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.

Get local stories you won't find anywhere else right to your inbox.
Sign up here

Just Posted

A proposed Official Community Plan amendment would designate a 56.3-hectare piece of land in Whistle Bend currently designated as green space, as urban residential use. Whitehorse city council will vote on the second reading of the Official Community Plan amendment on Dec. 7. (Courtesy City of Whitehorse)
Future area of Whistle Bend considered by council

Members set to vote on second reading for OCP change

The City of Whitehorse’s projected deficit could be $100,000 more than originally predicted earlier this year. (Crystal Schick/Yukon News file)
City deficit could be just over $640,000 this year

Third quarter financial reports presented to council

Chief Medical Officer of Health Dr. Brendan Hanley speaks during a COVID-19 press conference in Whitehorse on Oct. 30. Masks became mandatory in the Yukon for anyone five years old and older as of Dec. 1 while in public spaces. (Crystal Schick/Yukon News file)
As mask law comes into effect, premier says $500 fines will be last resort

The territory currently has 17 active cases of COVID-19

Crystal Schick/Yukon News file
Ranj Pillai, minister of economic development, during a press conference on April 1.
Government rejects ATAC mining road proposal north of Keno City

Concerns from the First Nation of Na-Cho Nyäk Dun were cited as the main reason for the decision


Wyatt’s World for Dec. 2, 2020

The new Little Salmon Carmacks First Nation council elected Dec. 1. (Submitted)
Little Salmon Carmacks elects new chief, council

Nicole Tom elected chief of Little Salmon Carcmacks First Nation

Submitted/Yukon News file
Yukon RCMP’s Historical Case Unit is seeking information related to the unsolved homicide of Allan Donald Waugh, 69, who was found deceased in his house on May 30, 2014.
Yukon RCMP investigating unsolved Allan Waugh homicide

Yukon RCMP’s Historical Case Unit is seeking information related to an unsolved… Continue reading

A jogger runs along Millenium Trail as the sun rises over the trees around 11 a.m. in Whitehorse on Dec. 12, 2018. The City of Whitehorse could soon have a new trail plan in place to serve as a guide in managing the more than 233 kilometres of trails the city manages. (Crystal Schick/Yukon News file)
2020 trail plan comes forward

Policies and bylaws would look at e-mobility devices

Snow-making machines are pushed and pulled uphill at Mount Sima in 2015. The ski hill will be converting snow-making to electric power with more than $5 million in funding from the territorial and federal governments. (Joel Krahn/Yukon News file)
Mount Sima funded to cut diesel reliance

Mount Sima ski hill is converting its snowmaking to electric power with… Continue reading

Colin McDowell, the director of land management for the Yukon government, pulls lottery tickets at random during a Whistle Bend property lottery in Whitehorse on Sept. 9, 2019. A large amount of lots are becoming available via lottery in Whistle Bend as the neighbourhood enters phase five of development. (Crystal Schick/Yukon News file)
Lottery for more than 250 new Whistle Bend lots planned for January 2021

Eight commercial lots are being tendered in additional to residential plots

The Government of Yukon Main Administration Building in Whitehorse on Aug. 21. The Canada Border Services Agency announced Nov. 26 that they have laid charges against six people, including one Government of Yukon employee, connected to immigration fraud that involved forged Yukon government documents. (Crystal Schick/Yukon News file)
Charges laid in immigration fraud scheme, warrant out for former Yukon government employee

Permanent residency applications were submitted with fake Yukon government documents

Black Press Media and BraveFace have come together to support children facing life-threatening conditions. Net proceeds from these washable, reusable, three-layer masks go to Make-A-Wish Foundation BC & Yukon.
Put on a BraveFace: Mask fundraiser helps make children’s wishes come true

From Black Press Media + BraveFace – adult, youth and kid masks support Make-A-Wish Foundation

Whitehorse City Hall. (Joel Krahn/Yukon News file)
City hall, briefly

A look at decisions made by Whitehorse city council this week

Most Read