The Yukon government will review its policies and procedures for transporting patients at community health centres to Whitehorse General Hospital, as recently recommended by the territory’s coroner.

The recommendation, as well as seven others, was put forward by the Yukon Coroners Service following an inquiry into the death of Cynthia Blackjack.

The 31-year-old woman was medevaced from Carmacks to Whitehorse last November.

“Certainly, we accept all of her recommendations,” Pat Living, a spokeswoman for the Department of Health and Social Services, told the Star this morning.

“We will be looking at our clinical practice guidelines to make sure our medevacs are timely and appropriate.”

Blackjack died of multi-organ failure as a result of hyperacute liver failure at the Erik Nielsen Whitehorse International Airport.

The coroner’s report also found she had 10 abscessed teeth and severe dental decay.

The pathologist speculated that regular usage of ibuprofen and acetaminophen for dental pain, combined with chronic alcohol consumption, might have been the reason for Blackjack’s liver failure.

On the two days prior to her death, she called the Carmacks Health Centre, complaining of tooth pain.

She went in to the centre on Nov. 6, and staff noted she had dental decay and slight swelling on the left side of her face.

They tentatively diagnosed her with alcohol-induced gastritis, and gave her medication for nausea and morphine for pain.

Staff tried to find her a ride to Whitehorse, but were unsuccessful.

The centre discharged her at 11:05 a.m., telling her to return if she couldn’t find a ride to Whitehorse by 4:30 p.m.

The following day, a family member called the health centre to say that Blackjack was disoriented and yelling out in pain. She was transported to the centre, where they drew blood for tests that had to be done in Whitehorse.

The results of these tests were only reported after her death.

At 11:15 that morning, staff decided to medevac Blackjack to Whitehorse. The medevac team – two paramedics and a physician – arrived in Carmacks at 1:35 p.m.

A blood transfusion was delayed because the wrong type of IV tubing had been brought to Carmacks.

The medevac team determined that Blackjack should be intubated for travel.

That was delayed because there was a lack of pressure oxygen to attach to the health centre’s ventilator.

The first ventilator tubing circuit also failed.

There was no working suction apparatus at the centre, so a manual device had to be used instead to intubate.

Blackjack and the team left Carmacks at 5:11 p.m., six hours after the decision was made to medevac her out of the community.

The paramedics and physician weren’t able to use the mechanical ventilator on board because of several pressure alarms, so Blackjack was ventilated using a hand-held device.

About 10 minutes before landing in Whitehorse, Blackjack’s heart began to slow. At 5:40 p.m., her vital signs were lost and the team started CPR.

The report says that the noise of the aircraft inhibited their ability to confirm proper ventilation.

Blackjack was pronounced dead at 5:59 p.m.

Chief coroner Kirsten Macdonald notes several “significant factors” in the case.

They included the fact that the wrong tubing for the blood transfusion was brought by the transport team, that airway suction equipment at the health centre wasn’t functioning, and that the medical team hesitated to intubate her, despite her reduced level of consciousness, signs of shock and slow respiratory rate.

She also states that the assessment and management of Blackjack by the health centre’s staff on the days leading up to the medevac on Nov. 7 was “reasonable given the presenting symptoms, medical and social history.”

Jan Stick, the NDP’s Health and Social Services critic, said today the recommendations should be taken seriously and properly addressed.

“These are easy fixes,” she said. “These aren’t onerous. These are common sense.

“I don’t know what the reasons were for those (equipment) failures but it impacted somebody’s life. She died. Whether the (failures and delays) were the direct result, I don’t know, but it’s concerning.”

Living said that some of the recommendations are part of the department’s ongoing campaigns and general awareness, like reminding staff to follow a checklist to ensure equipment is functioning.

As part of its review, which she said will begin shortly, the department will review clinical practice guidelines at its health centres.