Safety review contradicts coroner’s report

A patient safety review has found that it was an irregular heartbeat that caused the death of Teresa Ann Scheunert in Watson Lake Hospital.

A patient safety review has found that it was an irregular heartbeat that caused the death of Teresa Ann Scheunert in Watson Lake Hospital.

An earlier coroner’s report, based on evidence from a forensic toxicologist and a forensic pathologist, had found that Scheunert had died from a toxic mix of chemicals administered to her while in hospital.

Scheunert, a Watson Lake nurse, was admitted to the hospital on June 7, 2012, for back pain related to a workplace injury. She died June 21, 2012.

Toxicological testing found that fentanyl in her blood was “within a range reported in lethal cases.”

But Dr. Robert Robson, a Manitoba doctor with 12 years of experience conducting patient safety reviews, said that drug overdose is inconsistent with the manner of Scheunert’s death, based on interviews with those who gave her care.

A nurse reported an hour before she died that Scheunert was sleeping peacefully and breathing normally, said Robson. That doesn’t align with someone who is overdosing on drugs, he said.

The death was sudden and unexpected, based on all the evidence, said Robson.

Cardiac arrhythmia therefore is a more reasonable explanation for the death, he said. That condition has to do with a irregular heartbeat, and it can cause sudden death.

Unfortunately, because it has to do with chemical impulses to the heart, there is no way to prove after the fact that a cardiac arrhythmia happened.

Robson suggested that the arrhythmia was likely associated with sleep apnea.

There was nothing in Scheunert’s clinical presentation that would have alerted her caregivers to a problem with sleep apnea, although she did at times snore loudly, said Robson.

Although her care may not have been perfect, decisions made by doctors and nurses did not contribute directly to Scheunert’s death, he said.

“I could find no direct contributing factors that were linked to Teresa Scheunert’s death based on decisions or actions taken by the physicians or the staff at Watson Lake Hospital.”

Increases in doses of pain medication were done for “very understandable reasons,” he said.

The patient safety review differs in its findings from the coroner’s report in fewer ways than is obvious at first glance.

Robson said that pain medication was likely a contributing factor to Scheunert’s death, just not the immediate cause.

And the coroner’s report notes that Scheunert had an enlarged heart, which can predispose one to cardiac arrhythmias. The drugs could contribute to cardiac arrhythmia.

The major difference between the findings is that the coroner found the death was accidental but that the system let Scheunert down, while Robson found that actions of both the medical staff and the hospital corporation were appropriate.

The coroner included a number of recommendations about safeguards for administering high-alert medications, while Robson’s recommendations focused on developing a stronger legislative framework to trigger patient safety reviews more often.

Kirsten Macdonald, chief coroner, said it will ultimately be up to a forthcoming coroner’s inquest to determine how Scheunert died, and what contributed to her death.

An inquest has been called for March in Scheunert’s death, and into the death of Mary Johnny, who also died after receiving care from the Watson Lake Hospital.

The coroner’s inquest will start from scratch, said Macdonald.

“My opinion and my findings are no longer relevant. It’ll be for the jury to decide.”

A jury of six will hear all of the evidence and come to its own conclusions about the cause of death and recommendations, she said.

Macdonald will preside over the inquest, and the family will get a chance to call witnesses and ask questions.

But the latest confusion caused by the patient safety review has strengthened Scheunert’s family’s call for a public inquiry, not a coroner’s inquest, said Crystal Thomas, Scheunert’s daughter.

“We have very little trust that the public interest is being served right now.”

A coroner’s inquest is limited to examining the facts of the death and presenting recommendations about how to prevent similar deaths in the future.

A public inquiry can have a much broader mandate to examine issues of public interest.

The family has questions not only about Scheunert’s death, but about how things were handled in the wake of it, said Thomas.

For example, they want to know why it took four days to get an autopsy, which happened only after the family demanded it.

The family would also like to ask questions of the coroner, but they will not be able to, since Macdonald intends to preside over the inquest.

A coroner’s report was released on June 14, 2013, only to be retracted with a few hours. A new report was released on July 9 with significant changes.

The coroner has explained that new evidence came to light that required the changes.

The Opposition NDP has also continued to call for a public inquiry.

“The more we get into this, the more questions there are,” said MLA Jan Stick.

She was “gobsmacked,” “shocked” and “appalled” at the findings of the patient safety review, she said.

The review appeared to be more concerned with the cause of death than with actual issues of patient safety, said Stick.

The family can’t find a lawyer to represent them at the inquest, and couldn’t afford one anyway, said Thomas.

“Everything is on our own dime, including our time,” said Wanda Zimmerman, Scheunert’s sister.

“I just give kudos to the family for sticking to this,” said Stick. “They must be so tired and drained by this, and yet they keep moving forward.”

Contact Jacqueline Ronson at

jronson@yukon-news.com

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

Just Posted

Crystal Schick/Yukon News
Sandy Silver announces the territorial election in Whitehorse. Silver is seeking a second term as premier and third term as Klondike MLA. (Crystal Schick/Yukon News)
Getting to know Sandy Silver and the Yukon Liberal platform

Yukon Liberal Leader Sandy Silver is vying for a second term as… Continue reading

Whitehorse City Hall (Joel Krahn/Yukon News file)
This week at city hall

A look at issues discussed by Whitehorse city council at its April 6 meeting.

Chief Medical Officer of Health Dr. Brendan Hanley issued a public exposure warning on April 9. (Crystal Schick/Yukon News file)
COVID-19 exposure notice issued for Air Canada flight

The Yukon’s Chief Medical Officer of Health Dr. Brendan Hanley issued a… Continue reading

Wyatt's World
WYATT’S WORLD

Wyatt’s World for April 9, 2021.… Continue reading

Point-in-Time homeless count planned this month

Volunteers will count those in shelters, short-term housing and without shelter in a 24-hour period.

The Yukon’s new ATIPP Act came into effect on April 1. Yukoners can submit ATIPP requests online or at the Legislative Assembly building. (Gabrielle Plonka/Yukon News file)
New ATIPP Act in effect as of April 1

The changes promise increased government transparency

A new conservancy in northern B.C. is adjacent to Mount Edziza Provincial Park. (Courtesy BC Parks)
Ice Mountain Lands near Telegraph Creek, B.C., granted conservancy protection

The conservancy is the first step in a multi-year Tahltan Stewardship Initiative

Yukon RCMP reported a child pornography-related arrest on April 1. (Phil McLachlan/Black Press file)
Whitehorse man arrested on child pornography charges

The 43-year-old was charged with possession of child pornography and making child pornography

Team Yukon athletes wave flags at the 2012 Arctic Winter Games opening ceremony in Whitehorse. The postponed 2022 event in Wood Buffalo, Alta., has been rescheduled for Jan. 29 to Feb. 4, 2023. (Justin Kennedy/Yukon News file)
New dates set for Arctic Winter Games

Wood Buffalo, Alta. will host event Jan. 29 to Feb. 4, 2023

Victoria Gold Corp. has contributed $1 million to the First Nation of Na-cho Nyak Dun after six months of production at the Eagle Gold Mine. (Submitted/Victoria Gold Corp.)
Victoria Gold contributes $1 million to First Nation of Na-cho Nyak Dun

Victoria Gold signed a Comprehensive Cooperation and Benefits Agreement in 2011

Chief Medical Officer of Health Dr. Brendan Hanley speaks to media in Whitehorse on October 30, 2020. Hanley is now encouraging Yukon to continue following health regulations, noting it could still be some time before changes to restrictions are made. (Crystal Schick/Yukon News file)
No active COVID cases in Yukon

Hanley highlights concerns over variants, encourages vaccinations

Most Read