The territory's chief coroner says "the system let down” a Watson Lake registered nurse who died in her own hospital from mixed drug toxicity.

Teresa Ann Scheunert died June 21st, 2012 at the local hospital where she was a patient dealing with severe pain from an earlier injury.

It was originally thought that the 47-year-old died of a heart attack but an autopsy later revealed she had a toxic level of various pain medications in her system.

Scheunert had been under a doctor's care since April 4, 2012 for severe back pain she suffered after injuring herself allegedly during a CPR course.

She was eventually admitted to the Watson Lake Hospital for pain management and assessment.

In her report released today, chief coroner Kirsten Macdonald details Scheunert's experience at the hospital where she was given a variety of medications to manage her pain while she waited for approval to go Outside and see a specialist.

During her hospitalization, Scheunert received opiates for pain management.

She was initially given IV morphine and a patch containing 75 mcg/hr of fentanyl on the evening of June 8, 2012. Doctor's orders were to apply the patch every 72 hours.

"On June 10, 2012, according to hospital records, the patient was ‘noticeably unsteady on her feet' and ‘wobbly on her feet.' Ms. Scheunert also complained of feeling ‘doped' on the same day,” Macdonald writes.

Scheunert was given fentanyl patches on June 14 and 17. On the 18th she reported feeling "groggy” and "wacked out.”

Scheunert was also on other medication on top of fentanyl. On June 19th she was given two shots of fentanyl and three doses of hydromorphone.

On June 20, 2012 five doses of hydromorphone were given to her, and new fentanyl patches, double the original dose, were applied as per a doctor's order.

"On review of the notes, there appears to be a lack of clear documentation regarding the calculations for the increase dose of fentanyl,” Macdonald said.

At about 11 a.m. on June 21st she was found unresponsive in her hospital bed.

Macdonald notes best practices for "high-alert medications” like fentanyl is to have a tiered structure to confirm that medication is the right dose for the right patient.

"On review, it appears that more could have been done at Watson Lake Hospital with regard to high-alert medications and using a multi-faceted systemic approach to insure patient safety involving the physician, nurses and pharmacists,” Macdonald said.

Toxicology tests done after Scheunert's death found that she had a significantly elevated concentration of fentanyl in her system "within a range reported in lethal cases. Multiple other medications (including other pain medications with sedative side effects) were also detected.”

Fentanyl can cause respiratory depression, hypotension, seizures, coma and death at an increased concentration, especially in the face of multiple other medications with similar sedative effects, the coroner noted.

"There is currently no ability at Watson Lake Hospital to monitor the blood levels of fentanyl/norfentanyl in patients. The Watson Lake Hospital does not have the ability to do serum screening for medications such as gabapentin or fentanyl.”

In her conclusions Macdonald writes: "A patient at any hospital in Yukon has a stated right to participate in their treatment and have pain managed to the safest extent possible. I have no doubt Ms. Scheunert was trying to participate in her treatment or, at the very least, efforts towards diagnosis.

"It appears from the time pain started on March 31, 2012 to the date of her death on June 21, 2012, almost 12 weeks passed without a diagnosis or substantial treatment plan.

"It would appear from facts that the system let down Ms. Scheunert. More could have been done to document the administration, monitoring and evaluation of the effects and effectiveness of medications administered to Ms. Scheunert.

"Even when the patient is noted to be ‘wobbly' and ‘unsteady' it is unclear what action, if any, was taken to review the the effect of medications and monitor any subsequent clinical effects.

"The gaps in this case are systemic issues. It is the system that is responsible for reducing the risk of medication-related deaths.

"The system has the highest responsibility to ensure the policies are in place and enforced and are consistent with standards and best practices in the area of medication management.

"There is a significant opportunity to learn from this tragic incident and to enhance the culture of safety at the Watson Lake Hospital.”

In the end the coroner ruled the death accidental but made 12 recommendations to the Yukon Hospital Corporation.

These include: conducting an independent patient safety review of this incident, ensuring all staff who administer medication have access to training related to "high-alert” medications and to increase pharmacy support to both the Watson Lake and Dawson City hospitals.

A call to the Yukon Hospital Corporation was not returned in time for today's deadline.