The Watson Lake Hospital did not do enough to prevent the death of a Yukon nurse, according a coroner’s report.
Teresa Ann Scheunert died on June 21, 2012 at the age of 47 from mixed drug toxicity, according to the document signed by chief coroner Kirsten Macdonald.
The death was ruled accidental.
However, medical professionals did not do enough to mitigate the risks associated with the pain-killing drugs administered to Scheunert during her stay at the Watson Lake Hospital, the report states.
“It would appear from the facts that the system let down Ms. Scheunert. 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.
Scheunert was admitted to the Watson Lake Hospital on June 7, 2012.
She complained of back pain that she said was related to an injury she incurred during a CPR course a couple of months before.
She was employed as a registered nurse at the Watson Lake Hospital.
During her stay she was administered drugs to manage the pain, and plans were made for her to get an MRI and see a specialist.
But those steps should have been taken earlier, according to the report.
“It appears there was limited planning of Ms. Scheunert’s care beyond managing the immediate symptomology.”
On the morning of June 21, 2012 staff found Scheunert unresponsive in her hospital bed.
“Despite vigorous resuscitative efforts, she was pronounced deceased at 11:17.”
The coroner has made 12 recommendations to the Yukon Hospital Corporation, including reviewing this particular incident and implementing policies for managing the risk associated with medications.
The corporation did not respond to a request for comment by press time.
Scheunert left behind two daughters and four grandchildren. She had lived in Watson Lake for about two years before her death.
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