Tuktoyaktuk needs its own emergency medical service and a sobering centre, recommends a jury involved in an inquest into the 2021 death of a woman in police custody.

Following a two-and-a-half day coroner's inquest into the death of Sylvia Panaktalok at the Mackenzie Hotel in Inuvik, which wrapped up Oct. 3, the unanimous jury made 11 recommendations. Those include calling on stakeholders in Tuktoyaktuk to "make best efforts" to establish emergency medical services, ambulance service and sobering centre. In addition, it called on the Tuktoyaktuk to review and audit cellblock policies every six months, provide training within a year in assessing a person's capacity to be roused from being unconscious by civilian guards and to develop and practice a medical emergency procedure. It also recommended that all staff are made aware of Northwest Territories Health and Social Services Authority policies.

"These recommendations are all about ensuring a person who is brought into the custody of the , in particular when they have committed no criminal offence and are only being lodged for their safety, are treated with dignity and respect and are afforded proper medical care when it is necessary, said coroner`s lawyer Jessi Casebeer. "These recommendations are also about ensuring the consider this incident with the seriousness that it deserves and that members are properly following the policies that are already in place."

The jury also concluded Panaktalok's death was accidental and that the cause of death was alcohol poisoning, occurring shortly before midnight at the Tuktoyaktuk Health Centre on July 31. She was taken from the detachment to the health centre in the back of a police pickup truck.

During the third day of hearing from experts, the jury heard from Dr. Evan Wood, who works in the sobering centre in downtown Vancouver. He said footage shown of Panaktalok breathing erratically matched up with similar symptoms of extreme alcohol poisoning, noting it can disrupt the heartbeat and result in cardiac arrest.

Casebeer thanked the jury for their time over the week.

"All of the evidence points towards an accidental death," she said. "It is important for the matter to be reviewed through an inquest, in part, to rule out speculation to other manners of death.

"Ms. Panaktalok experienced odd patterns of breathing only 10 minutes after being lodged in cells in what could be described as gasping for breath. Dr. Wood testified about the possible medical reasons for this type of breathing, within the limits of what can be reviewed in video footage, and that it matched with symptoms of severe alcohol poisoning or someone in palliative care," Casebeer continued.

"Sylvia Panaktalok was a mother, a grandmother, a sister and a cousin. She was loved and cared for by a large family. Think about how you would want your family member treated in similar circumstances."

The jury also heard from Dr. Tara Dixon, a pathologist who confirmed the cause of death was alcohol poisoning.

In his closing remarks, GNWT lawyer Jeremy Walsh said the territorial government would make best efforts to meet the recommendations but noted the circumstances in Tuktoyaktuk are challenging.

"I take no issue with the recommendations that were proposed," he said. "It is a very challenging situation and a very challenging location. We've heard that services in Tuktoyaktuk and other communities are not the same as everywhere else, because of cost, distance and population size. I'm not saying people in Tuktoyaktuk don't deserve services, but it's the reality there's going to be logistical issues and challenges around that.

"We've heard that services here in Inuvik are very different, just a few hours down the road. We've also heard from Dr. Wood, who testified this morning, that even the services in Vancouver aren't ideal, so in a situation like this I think it calls for some creativity, discussion and an assessment of what's available.

"We didn't have time this week to hear from everyone to know who all the stakeholders are in Tuktoyaktuk. It's the reality there are different stakeholders with different responsibilities, and oftentimes there are reasons for that."

A coroner's inquest is held to investigate a cause of death and make recommendations to prevent similar incidents in the future.

"This is not a trial and no one stands accused of anything," said NWT chief coroner Garth Eggenberger.