Coroner failed to investigate systemic discrimination allegations: Yukon Supreme Court

A Yukon Supreme Court judge has ordered a public inquest into the death of a First Nation woman in November 2013.

A Yukon Supreme Court judge has ordered a public inquest into the death of a First Nation woman in November 2013.

Justice Ron Veale ruled the Yukon chief coroner’s investigation failed to address allegations of systemic failures of the health care system against First Nation citizens and a lack of ambulance service for Cynthia Blackjack.

Blackjack died in November 2013 while being medevaced from Carmacks to Whitehorse.

From the moment Blackjack sought help, her treatment was fraught with delays and mistakes.

She went to the Carmacks health centre on Nov. 6, 2013 complaining of a toothache, abdominal pain and vomiting.

She was told that day to make her way to Whitehorse General Hospital, but she didn’t go.

The next day her relatives phoned the health centre as Blackjack was screaming in pain. At 11 a.m. medical personnel decided to medevac her. But because of mistakes and equipment issues, Blackjack was only moved to the medevac at 5 p.m.

She died an hour later, minutes before landing in Whitehorse.

In fall 2014, Yukon Chief Coroner Kirsten Macdonald released her investigation into Blackjack’s death. She made eight recommendations to the Department of Health and Social Services. She found a number of issues, from the wrong tubing brought by the medevac team to the failure of the ventilator equipment at the health centre.

But Macdonald ruled there was no reason to order a public inquest.

The Little Salmon Carmacks First Nation and Blackjack’s mother, Theresa, challenged that decision, alleging LSCFN citizens suffer from systemic failures of the Yukon health system.

“I am aware that various stereotypes play a big role in the manner how health care services are provided and that these stereotypes are the root causes of the underlying deficiencies in health care services with deadly results,” LSCFN director of health and social programs Rachel Byers wrote in an affidavit.

Theresa raised a number of issues with how her daughter was treated, alleging she was treated differently because she was Indigenous.

“Why did my mother (Theresa’s mother) have to threaten … legal action before the ambulance picked her up on Nov. 7, 2013?”

Veale found that Macdonald refused to investigate complaints from the First Nation’s citizens about the refusal to provide Blackjack with an ambulance.

She also didn’t address the underlying reasons for the “inadequate ambulance service,” Veale wrote, which is enough to order an inquest.

“I find it surprising that, given the Chief Coroner’s adoption of the recommendations of the PSRC (Ontario Patient Safety Review) to review the procedures for transfer of patients from community health centres, the Chief Coroner is not prepared to continue her investigation into the new allegations, especially where the delays in service seem established on the evidence,” Veale wrote.

“If one combines this evidence with the demonstrable concern of the First Nation individuals and the First Nation itself, I find it makes a very compelling case for an inquest.”

Macdonald’s lawyer argued that there was no direct link between Blackjack’s death and the alleged systemic failures.

But in Macdonald’s own submission to the court, part of the role of a public inquest is to ensure the public confidence in health services, Veale wrote.

When Macdonald investigated Blackjack’s death, she focused on the technical medical aspect only, Veale wrote, and imposed “unreasonable limitations on herself.”

She refused to include information that would attribute fault or criticize the medical personnel.

“It is difficult to imagine how the chief coroner can fulfill that mandate when she will not impute fault or criticism toward any of the personnel or their practices,” Veale wrote. Nothing in the Coroners Act prevented her from doing that, he added.

“Indeed, such criticism is in the public interest of saving lives.”

The other limitation in her investigation is that she didn’t find it relevant to identify Blackjack as a LSCFN citizen — the very issue her relatives raised regarding discrimination.

LSCFN questioned why Macdonald didn’t contact them when investigating Blackjack’s death.

The chief coroner explained the First Nation didn’t have standing.

But there is no such thing as standing in an investigation. That concept only applies to formal inquests, Veale wrote.

Veale recommended a territorial judge be appointed to spearhead the inquest.

Contact Pierre Chauvin at pierre.chauvin@yukon-news.com

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