The family of Teresa Ann Scheunert, who died in the Watson Lake Hospital last year, is calling for an inquest into her death.
“Our ultimate goal is that the system that failed our mom will be fixed, so this type of tragedy is prevented in the future,” said Crystal Thomas, Scheunert’s oldest daughter, at a press conference yesterday.
Scheunert had been working as a nurse at the Watson Lake Hospital for three years when she was admitted for back pain related to an injury she sustained during a CPR course a few months before.
She died two weeks later, on June 21, 2012, from mixed drug toxicity at the age of 47, according to the coroner’s report.
“It would appear from the facts that the system let down Ms. Scheunert,” the report states. “More could have been done to document the administration, monitoring and evaluation of the effects or effectiveness of medications administered to Ms. Scheunert.
“Even when patient is noted to be ‘wobbly’ and ‘unsteady’ it is unclear what action, if any, was taken to review the effect of medications and monitor any subsequent clinical effects.”
A post-mortem toxicological analysis found that Scheunert had “a significantly elevated concentration of fentanyl,” a pain-killing drug, in her system when she died.
The levels were “within a range reported in lethal cases.”
Multiple other pain medications were also detected in her system.
The day before she died, her prescribed dosage of fentanyl doubled.
“On review of the notes, there appears to be a lack of clear documentation regarding the calculations for the increased dose of fentanyl,” according to the report.
The death was ruled accidental.
But documents released yesterday reveal that two versions of the coroner’s report were published.
The family received the first on June 14, 2013.
Within five hours, chief coroner Kirsten Macdonald called them and said that the report would have to be redacted and revised because of a possible error, said Thomas.
They were given no specific information about what the problem was, she said.
The second and final report was released on July 9, 2013, nearly a month later.
Many changes and redactions had been made, compared with the original.
For example, “there was a gap identified” was replaced with “on review, it appears that more could have been done.”
“There was a lack of documentation” became “there appears to be a lack of clear documentation.”
And a whole section related to prescriptions that Scheunert filled at the pharmacy in Watson Lake in the weeks before her death was omitted.
Recommendations related to patients administering their own medication were deleted as well.
In a statement released to the media, the chief coroner explained that the report was retracted because new facts came to light after it was released.
Specifically, there was a question as to whether or not Scheunert had taken a subsequent dose of one medication, according to the statement.
The coroner could not be reached for further comment by press time.
“This hurts just as much today as it did the unforgettable day that it happened,” said Chandre Burchell, Scheunert’s second daughter. “Things will never be the same.”
Scheunert’s sister, Wanda Zimmerman, also attended the press conference.
She said that losing Scheunert meant losing the last link to her immediate family, since her brother and parents had already passed away.
The family “knocked on many doors” following the death, looking for answers, said Thomas.
But they were “stonewalled for months,” she said.
“We were told over and over again to wait for the coroner’s report,” said Thomas.
But since the report took so long, the family is now limited in what actions they are able to take, she said.
“After their mother, their sister was let down by the system, they also had to struggle with the same system to have their questions answered,” said MLA Jan Stick at the press conference, which was hosted by the NDP.
Members of the NDP questioned the government about the two conflicting reports in the legislature Tuesday.
Health Minister Doug Graham said he trusts the processes in place to deal with incidents like this when they come up.
“I find this whole discussion somewhat distasteful because there are processes in place, be it with the Yukon Medical Council, be it with the Yukon Registered Nurses Association or through an appeal process. There are processes in place to address the concerns of the family throughout this unfortunate circumstance and I think those processes should be used.”
He also said that he would correspond with the Yukon Hospital Corporation to find out what has been done and what will be done in the future.
The hospital corporation did not respond to a request for comment by press time.
Contact Jacqueline Ronson at