Yukon North Of Ordinary

News archive for December 18, 2013

Inquest negated need for a patient safety review, YHC explains

The Yukon Hospital Corp. says it didn’t initiate a patient safety review into the August 2012 death of Mary Johnny because the chief coroner called an inquest.

By Ainslie Cruickshank on December 18, 2013 at 3:41 pm

photo

Photo by Whitehorse Star

Val Pike

The Yukon Hospital Corp. says it didn’t initiate a patient safety review into the August 2012 death of Mary Johnny because the chief coroner called an inquest.

But the corporation hasn’t explained why a review wasn’t undertaken in the 15 months between Johnny’s death and the decision to move forward with the inquest.

A patient safety review was held into the death of Teresa Scheunert, who died about two months before Johnny in June 2012. The inquest will also investigate her death.

Both women died after receiving treatment at Watson Lake’s hospital.

Jason Bilsky, the hospital corporation’s CEO, was not available for an interview on the matter, but provided comments through spokesperson Val Pike.

“The Yukon Hospital Corporation has an assessment process that aids in determining the approach for the type of review for each death,” Pike said today.

“All deaths at the hospital are reviewed,” she said, noting the corporation conducted an internal review of Johnny’s death.

Asked why the hospital took different approaches when investigating the deaths of Scheunert and Johnny, Pike said,

“With the first death that occurred (Scheunert’s), we took action right away and did a patient safety review.”

That review was recently completed and the results were made available last week.

But in the case of Johnny, Pike said, “the coroner’s inquest was called, so it wouldn’t serve any purpose for (the hospital corporation) to do a patient safety review prior to a coroner’s inquest, because a coroner’s inquest would take priority.”

The question, however, remains: why was an external patient safety review investigating Scheunert’s death undertaken “right away,” but Johnny’s case was reviewed internally?

Pike couldn’t provide an answer to that question before this afternoon’s press deadline, saying Bilsky is in a board meeting all day.

Jan Stick, the NDP’s Health critic, raised the question of a patient safety review into Johnny’s death during question period Monday.

Health Minister Doug Graham said he did not know whether a patient safety review had been undertaken into Johnny’s death.

Johnny was 60 when she died on Aug. 9, 2012 of a bowel obstruction.

She had been admitted to the Watson Lake hospital, spending six days there before being transferred to Whitehorse General Hospital.

Chief coroner Kirsten Macdonald’s report into her death noted the initial diagnosis was “alcoholism” – despite abnormal vital signs and persistent complaints of lower abdominal pain, nausea and vomiting which smelled of stool.

It was only after three days in hospital that Johnny’s abdominal pain was investigated and x-rays were ordered.

“Even then, the finding of dilated loops of small bowel did not result in further investigation or intervention,” the coroner’s report reads.

Johnny arrived at the Whitehorse hospital suffering from shock and organ failure. A CT confirmed she’d been suffering from a bowel obstruction.

Scheunert was 47 when she died on June 21, 2012 at the Watson Lake hospital.

Three possible causes of death have been released since that time.

Initially, her family was told she’d died of a heart attack.

An autopsy later revealed she’d more likely died from a deadly cocktail of prescribed medications.

The patient safety review results released last week suggested she’d died from an irregular heart beat associated with sleep apnea.

The inquest into both deaths will be held March 24-April 4, 2014 in Whitehorse.

CommentsAdd a comment

June Jackson

Dec 18, 2013 at 6:49 pm

As usual, I speak only for myself..I don’t believe any place is safe when you are vulnerable and dependent on others to look after you.  In these cases? People died. Blame should be laid, action taken. 

It’s not like they slid on the ice and had an accident..These women were 60 and 47 years old AND in care in a medical facility.  They were there to live, but they died. I didn’t know either one of these women, however, the scenarios described above apply to 3/4s of the Yukon, and should it be me, or mine.. I want someone to care.

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