Recommendations have been handed down to the Yukon Hospital Corp. following the death of a 60-year-old woman at Whitehorse General Hospital last August.

The recommendations are part of a coroner's report on the death of Mary Johnny.

Chief coroner Kirsten Macdonald classified the death as due to natural causes, but also stated:

"It would appear that a misdiagnosis of alcohol withdrawal/delirium tremens was made. The assessment and rationalization of the physician to request (or not request) transfer of the patient to another hospital, was also unclear.”

Macdonald then recommends that steps be taken to address why documentation wasn't complete and, where appropriate, provide the physician with peer feedback on the care provided in this case.

It's also recommended that a standard for all Yukon hospitals be applied in dealing with death.

"It would appear that the practice of reviewing deaths would be supported through the development of a corporate-wide, integrated approach,” reads the report.

"Reviews of deaths occurring in Yukon hospitals would benefit from the guidance of corporate-wide quality assurance processes, which will ultimately standardize the approach of review throughout all Yukon hospitals.”

As Macdonald describes it, Johnny was admitted to the Watson Lake General Hospital by ambulance from the Parhelion Medical Clinic. She was suffering from nausea, vomiting and severe dehydration as well as intermittent lower abdominal pain.

"Notes from Watson Lake Hospital included a very brief admitting history and physical exam by the most responsible physician,” reads the report.

"There were no progress notes by the most responsible physician in the chart. There appeared to be a paucity of investigations and no documentation of response to concerns raised by nursing staff.”

Johnny never became stable during her six days in the Watson Lake hospital. She continued to complain of abdominal pain, nausea and vomiting despite medical interventions.

There was no radiological exam done until Aug. 6, 2012, three days after it was ordered. A repeat chest x-ray was ordered two days later, with both showing a small bowel dilation.

"The patient's condition in hospital had deteriorated with grossly unstable vital signs and deteriorating mental status,” reads the report. "Oxygen saturation was difficult to maintain.”

Johnny was medevaced to Whitehorse General Hospital, suffering from severe shock with multi-organ failure.

A CT scan confirmed the diagnosis of a small bowel obstruction.

"Despite appropriate intervention, the patient succumbed to severe shock and was declared dead on Aug. 9, 2012,” the report states.

Macdonald found Johnny died of natural causes of hypovolemic shock due to severe dehydration due to the small bowel obstruction.

Macdonald's report goes on to note the initial diagnosis was "alcoholism” despite abnormal vital signs and Johnny's persistent complaints of "lower abdominal pain which was associated with nausea, vomiting, apparent melena and vomitus which smelled of stool.”

It was only after three days in hospital that the abdominal pain was investigated and x-rays ordered.

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

"There was a lack of documentation by the attending doctor with only a superficial history and physical exam and no daily progress notes,” reads the report.

"Review of the nurse's notes suggested that the doctor did attend from time to time, or that the nurses did notify the doctor, but the physician response to these concerns is quite unclear.”