Government acting on coroner’s recommendations

Yukon's minister of health says his department is acting on the coroner's recommendations made following the death of a Carmacks woman.

Yukon’s minister of health says his department is acting on the coroner’s recommendations made following the death of a Carmacks woman.

Coroner Kirsten Macdonald made eight recommendations after 31-year-old Cynthia Blackjack died while being medevaced from Carmacks to the Whitehorse General Hospital.

“She said there are a few other things that might be improved. And we agree. There’s always things that can be improved, and that’s what we’re going to do,” said Doug Graham.

Blackjack was a familiar face at the Carmacks Health Centre. She called in with dental pain on Nov. 4 and 5, 2013.

After her death, a dental examination found 10 abscessed teeth and rampant tooth decay.

On Nov. 6 she was seen at the health centre and advised to try and get a ride to Whitehorse and come back if she couldn’t find anyone.

“The medical triage, assessment and management of Ms. Blackjack at the health centre in Carmacks November 4, 5 and 6 was reasonable given the presenting symptoms, medical and social history,” Macdonald said.

On Nov. 7, family called the health centre, saying Blackjack was disoriented and yelling out in pain. Blood was taken for tests, but the samples had to be sent to Whitehorse for analysis.

It was decided she would be medevaced to Whitehorse. Her heart slowed down about 10 minutes before arriving at the hospital.

The cause of her death was ruled to be the failure of her liver and other organs.

The pathologist speculated that Blackjack’s use of ibuprofen and acetaminophen on a regular basis for her dental pain, combined with chronic alcohol use, may have contributed to her liver failure.

In her report, Macdonald lists a number of significant factors in Blackjack’s death. These include that the wrong IV tubing was brought for a blood transfusion and that the health centre’s suction machine did not work so Blackjack had to be suctioned manually.

The eight recommendations include that point-of-care blood testing be made available in rural communities and that health centres have functioning suction devices at all times.

“Yes, the first suction device they used didn’t work properly, but they have backups. So they immediately went to their backup. It worked properly and there was very, very little time lost,” Graham said.

The minister said staff in the communities have regularly-scheduled telehealth meetings. He said management will be highlighting the importance of the quality assurance checklist. That list instructs staff to check that all the equipment is working.

But when it comes to whether or not blood testing should be done in the communities, Graham said that’s something that will take time to look into. It’s likely an expensive proposition, and there may be problems when it comes to the ongoing skilled staff that would be needed, he said.

“We’ll have to do an evaluation and the department is in that process right now. We’re going to take a look at it, but we’re not going to rush out and do it in all community health centres.”

Similar to the issues with the suction device, the wrong tubing for the blood transfusion was replaced quickly, Graham said.

“The first tubing that they took was incorrect. But again, they have backup systems. So again, there was a short delay but they did have the correct equipment necessary.”

In Macdonald’s report, she points out that “the intubation of Ms. Blackjack was delayed because there was a lack of pressure oxygen to attach to the ventilator at the heath centre, and by failure of the first ventilator tubing circuit.”

A second system was set up, and worked.

Graham said health centres don’t have ventilators.

“The only thing I can think of is that’s part of the equipment that the EMS folks brought with them because we don’t have ventilators at health centres,” he said.

A call to Macdonald for clarification was not returned in time for today’s deadline.

Graham said Yukon EMS is currently reviewing its practices.

Anyone involved with a medevac is properly trained, he said.

“The money is there to provide that education and to the best of our knowledge, the people involved with this one were all skilled, trained people”

Contact Ashley Joannou at

ashleyj@yukon-news.com

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

Just Posted

Whitehorse musher Hans Gatt crosses the 2021 Yukon Journey finish line in first place at approximately 10:35 a.m. on Feb. 26. (Gabrielle Plonka/Yukon News)
Hans Gatt wins inaugural 2021 Yukon Journey

The Yukon Journey, a 255-mile race from Pelly Crossing to Whitehorse, kicked off on Feb. 23

In a Feb. 17 statement, the City of Whitehorse announced it had adopted the what3words location technology used for emergency response. (Haley Ritchie/Yukon News)
Three words could make all the difference in an emergency

City of Whitehorse announced it had adopted the what3words location technology

Jesse Whelen, Blood Ties Four Directions harm reduction councillor, demonstrates how the organization tests for fentanyl in drugs in Whitehorse on May 12, 2020. The Yukon Coroner’s Service has confirmed three drug overdose deaths and one probable overdose death since mid-January. (Crystal Schick/Yukon News file)
Three overdose deaths caused by “varying levels of cocaine and fentanyl,” coroner says

Heather Jones says overdoses continue to take lives at an “alarming rate”

Wyatt's World for Feb. 24, 2021.
WYATT’S WORLD

Wyatt’s World for Feb. 24, 2021.

Susie Rogan is a veteran musher with 14 years of racing experience and Yukon Journey organizer. (Yukon Journey Facebook)
Yukon Journey mushers begin 255-mile race

Eleven mushers are participating in the race from Pelly Crossing to Whitehorse

Legislative assembly on the last day of the fall sitting in Whitehorse on Nov. 22, 2018. As the legislature prepares to return on March 4, the three parties are continuing to finalize candidates in the territory’s 19 ridings. (Crystal Schick/Yukon News file)
Nine new candidates confirmed in Yukon ridings

It has been a busy two weeks as the parties try to firm up candidates

David Malcolm, 40, has been charged with assaulting and attempting to disarm a police officer after an incident in Whitehorse on Feb. 18. (Phil McLachlan/Capital News)
Man resists arrest, assaults officer

A Whitehorse man has been charged with assaulting and attempting to disarm… Continue reading

Yukon Energy in Whitehorse on Aug. 4, 2020. A site on Robert Service Way near the Alaska Highway has been selected as the future home of Yukon Energy’s energy storage project. (Crystal Schick/Yukon News file)
Site selected for Yukon Energy battery project

Planned to be in service by the end of 2022

The Yukon government and the Yukon First Nations Chamber of Commerce have signed a letter of understanding under the territory’s new procurement policy. (Crystal Schick/Yukon News file)
First Nation business registry planned under new procurement system

Letter of understanding signals plans to develop registry, boost procurement opportunities

US Consul General Brent Hardt during a wreath-laying ceremony at Peace Arch State Park in September 2020. Hardt said the two federal governments have been working closely on the issue of appropriate border measures during the pandemic. (John Kageorge photo)
New U.S. consul general says countries working closely on COVID-19 border

“I mean, the goal, obviously, is for both countries to get ahead of this pandemic.”

Legislative assembly on the last day of the fall sitting in Whitehorse on Nov. 22, 2018. (Crystal Schick/Yukon News file)
Start of spring sitting announced

The Yukon legislature is set to resume for the spring sitting on… Continue reading

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

A look at decisions made by Whitehorse City Council this week

Most Read