JURY da. APCPYLe Dtd*en eds Bc CN*Teo ‘We the jury, recommend: & Adoption of 41 of the 42 evaluation report recommendations of the Nunavut Suicide Prevention Strategy Action Plan. We also agree that recommendation 18 and 24 second paragraph, in referencing to youth peer counselling not be adopted. Adoption of the Qikigtani Truth Commission recommendations: i, Creating Healthy Communities: recommendation s | and 2, ji, Strengthening Inuit Culture: Recommendation 3. Adoption of the Truth and Reconciliation Commission: Call of Action, Health section recommendation #21. 2. Specific initiatives: We accept all 10 recommendations presented by the Government of Nunavut. We further recommend the following action items for the GN: ‘Whole of Government of Nunavut: 1 The Government of Nunavut shall immediately declare Suicide as Public Health Emergency. 2. The GN appoints a Minister responsible for Suicide Prevention at the next sitting, Honour recommendation 37 from the Nunavut Suicide Prevention Strategy Action Plan Evaluation. This should be in the form of Secretariat reporting directly to the Minister responsible for Suicide Prevention. The Secretariat will have the mandate and resources to demonstrate the Govemment’s commitment to this crisis. This will be completed before April 1, 2016. 4. Immediately create a public awareness campaign to change the attitude and de-normalize suicide in Nunavut. 5. The GN shall pilot Clyde River's Illisagsivik model in other communities. ansans 9 FORM9 FORMULE9 LoL 9 SECTION 9 ARTICLE 9Anse 9 irl’ 9 SECTION 9 ARTICLE 9 VERDICT OF CORONER'S JURY A DAAPCPYLY® JSdecnAtde ac ENO Department of Education Inservice RespectED and their curriculum components as mandatory curriculum in schools: Be Safe, Integrated Training Resource and Toolkit and the Ten Steps to Creating Safe Environments: this shal be done by the end of the 2015-2016 school Year. ‘As per recommendation 9 from the GN. This review shall be completed by September 2016. Develop an action Plan to address the high rate of student drop-outs. This Action Plan will be developed by March 2016 and implementation will begin in the 2016/2017 school year Education shall pilot Zippy’s Friends, Aboriginal Shield Program and Passport: Skills for Life during the 2016/2017 school year and review and evaluate the effectiveness in the following year. i. Department of Health: Pilot the creation of community-based grief support networks. This should be implemented by September2016 and evaluated in 2017, Shall create a youth targeted PSA awareness campaign for cannabis and alcohol abuse by September 2016, Create staff specialist positions in the area of youth and addictions counselling by September 2016. Establish a formal foll April 2016. yw-up protocol for individuals who have attempted suicide by We adopt Dr. Mishara’s 15 recommendations: “I recommend that the GN change the Mental Health Act to allow for the family to be contacted and immediately involved after a suicide attempt regardless of the age of the person who has attempted suicide. This should be systematic. and it requires also that Mental Health workers receive training and re-orientation to always develop safety plans and conduct counselling with the family present. This is 2 new recommendation that involves allotment of resources tore-training and a change in orientation to a more family and community intervention approach.” FORM9 FORMULE9sa) wv. Ansan 9 WL VERDICT OF CORONER'S JURY 2A APCDYLY™ DSd*Lkenabde Ac No Department of Family Services: 1. Shall open Substance Abuse ‘Treatment Centers in cach of the three regions in Nunavut by 2008. 2. Shall develop culturally-relevant relationship building, parenting, coping skills and anger management programing by September 2016. Department of Culture and Heritage: 1. Shall create an in-person cultural orientation program with all Implementation ‘Committee members to streamline frontline worker training, This program shall be used to increase cultural sensitivity and awareness of suicide risk factors. This will be created and implemented by April 2016. Nunavut Housing Corporation: 1. Shall provide ASIST training to all local housing organizations by December 2016 2. Shall immediately become a signatory on the Interagency Information Sharing Protocol. ‘The RCMP shall aide in the creation of the GN cultural orientation program. This training shall be mandatory for any member who is stationed, or will be stationed, in Nunavut. ‘The Government of Canada shall increase funding to expedite the 20 year Blue Print for Action Plan of the Nunavut Housing Corporation to reduce the risk factors of Suicide. ‘The Government of Canada shail establish a National Suicide Prevention Strategy by 2017, Embrace Life Council launch the grief support groups for surviving families that Embrace Life Council had prepared to pilot in Iqaluit; this will be actioned in 2016, All partners will incorporate Inuit Qaujimajatugangit in every initiative to restore the role of Elders as mentors, leaders and educators immediately. All Interagency Information Sharing Protocol members will immediately local weliness ‘committees to foster the sharing of information within the community. annual suicide prevention conference with ‘gaps starting in September2016. The implementation committee shall hold a stakeholders to review best practices and identi FORM9 FORMULE9 8 SECTION ARTICLE 9VERDICT OF CORONER'S JURY Asa APCPYLS® Ise ded Aen 3. Financial Resources: 2 Al poe sal vie feu an eid Associations by April 2016. b. The Government of Canada will re-establish funding streams to which the RIA’s and other ‘Nunavut agencies will have access to fund suicide prevention initiatives in the territory by April 2016. 4. Recount Nene See Provntion Seg ‘a, Statement of support from the highest political level from all partners immediately. RIS's. non-government agencies and other stakeholders. This committee will be articulated 'b. Release 2” action plan with dedicated resources and evaluation criteria by March 2016. pri Cerone Garth Eggenberger Padma Suramala Welw 9 SECTION 9 ARTICLE 9