Among the most egregious complaints against Debbie McKeown was that she refused to see a three-month-old Cape Dorset boy, Makibi Timilak, when his mother phoned her one evening in early 2012 saying the child was ill and needed attention. The boy died hours later.
Nunavut rules dictate that nurses on call in the evening must open the health centre to see an infant under the age of one who might be ill.
A CBC News investigation found that the territorial government admitted in emails that it put the hamlet of Cape Dorset "at risk" by mishandling complaints against McKeown. She was promoted to the top nursing post in the community despite conditions on her licence preventing her from treating children.
According to a disciplinary settlement summarized in the recent newsletter by the Registered Nurses Association of the Northwest Territories and Nunavut (RNANT/NU), McKeown "accepted responsibility for failing to follow employer telephone triage guidelines involving an infant."
The only infant complaint against McKeown was in connection with Timilak. When Timilak's mother, Neevee Akesuk, called the health centre, she says McKeown told her to give the baby boy a bath and come to the Cape Dorset Health Centre in the morning.
CBC News obtained a March 2014 copy of RNANT/NU's summary of the 19 allegations against McKeown that were filed about incidents in late 2011 and early 2012, plus a 2013 incident later discovered during the investigation.
However, it's difficult to determine what allegations McKeown is admitting to in the disciplinary finding in the newsletter because it doesn't reveal specifics.
McKeown has not responded to CBC News.
Years of conditions
The disciplinary finding in the newsletter also refers to McKeown "failing to follow" rules around when to see a sick child when a parent phones the clinic.
Though the newsletter doesn't specify the case, in the RNANT/NU summary of allegations from earlier this year, there were at least two complaints against McKeown concerning children.
One allegation referred to a mother calling the centre about a child with a fever. McKeown allegedly told the mother she was to busy to see the child and instructed her to give the child Tylenol and a bath.
McKeown was also accused of telling another mother she was too busy to see a child, according to the March summary of allegations. That child was later medically evacuated on a flight to Winnipeg.
In the newsletter, McKeown is identified only by her member registration number: 4245. However, the college confirmed to CBC News that number refers to McKeown.
The disciplinary finding also states that McKeown admitted to failing to properly treat patients on more than one occasion, failing to "adhere to acceptable medication administration" more than once. and admitted to violating the Code of Ethics.
To return to work, McKeown, who lives in Thunder Bay, Ont., faces a litany of courses she must complete and conditions she must meet.
They include a registered nurse refresher program, an ethics course, a cultural competence course, a pediatric advanced life support course, an advanced cardiac life support course, plus 300 hours of supervised nursing practice in a hospital.
RNANT/NU's executive director, Donna Stanley-Young, says a refresher course takes one year, while the ethics and competence courses will likely take a few months. The pediatric and life-support courses are held on weekends. The 300-hours in a hospital can be completed in two months.
Even once she's met those requirements, the 56-year-old nurse will have conditions on her licence for five years.
Stanley-Young said only a "small percentage" of the college's disciplinary cases involve such an impact on the nurse.
"Anytime a decision is made that impacts the livelihood of a nurse, it's significant," said Stanley-Young.
RNANT/NU suspended McKeown's licence in May, rendering her unable to practice in Nunavut.
The Ontario-based registered nurse is listed on the College of Nurses of Ontario (CNO) website as "entitled to practice with no restrictions." CNO says it's currently investigating McKeown.
Ex-director questions review
After the CBC News story was published on Nov. 7, Nunavut Health Minister Monica Ell ordered an external investigation of the "administrative processes associated with the Cape Dorset case." The department says it is still determining the scope of the review.
At that time, the health minister also said the department had already conducted an internal review.
Elise Van Schaik, a former health department employee, is questioning whether that review was ever done because there were no signs of a probe nor of changes made.
Van Schaik was part of a regional group that recommended an internal investigation be done in the first place. She worked as the director of health programs for the southern Baffin region overseeing five health centres, including Cape Dorset's.
In mid-January, four regional managers including Van Schaik, recommended several actions be taken to protect the public. They included internal investigations into concerns around McKeown and how management handled the matter, that McKeown be "terminated immediately" and that the regional director lead the investigations.
One of the key concerns was about how Heather Hackney, the manager overseeing Cape Dorset during McKeown's time there, had handled complaints filed against the nurse.
In an internal email obtained by CBC News, Van Schaik summarized her concerns for the regional team, saying Hackney was "grossly incompetent," failed to properly investigate McKeown and suppressed information about about 20 cases that she should have provided to a consultant looking into complaints against the nurse.
Hackney is no longer a regional manager, but is currently listed as a community health nurse working for the government in Igloolik.
Later in January, Van Schaik says she asked about the investigation and was told the Iqaluit office had taken over. In the following months, she says she saw no signs of the investigation happening, such as witnesses being contacted and actions being taken against those involved.
In an interview from her hometown of Ottawa, Van Schaik told the CBC News that "issues get swept under the rug" in the health department due to a lack of transparency and accountability.
Van Schaik was dismissed in May after a year in the director role and four years as a contract nurse practitioner in the territory. She says it was because she had filed a harassment grievance against her supervisor and also because she went against the status quo to push for change.
The health department has not commented on Van Schaik's accusations.
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