The Supreme Court of Yukon has ordered an inquest held into the death of Cynthia Blackjack.

Justice Ron Veale made the ruling Monday following a request by Theresa Anne Blackjack and the Little Salmon-Carmacks First Nation (LSCFN) that an inquest be ordered to examine the role systemic racism may have played in her death.

Cynthia Blackjack, 29, died Nov. 7, 2013 while being medevaced from Carmacks to Whitehorse.

In his reasons for decision, Justice Veale wrote that chief coroner Kirsten Macdonald took a “very narrow interpretation” of the Coroner’s Act when she decided against an inquest based on allegations of systemic racism.

“While teasing out and identifying factors that have contributed to or caused someone’s death are important, inquests are also a means of ensuring public confidence in government services and the overall health and safety of communities,” he wrote.

“The community must have an opportunity to address their concerns in a public way at an inquest.”

Following Cynthia’s death, the chief coroner, who identifies as Metis, began an investigation that included having her teeth examined by a forensic dentist, seizing and testing blood taken at the Carmacks Health Centre, and conducting interviews with people who had seen her on the day of her death.

However, the investigation did not identify Cynthia as a First Nations member.

In a five-page Judgement of Inquiry on Aug. 4, 2014, Macdonald concluded that Cynthia’s death was “natural” and a result of multi-organ failure due to hyperacute liver failure of an unknown cause.

In June 2015, despite requests by the LSCFN and Cynthia’s mother, Macdonald decided against an inquiry.

Theresa Anne Blackjack wrote in an affidavit filed with the court, “When she died, I struggled to get answers from the relevant authorities.”

“I feel the chief coroner’s inquiry left many questions unasked and unanswered.”

However, Macdonald, represented by Richard Buchanan, argued in court there was no evidence linking systemic racism to Cynthia’s death.

Justice Veale wrote this argument ignores broader wording in the Coroner’s Act and that reasons for delayed ambulance service, which were not investigated, are reason alone for an inquest.

He is also recommending that a territorial court judge be appointed to preside over the inquest.

As well, he says the First Nation, Cynthia’s family and the director of health and social programs should be included in the investigation.

The day before her death, Cynthia visited the Carmacks Health Centre complaining of a toothache, abdominal pain and vomiting.

She was known to health centre staff as struggling with alcoholism, and was tentatively diagnosed with alcohol-induced gastritis and treated accordingly.

But in her affidavit, Cynthia’s mother says she doesn’t understand this diagnosis, as her daughter had stayed sober at the time.

Cynthia was also urged to make her way to Whitehorse General Hospital, a two-hour drive, or return to the centre later the next day.

The next morning, she was brought back to the centre in an “agitated and disoriented state” by ambulance.

There were approximately 80 minutes between the time the ambulance was called and when it arrived.

At 11:15 a.m., it was decided that Cynthia would be medevaced to Whitehorse.

But treatment was delayed due to wrong tubing for a blood transfusion on the plane, and the failure of ventilator equipment at the centre.

The flight left Carmacks at around 5 p.m., but Cynthia lost vital signs 10 minutes outside of Whitehorse. She was pronounced dead just before 6 p.m.

This is not the first time the LSCFN has raised concerns about discrimination against First Nation members in the health care system.

In February 2011, it wrote to the Yukon Medical Council about concerns with the dispatch of ambulance service.

An affidavit by Rachel Byers, the director of health and social programs for the LSCFN, filed in the fall of 2015 states, “I am aware that various stereotypes play a big role in the manner how health care services are provided and that these stereotypes are the root causes of the underlying deficiencies in health care services with deadly results.”