The mother of Cynthia Blackjack, a Carmacks woman who died after a medevac to Whitehorse, has filed a lawsuit against the Yukon government and health care providers who looked after her daughter, alleging negligence that caused her death.

Blackjack was 31 when she died last November of multi-organ failure as a result of hyperacute liver failure at the Erik Nielsen Whitehorse International Airport.

An inquiry last summer into her death by the Yukon’s chief coroner detailed several issues with equipment and delays in the lead-up to Blackjack’s medevac.

The coroner made eight recommendations for the Yukon government, including a review of medevac policies and procedures.

Shortly after, the Department of Health and Social Services said it would examine its clinical practice guidelines.

Theresa Blackjack alleges in a statement of claim filed Tuesday:

• that health centre nurse Deborah Crosby failed to recognize that Cynthia needed urgent medical care;

• that medevac doctor Jake Morash failed to assess her in a proper and thorough way and failed to determine whether a medevac was appropriate under the circumstances; and

• that two medevac paramedics, Mark Loewenberger and Erik Miller, failed to ensure that the correct medical equipment was on board the flight before leaving Whitehorse.

The Department of Health and Social Services also failed to keep the Carmacks Health Centre supplied with proper functioning equipment, she further alleges in her lawsuit.

Due to the parties’ negligence, her daughter died, Theresa alleges in the document.

She’s had to cope with that loss, as well as pay for grief counselling and Cynthia’s funeral.

In her August report, coroner Kirsten Macdonald listed “significant factors” in Cynthia’s death:

• a blood transfusion was delayed because the wrong type of IV tubing had been brought to Carmacks;

• there appears to have been hesitation about whether to intubate her for the flight, despite signs of shock, decreased level of consciousness, and high respiratory rate;

• once decided on, intubation was delayed due to a lack of pressure oxygen to attach to the health centre’s ventilator;

• the first ventilator tubing circuit failed;

• there was no functioning suction apparatus at the centre, which delayed and could have compromised management of Cynthia’s airways; and

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

Cynthia was well-known to staff at the Carmacks Health Centre, Macdonald wrote.

On Nov. 4 and 5, 2013, Cynthia called the centre, complaining of dental pain.

The day before her death, she dropped by, and staff noted dental decay and slight swelling on the left side of her face.

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

Cynthia was released that morning, and was told to return to the health centre if she couldn’t find a ride to Whitehorse by later in the afternoon.

On Nov. 7, a family member called to say that Cynthia was disoriented and yelling out in pain. Staff at the health centre drew blood for a series of tests, some of which had to be done in Whitehorse.

At 11:15 a.m., they decided to medevac her to Whitehorse General Hospital. The medical team, consisting of a doctor and two paramedics, arrived about two hours later, but the flight didn’t leave Carmacks until 5 p.m.

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

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

An autopsy revealed she had 10 abscessed teeth and “rampant” generalized dental decay. She had fluid in her lungs and her liver was pale and fatty, the coroner’s report states.

Macdonald wrote that health centre staff’s assessment and management of Blackjack’s condition on Nov. 4, 5, and 6 was “reasonable given the presenting symptoms, medical and social history.”

But sending her to Whitehorse on Nov. 6 for more thorough testing – Carmacks has limited ability to conduct lab work – would have provided a more complete assessment, the coroner said.

A case management conference for Theresa’s lawsuit has been scheduled for February of next year.