The death of Cynthia Blackjack more than eight years ago spurred eight recommendations through a coroner’s inquest that considered whether systemic failings caused or contributed to her loss of life.
Blackjack, a member of the Little Salmon/Carmacks First Nation, would have celebrated her 38th birthday on Feb. 10. The territorial government and the First Nation are still working to put the coroner’s inquest recommendations into practice.
The 29-year-old woman died on the evening of Nov. 7, 2013, at the end of a four-day period during which she called or visited the Carmacks nursing station several times complaining about toothache, abdominal pain and vomiting, according to court documents. Blackjack was tentatively diagnosed with alcohol-induced gastritis and died while being medevaced to the Whitehorse hospital.
A six-person jury heard witness testimony during an inquest held in Carmacks and Whitehorse from Jan. 20 to Jan. 31, 2020. The jury charged the death as a result of “multi-organ failure due to hyper acute liver failure likely triggered by toxicity to a drug or other substance” in its verdict.
“We the Jury classify this death as an accident,” reads the three-page verdict, which is signed by coroner Peter Chisholm and the members of the jury.
The Yukon Coroner’s Service investigates and reports on unnatural or unexpected deaths in the territory to “improve public safety and prevent future similar deaths” on its website. The website says it serves to speak for the dead to protect the living.
“Each recommendation is designed to prevent similar deaths in the future. Coroners pass on these recommendations to the public, government, or agencies, and monitor responses,” reads the website.
But there is currently no legislated monitoring process in place.
In the verdict form, each recommendation must be directed to an agency or person. It does not place blame or find fault.
Chief coroner Heather Jones commented on the importance of the inquest during a Feb. 16 phone call. “It’s a very significant case,” Jones said, adding the jury’s recommendations are important to people in those communities.
All recommendations in the verdict are directed to the Government of Yukon, while six of the eight recommendations are directed to Little Salmon/Carmacks First Nation.
“We look forward to reconnecting with the Yukon Government on the Blackjack Inquest recommendations,” Chief Nicole Tom said in an email statement on Feb. 18 that did not address the specific recommendations.
“As we experience one health crisis after another in our territory and surrounding, we are pleased to work with the federal and territorial government on solutions to the devastating health issues.
“Along with many others that the Northern Yukon has lost due to straining access to a hospital, we must not lose sight that she was a granddaughter, daughter, sister, aunty, cousin, friend, citizen of Little Salmon Carmacks First Nation. Our community still feels the grief.”
During a Feb. 17 phone interview on another topic, Tracy-Anne McPhee, the minister of Health and Social Services, commented that the recommendations should be respected.
“I think that the process that was undergone and the result of that inquest was extremely important,” McPhee said. “We only hope that the process itself was healing for individuals that were involved.”
The communications director of Yukon government’s department of Health and Social Services said that an email statement from Feb. 10 that responds to seven of the eight recommendations is not attributed to a spokesperson because there is no one key person.
The Department of Health and Social Services statement said it has the lead role on four of the eight recommendations and “we have been taking action to address the recommendations.”
The territory’s Department of Highways and Public Works responded to the eighth recommendation.
Status of recommendations
Yukon government spokespeople from two departments updated the News on the recommendations in email statements earlier this month.
Recommendation 1 is to prioritize the hiring of a Nurse Practitioner in Carmacks. It’s directed to both the Yukon government (YG) and Little Salmon/Carmacks First Nation (LSCFN).
According to YG, a nurse practitioner was hired for the Carmacks Health Centre in September 2021. A full-time nurse practitioner serves Carmacks and another community, plus the government is working to hire more nurse practitioners in rural communities and competitions are underway to fill those positions.
Recommendation 2 is to develop a framework addressing patient advocacy by having a community health representative at the Carmacks Health Centre. This role should be carried out by a local First Nation, but was directed to both LSCFN and YG.
“We understand that Little Salmon/Carmacks First Nation has a Community Health Representative. A new position for a navigator or advocate has not yet been created,” said Carleen Kerr, spokesperson for Health and Social Services.
Recommendation 3 is directed to YG and asks for dedicated medical transportation to Whitehorse for Carmacks residents who are not sick enough for medevac but who are deemed to require a level of medical care that Whitehorse General Hospital can provide.
“We understand that Little Salmon/Carmacks First Nation has started a service but it has been paused due to COVID-19,” Kerr said.
Recommendation 4 is directed to YG and LSCFN, and asks for a review of terminologies used in charting and steps to eliminate the use of stigmatizing language.
There was some debate during the inquest investigating whether racism and stereotyping contributed to notes in Blackjack’s file describing her as “dramatic” and “on a bender.”
“There is an ongoing quality improvement process that was initiated prior to the inquest and continues to work to ensure language used in charting is respectful and inclusive,” Kerr said.
Recommendation 5 is directed to YG and LSCFN and asks for a fully staffed wellness hub in Carmacks that focuses on alcohol and drug dependency. The hub should address issues of social, mental, psychological health and child development.
“We currently have one Community Counsellor and one Support Worker in place to support Carmacks,” Kerr said. “We are currently working to recruit one additional Community Counsellor and one mental health nurse. Counsellors from other communities are able to take phone/virtual clients as needed.”
Recommendation 6 is directed to YG and LSCFN and asks for community education on health and dental care, available resources and how to access available services and funding.
The Yukon Children’s Dental Program provides services in Carmacks two to three times per year, according to YG.
“During these visits, oral health education is provided during the dental appointments,” Kerr said.
The itinerant dentist visits the community twice each year.
“During the past year, the dentist has reported that he has talked with many community members on the benefits of oral health care. These conversations have been with both patients at booked appointments and those that have made enquiries but are hesitant or feeling unsure in the dental setting. The itinerant dentist has worked to build trust and engagement with the community.”
Recommendation 7 asks both YG and the First Nation to develop a curriculum on cultural safety specific to LSCFN.
“We understand that Little Salmon/Carmarks First Nation has been working on this,” Kerr said.
Recommendation 8 is directed to YG and asks for investigation of lighting at community landing strips to extend flight hours for medevac.
“Government of Yukon commissioned a multi-year strategic investment strategy for the aviation network and the final report was released in 2021,” reads a statement from the Department of Highways and Public Works. “[The department] is currently reviewing the classification and service levels recommended in the report and will be reviewing with [Government of Yukon] emergency service providers.”
Contact Dana Hatherly at dana.hatherly@yukon-news.com