Thank you for this question, which is very pertinent.
I think that a distinction has to be made. We have a principle which, generally speaking, is good and should remain. For most medical supplies, the nurse working in the field is in the best position to use her judgment when placing orders. There are certain exceptions. Drugs, narcotics, for example, are an exception and we already monitor such items very closely.
Up until now, the body bags have not been an exception. This was not an item that we ordered on a regular basis, because there was very little requirement for it. In some instances, there are other resources available, such as the RCMP. If the reserve is quite close to one of these detachments, the RCMP may have these items.
I personally learned something from this investigation: for cultural reasons, this order raised the alarm in the community. We respect that. We need to add a new exception to this principle where we leave it up to the nurses to decide when this type of product should be ordered.
You mentioned something else. There appears to be a lack of control. I agree with you, that is another aspect. And perhaps there is a certain lack of communication. Once again, there is no ill-will involved. As for products such as controlled drugs, there is communication, control and stringent restrictions.
We need to have a system, and we are in the process of implementing one, although it has yet to be completed. I have made this recommendation in the report. We are going to be doing this to avoid a repetition of this incident, and that will involve the nurses, the employees at the regional head office in Winnipeg, and others if necessary.
We learned another thing. Not only do we probably need better communication between the employees of Health Canada who are in the first nations communities and the Health Canada employees in Winnipeg, but we also have to think about the need to involve the first nations.