The jury participating in an inquest into the death of seven-month-old Kaiya Stone-Kirk in Watson Lake in 2021 issued their final ruling last Saturday.

Jurors found that the child’s passing was accidental, and provided 13 recommendations to prevent similar tragedies from occurring in the future.

Stone-Kirk died after her head became lodged between a wall and bed during the night.

That caused what was determined to be “positional asphyxia” to occur when the infant became trapped in a way preventing her from breathing.

This happened while Stone-Kirk was under the care of a babysitter, as her grandmother and regular caregiver, Margaret Sue Stone, sought medical care for COVID-19 symptoms.

The inquest did not set out to find blame for the death, but to determine what circumstances led to it and what can be done to prevent similar deaths.

The recommendations include proposals for the development of legislation to regulate social workers in the Yukon, and for the creation of an Infant Mortality Review Committee to oversee inquiries into infant deaths in the territory.

The committee would include First Nation health providers, Yukon government representatives, Yukon Coroner’s Service representatives and other experts in infant care.

The review committee would be tasked to “monitor and review all infant deaths within the territory with a focus on deaths that have a preventable component.”

The report also urges the results from these reviews be made public.

Other recommendations are aimed at ensuring children have a safe place to sleep when last-minute child care is sought by families or social workers.

They also outline the need for proper sleeping equipment and training be provided by Family and Children’s Services staff.

Stone-Kirk’s family are members of the Liard First Nation.

Consequently, several recommendations relate to issues resulting from how Family and Children’s Services work with community First Nation partners to provide short-term or overnight care for infants.

These recommendations also advocate for the government to provide the adequate funding for implementation.

Chief coroner Heather Jones told the Star in an email these recommendations will now be sent to the Department of Health and Social Services with a yet-to-be-determined timeframe for staff to respond with details of any actions they will take.

A statement Thursday from Health and Social Services Minister Tracy-Anne McPhee said the department is working to respond and make needed changes.

“Our government is working quickly to respond to each recommendation and improve the safety of children receiving services from Family and Children Services,” the statement reads.

“We are committed to working closely across Yukon government departments and with Yukon First Nations governments to make the changes needed to keep children safe, protected and cared for.”

The coroner’s service may follow up by publicizing any action or response it receives from the territorial government.

Most of the jury’s recommendations seek to address specific problems identified during witness testimony at the inquest.

Stone-Kirk and her 17-year-old brother were put in the care of babysitter Cheryl Wolftail while Stone sought treatment for COVID-19 symptoms.

The children had tested positive as well, and Wolftail herself was in isolation due to family members having COVID.

It was reported by several news outlets that testimony during the inquest disclosed the choice of caregiver was made by Stone and Family and Children’s Services jointly – despite questions surrounding the suitability of Wolftail as a babysitter due to alleged challenges she had caring for her own children.

To prevent these issues during short-term urgent situations, the jury recommends the creation of new policies for Extended Family Care Agreements, including safety plans.

These policies would be required to clearly outline Family and Children’s Services’ role and responsibilities in these situations and include consultation from First Nations and other community partners.

It had also been widely reported in the media that Family and Children’s Services provided a bassinet for the infant to sleep in, but it was not being used at the time of the infant’s death.

So, to ensure the sleeping equipment is properly used in the future, the jury laid out the need for a “safe sleep” policy that includes information and equipment specifications, including reasons why the equipment is needed and how to properly use it.

This would include eduction for Family and Children’s Services staff on the owner’s manuals included with the equipment.

This training is recommended to be mandatory and re-done every two years.

They also recommend the creation of a course on safe sleep to be developed in collaboration with First Nations, and that this be completed by any person who is paid to provide care for infants.

Specific to the Liard First Nation, the jury outlined how to better provide access to overnight care in these situations by developing a roster of reliable people in that community and advocating for the establishment of resources in the Liard First Nation and other communities for overnight care of infants and children.

The last recommendations of the jury call for a public inquiry into how notification was given of Stone-Kirk’s death to caregivers and family members, and for community safety officers to be relied upon by Family and Children’s Services rather than the RCMP when appropriate.