A coroner’s inquest has ruled the cause of Mary Johnny’s death was homicide.
That means the death was caused by a human, but it doesn’t lay the blame on anyone specific.
The six-person jury, comprised of five women and one man, returned its verdict on Friday evening after deliberating for five hours.
The decision came after four days of testimony from 20 witnesses.
They included several nurses, physicians, relatives, members of the medevac team that flew Johnny to Whitehorse and other medical experts.
The 60-year-old died on Aug. 9, 2012, six days after being admitted to Watson Lake Hospital suffering from abdominal pains and severe dehydration.
According to the coroner’s report, Johnny died of a bowel obstruction after being originally diagnosed as having alcohol withdrawal.
But the jury listed the cause of death as hypovolemic shock secondary to intravascular volume depletion and multi-organ failure.
Hypovolemic shock is a situation where severe blood loss makes the heart unable to pump enough blood to the body.
Intravascular volume depletion refers to extreme vomiting or diarrhea.
On Friday afternoon retired coroner Norm Leibel, appointed to preside over the inquest, told the jury they had to carefully weigh the evidence they had heard and reach a verdict among the following options: natural causes, accident, homicide, suicide or undetermined.
They also had the option of making recommendations to an agency or person.
Coroner’s inquests don’t lay blame. The jury has the option of making recommendations to prevent similar deaths from happening again.
Based on their findings, the jury made four recommendations, all of them directed at the Yukon Hospital Corporation.
The first is to carry out routine audits to “ensure standards for adequate and timely documentation of patient care are adhered to.”
The second is to review policies and procedures for the transfer of patients from rural medical centres to regional care centres.
The third is to develop a standardized process to address do-not-resuscitate orders.
The fourth is to mandate physicians working in rural hospitals to complete Advanced Trauma Life Support, as well as Advanced Cardiac Life Support courses.
During his time on the stand, Watson Lake physician Dr. Said Secerbegovic admitted he hadn’t completed either course in the past 15 years.
“Just because I haven’t done a specific course, it doesn’t mean I’m not current,” he said.
He also told the court he had been severely overworked in the days and weeks leading up to Johnny’s admission at Watson Lake Hospital.
Sixteen to 18-hour workdays were normal, he said.
On Friday, Dr. Stephen Hwang and Dr. Robert Saunders, both expert witnesses, testified that Dr. Secerbegovic should have made the decision to medevac Johnny much sooner based on her condition in the first few days of her stay at Watson Lake Hospital.
Joy Ferguson, a licensed practical nurse on staff the week Johnny was admitted to the hospital, also said the decision to medevac should have been taken earlier.
“Generally if someone is this sick, we’d medevac them,” she told the court, referring to Johnny’s deteriorating condition the night of Aug. 6.
The Yukon Hospital Corporation issued a statement on Monday, saying it would look closely at the jury’s recommendations.
“There will be a role for Yukon’s hospitals, physicians and other system partners as we undertake a review and work together to make improvements,” said CEO Jason Bilsky.
“As an organization, we continually strive to improve the care we provide and prevent outcomes such as this.
“We are committed to this process as it is our opportunity to learn from all of the circumstances in this case.”
It’s the second coroner’s inquest this year into the death of someone following treatment at the Watson Lake Hospital.
Teresa Ann Scheunert died less than two months before Johnny did in 2012.
On June 7, a six-person jury ruled Scheunert’s death an accident.
Contact Myles Dolphin at myles@yukon-news.com