Whitehorse Daily Star

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Chief Coroner Kirsten Macdonald

Family petitions court for inquest into woman’s death

The Little Salmon-Carmacks First Nation and the family of Cynthia Blackjack want the Yukon’s chief coroner to hold an inquest into the death of the First Nations woman two years ago.

By Pierre Chauvin on October 9, 2015

The Little Salmon-Carmacks First Nation and the family of Cynthia Blackjack want the Yukon’s chief coroner to hold an inquest into the death of the First Nations woman two years ago.

Blackjack died on Nov. 7, 2013 on a medevac flight from Carmacks to Whitehorse.

She died of multi-organ failure due to hyperacute liver failure, according to Chief Coroner Kirsten Macdonald’s report.

Macdonald investigated her death.

The woman’s mother, Theresa, filed the petition with the Yukon Supreme Court on Oct. 1.

She wants an inquest to be held.

Inquests are court-like proceedings, open to the public, where a jury of six community members hear witnesses and evidence about a death.

They are tasked with determining the exact circumstances of the death and making recommendations.

Those recommendations are not legally binding.

Macdonald did not recommend an inquest be held.

It’s now up to Yukon Supreme Court to review that decision.

“The chief coroner’s decision to not hold an inquest does not address (...) the systematic failures in health care provision to citizens of (the) Little Salmon-Carmacks First Nation,” wrote Theresa in her petition.

She claims the inquiry Macdonald conducted “left many questions unasked or unanswered.”

Macdonald did not contact the First Nation during her investigation, Theresa wrote in her petition.

As part of the petition, an affidavit from Rachel Byers, the First Nation’s director of health and social programs, was filed.

“I am aware of systemic problems in the provision of health care services to members of our First Nation,” she wrote.

Macdonald’s inquiry did not make any recommendations to address the “root causes of deficiencies and inequalities in the provision of health care services to members of our First Nation,” she added.

“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 result,” she said.

Theresa also initiated a civil lawsuit in November 2014 against the Yukon government and medical staff who were in the medevac flight, alleging negligences that ultimately cost her daughter’s life.

That civil litigation is still ongoing.

Cynthia came to the health centre on Nov. 6, 2013. She had called the day before complaining about dental pain.

The staff noted she had dental decay and swelling from the left side of her face.

She received a tentative diagnosis of alcohol-induced gastritis and was given medication for the nausea and morphine for the pain.

The coroner’s report said she was told to go to Whitehorse for more thorough testing.

She was told to return to the health centre if she couldn’t find a ride.

On Nov. 7, a family member called the health centre to say Cynthia was yelling out of pain.

She was brought to the centre and the decision to medevac her to Whitehorse was made.

The medevac flight left Carmacks at around 5:11 p.m., six hours after the decision to medevac Cynthia was taken, the chief coroner noted.

Ten minutes before landing in Whitehorse, Cynthia’s heart slowed down.

“(It) can be a serious problem if the heart doesn’t pump enough oxygen-rich blood to the body,” Macdonald noted.

At 5:40 p.m., vital signs were lost and CPR was started.

Nineteen minutes later, she was pronounced dead.

Macdonald noted a number of failures in the medical system throughout Blackjack’s care.

Wrong tubing on the plane delayed Cynthia’s blood transfusion by the medevac team.

Some equipment at the Carmacks health centre malfunctioned that day when the decision was made to intubate Cynthia.

“Airway suction equipment at the health centre was not functioning and this delayed (and could have compromised) the airway management of Ms. Blackjack,” Macdonald noted in her judgment of inquiry.

Staff also hesitated to intubate her, “despite her presentation of a decreased level of consciousness, signs of shock, a respiratory rate of 40-50, and poor oxygen saturation,” Macdonald noted.

The triage, assessment and management of Cynthia in Carmacks though was “reasonable given the presenting symptoms, medical and social history,” the chief coroner also noted.

She made eight recommendations to the Yukon government, including a review of procedures when transferring patients from community health care centers to Whitehorse.

A case management conference is scheduled for Nov. 3.

Comments (5)

Up 0 Down 7

yukon56 on Oct 15, 2015 at 7:11 pm

Cynthia came to the health centre on Nov. 6, 2013. She had called the day before complaining about dental pain.
The staff noted she had dental decay and swelling from the left side of her face.
She received a tentative diagnosis of alcohol-induced gastritis and was given medication for the nausea and morphine for the pain.

The coroner’s report said she was told to go to Whitehorse for more thorough testing.
She was told to return to the health centre if she couldn’t find a ride.
Couldn't a family member or anyone from her band take her the hour and a half to Whitehorse? Seems more than the system let her down.

Up 37 Down 45

Respect and making a difference on Oct 13, 2015 at 11:51 pm

These tragedies with FN people don't have to play out the way they do. 'Why not locals?', you ask why don't people become educated in the medical field and go back to their community? Raymond Silverfox's daughter is becoming a nurse. She is ready to get her education and go back to her community and make a difference. The Raymond Silverfox story is absolutely disgusting, and you wouldn't think that something so racial and horrific could happen here…but it did. Cynthia is dead and it is due to inadequate medical care and attention. Damn right an inquest needs to happen. It needs to happen for all of the FN people we lose, especially when the circumstances of the death are neglectful or negligent on the part of authorities or health care personal. And I don't care about the alcohol issues and blaming it on that--people are people and everybody deserves to be treated in a dignified way.

Up 46 Down 32

Why Not Locals? on Oct 13, 2015 at 6:31 am

My understanding is that it is difficult to get health professionals from down south to go and more importantly stay in these small communities due to a variety of reasons I won't get into here. Why don't people born and raised in these smaller places who now have every opportunity available for funded education go to nursing school and come home to a good profession while serving thier fellow residents and community? There have been opportunities for local residents to go to college and university in medical fields for decades now.

Up 70 Down 44

Moose101 on Oct 11, 2015 at 8:06 am

I agree with your last statement where are the hundred of millions of dollars that has been spent on First Nations ???? It has been given to the bands for housing social programs and education to the tone of triple what is spent per capita on the general population .

Up 62 Down 75

Why? on Oct 9, 2015 at 11:05 pm

The first time I read about this I didn't really believe it. But after reading:
"Airway suctioning equipment at the health center was not working..."
"Wrong tubing on the plane delayed Cynthia's blood transfusion by the medical team."
"Staff hesitated to intubate her...
But it was reasonable given the presenting symptoms, medical and SOCIAL HISTORY."

HUH?

That is why Raymond Silverfox, also from Carmacks, died in RCMP cells, the "social history" of Yukon Indian people, (now known as "first nations.") Raymond died of Sepsis (blood poisoning) but it was not recognized because of his "social history." He was a Canadian Indian. And of course, that means a drunk one. His illness was quickly diagnosed as "drunk."

After they watched him vomit over 20 times, he died in a pool of vomit, piss and s**t. Or, for more tender ears, in the words of the coroner, vomitus, urine and feces. After he was essentially dead, people wanted to help him. Because we all want to help "first nations", right? It is after all, the politically correct thing to do.

Hundreds of people were upset over Trevor, the dog. He just didn't deserve to die they said. And when the red fox was killed at the airport in Whitehorse. "The incident faced public outcry after a letter, published in the Whitehorse Star and recounted on social media, claimed the employees tried to run over the fox and then kicked it to death." Like the saying goes, it was a good thing it wasn't a Silverfox. Or it would have gone unnoticed.

Which brings me back to Cynthia. And the red necks that read this and want to write about the "millions of taxpayers dollars" that are spent on these "Indians."

I ask you this: Where is it?

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