The coroner should be more candid

Yukon's chief coroner should clarify why she amended her report into the death of Teresa Ann Scheunert.

Yukon’s chief coroner should clarify why she amended her report into the death of Teresa Ann Scheunert.

If you’ve followed the relentless questioning by the NDP’s Jan Stick about these changes over the past two weeks, you will have heard her repeatedly suggest, without quite coming out and saying it, that the coroner was leaned on by the Yukon government to soften her final report, and that she omitted relevant information as a result.

That’s a serious charge, and there’s no smoking gun to support it. That’s why the Opposition only hints at these conclusions, rather than stating it outright.

Coroners are not of habit of justifying how they do their jobs to the public. Faced with the NDP’s insinuations, Chief Coroner Kirsten Macdonald first responded with a terse, one-page news release, followed by a more detailed release. Yet outstanding questions about some changes still remain. A better explanation is warranted.

Scheunert, a 47-year-old registered nurse living in Watson Lake, died from a lethal combination of painkillers administered to her while admitted at Watson Lake’s hospital, the coroner concluded.

Scheunert had injured her back while participating in a CPR workshop in late March and early April 2012. Upon being later admitted to the Watson Lake Hospital in June, Scheunert was prescribed and administered a bevy of painkillers. She died two weeks later.

The family waited nearly a year for the coroner’s report, only to be told just hours after receiving it that the report had a mistake and it would be retracted.

The matter in dispute was whether Scheunert had self-administered oxycodone pills, and whether these drugs contributed to her death. The coroner, based on the evidence she had at the time, assumed this had occurred, and made many recommendations that detailed how to prevent such lapses in the future.

But new information undermined this theory. It turned out that a prescription filled in Scheunert’s name had actually been collected by a doctor for the hospital’s use, and that Scheunert’s oxycodone levels could be explained solely by the drugs administered by the hospital. In recognition of this, the coroner tossed out sections of her report dealing with patients self-administering drugs.

The coroner also modified unrelated sections of her report. Many of these revised passages soften the criticisms aimed at the government, but these are largely changes in tone, rather than content. For instance, the initial report says “there was a gap identified” in how the hospital managed the use of risky drugs. The later report says “it appears that more could have been done.”

The NDP wonders what would have contributed to these changes. It’s easy to imagine someone like, say, the chair of the hospital corporation – a body that received a copy of the report – phoning the coroner and warning she would receive a legal thumping if she didn’t tone things down, and that the later version underwent a thorough lawyer-proofing. Yet this is purely speculation, as neither government MLAs nor the coroner will say what was communicated to her.

It’s important to note that the final report does not read as if it were written by a government patsy. Both reports conclude that the system failed Scheunert by allowing her to receive a lethal combination of drugs. Both make very similar recommendations. And both manage to make the management of Watson Lake Hospital looks extraordinarily bad.

Perhaps most damningly, doctors are supposed to check for medication conflicts with an on-call pharmacist, according to Yukon Hospital Corporation policy. But it appears that policy wasn’t being followed at the Watson Lake Hospital, despite the facility being taken over by the hospital corporation three years ago.

Other best practices to prevent drug conflicts were similarly not followed in Scheunert’s case.

The coroner’s final report makes it clear that Scheunert’s death was preventable. Her distraught family has every reason to pursue damages against the Yukon government, and it’s saddening to hear they haven’t yet managed to find a lawyer willing to represent them.

Scheunert’s family wants to see a public inquiry. They are right to demand clear answers, but it’s hard to say whether an expensive and time-consuming inquiry would actually serve the public interest.

The coroner has already documented many of the mistakes that contributed to Scheunert’s death, and the government has agreed to make suitable changes to ensure similar deaths don’t occur in the future. Scheunert’s family will also soon receive the hospital’s own review into the death, which ought to contain more details.

One matter that a public inquiry could resolve is the question of whether the government pressured the coroner to change her report, and in what way.

But there’s a simpler fix. The coroner should simply put the matter to rest by having a candid discussion with reporters about any concerns that government officials may have expressed. This is in her own interest as well: by remaining mum, she only contributes to perceptions that the independence of her office has been compromised.