Cynthia Blackjack’s death was an “accident,” according to an unanimous decision from a six-member jury.
Her liver failed, “likely triggered by toxicity to a drug or other substance,” the Jan. 31 verdict reads.
The finding marks the end of a two-week-long inquest charged with determining what could have led to the death of the 29-year-old.
The jury made eight recommendations for the Yukon government and Little Salmon/Carmacks First Nation to implement.
Blackjack’s mother, Teresa, who was in attendance for the verdict, said her daughter was misjudged during the inquest.
“I think they misjudged her bad because they called her an alcoholic and she’s not,” she said. “She’s my daughter, and I know her. She phoned and everything to me all the time and she’s always complaining about the nurse. …
“I feel really upset but can’t do nothing about it.”
Teresa said that she hopes the inquest brings more services to First Nations people.
“I’m glad my daughter opened up everybody’s eyes.”
The Council of Yukon First Nations, an intervenor in the inquest, declined to comment.
Russell Blackjack, chief of Little Salmon/Carmacks First Nation, wasn’t immediately available for comment.
Blackjack was airlifted out of Carmacks on Nov. 7, 2013 in order to undergo treatment at the hospital in Whitehorse. She died on route, suffering a heart attack.
According to an expert witness this week, Tylenol, coupled with alcohol, likely caused Blackjack’s liver to shut down, which then caused collateral damage to neighbouring organs.
Dr. Robert Saunders said acute liver failure spurred by Tylenol is rare.
Saunders suggested it was too late to adequately treat Blackjack and save her life. She required a liver transplant well before she went to the health centre in Carmacks on Nov. 6. Her condition, he said, necessitated treatment at the Whitehorse hospital.
Jurors had asked whether “negligence” could be used as part of their decision into Blackjack’s cause of death.
Presiding coroner Peter Chisholm ruled the word out of bounds.
Earlier in the day, on Jan. 31, when he charged the jury with the facts of the inquest, a quasi-judicial court process, he said its purpose is not find fault or blame.
A key component of inquests is making recommendations that could prevent similar problems from resurfacing.
The jury called on the Yukon government and the First Nation to hire one nurse practitioner at the health centre in Carmacks, eliminate “stigmatizing language,” ensure that a wellness hub — with a focus on alcohol and drug problems — is fully staffed and extend medevac hours in communities.
The inquest heard from multiple community members who said they do not feel comfortable seeking help from the Carmacks health centre, alleging that they’re not taken seriously or treated like second- class citizens.
Developing a curriculum that addresses cultural safety, one that’s specific to the First Nation, is another recommendation.
Questions around whether patients have advocates also came out during the inquest. A community health representative should be posted at the nursing station, the jury recommended, in order to help patients navigate the health care system. It would be carried out by a local First Nation.
Adequate transportation to Whitehorse was a theme. Blackjack appeared to have problems finding a ride from the community in order to receive treatment at the hospital. The jury recommended there be “dedicated medical transportation” for residents who may not be sick enough to warrant a medavac but need hospital care.
Pat Living, a spokesperson for health and social services, said in a written statement, “We are now in the process of carefully reviewing the decision and recommendations of the jury and will be in a position to speak about next steps once we have completed that review.”
Contact Julien Gignac at