Whitehorse Daily Star

Government ices NDP's call for inquiry

The Yukon government will not call an independent inquiry into the death of Teresa Sheunert at this time, Health Minister Doug Graham said Wednesday in the legislature.

By Ainslie Cruickshank on November 21, 2013

The Yukon government will not call an independent inquiry into the death of Teresa Sheunert at this time, Health Minister Doug Graham said Wednesday in the legislature.

Following question period, the NDP brought forward a motion for debate urging the government to call a public inquiry into Scheunert's 2012 death.

Only Jan Stick, the NDP's Health and Social Services critic, and Graham had the opportunity to speak to the motion before Graham moved to simply adjourn the debate. The government, using its house majority, forced adjournment.

"We believe that a professional, independent and in-depth inquiry into how a 47-year-old registered nurse could die from a toxic combination of medications while she was a patient in the very hospital she worked in would bring relevant facts to light,” Stick told her colleagues.

"Furthermore, we believe a public inquiry that investigated and determined the facts about how this mixed drug toxicity occurred would result in policy recommendations on how to prevent similar deaths in the future,” she continued.

The NDP offered several reasons in support of an inquiry, listing numerous unanswered questions regarding Scheunert's death in June 2012 and the care she received prior.

Scheunert was receiving treatment at the Watson Lake hospital for back pain caused by an injury she sustained during a CPR course at the end of March 2012.

She died of mixed-drug toxicity, although her family was initially told she had died of a heart attack. According to the NDP, the family had to insist on an autopsy to determine Scheunert's true cause of death.

Stick offered four key rationales for calling a public inquiry into this death – including that Scheunert had never received a proper diagnosis nor a treatment plan.

She also lists the difficulty in securing an autopsy, and the "problematic issuing of two substantively different coroner's reports into the same death.”

Her fourth reason is concern about insufficient communication with the family, between the Yukon Hospital Corp. and the health department and more broadly, with the Yukon public.

Graham agreed Scheunert's death was a tragic incident.

However, he noted "there are a number of safeguards in place to ensure that such an incident is investigated and that, when a review is completed, safeguards are put in place – if they are not already in place – to ensure that such an incident doesn't happen again.”

The minister went on to note that a patient safety review has been undertaken by the hospital corporation and the family has filed a complaint with the Yukon Medical Council.

"We believe the process to date has been relatively clear,” Graham continued.

"It's unfortunate it has taken so long. Everyone on this side of the house believes that that probably has to be the most frustrating part of this whole experience. It has taken too long, and these people are left in limbo while it's happening.

"For that, we apologize, but the process must be allowed to finish,” he said.

"We on this side of the house do not believe that we should call an independent inquest at this time. We don't believe it's warranted until all the steps in the process have been concluded. Therefore, we will not be calling an inquest,” he said, concluding his comments.

Many of the issues Stick raised during debate have been discussed repeatedly in question period and through the media.

She did raise concerns about the Yukon Workers' Compensation Health and Safety Board's (WCB's) management of Scheunert's claim following her injury during the CPR course, for the first time yesterday.

"On April 6, days after her injury, Ms. Scheunert filed an application with the Yukon Workers' Compensation Health and Safety Board,” Stick recounted.

"As this was a workplace injury, Workers' Compensation and their medical opinion, would pay a large role in future treatment. As early as April 13, it was identified that Ms. Scheunert needed an MRI and to see a specialist, but this never happened,” Stick noted during question period, highlighting further potential system failures that may have contributed to Scheunert's death.

"Can the minister responsible for workers' compensation explain why Ms. Scheunert did not get the MRI and specialist's referral, and shed some light on the role workers' compensation played in this tragic oversight?” she asked.

While Graham, under the workers' compensation legislation, does not have access to individual case files, he said he understands an MRI was ordered and the board had been trying to expedite that process.

Stick said Scheunert, as a nurse, was aware she was not receiving proper care and sold her motor home to finance a private MRI.

"On the day of her death, Ms. Scheunert's physician contacted WCB, inquiring when she could see a specialist. According to the physician's notes, WCB was working on her case and was planning to have an MRI and specialist consultation done once they finished their investigation,” Stick continued.

"In both judgments of inquiry, the coroner wrote, ‘a seemingly long amount of time passed between the first reports of pain and a requisition for an MRI and/or referral to the proper specialist,'” Stick said, continuing her line of questioning.

"WCB bears some of the responsibility for this. On March 8, 2013, over eight months after her death, WCB then sent a letter to Ms. Scheunert, deceased, at her Watson Lake residence to inform her that her claim was denied,” she said.

Graham noted that he has asked the WCB for an explanation, which he has not yet received, but expects soon.

The board wouldn't speak to Scheunert's specific case.

Spokeswoman Becky Striegler noted at noon today a WCB investigation would never prevent a doctor from ordering a treatment nor procedure determined to be necessary for the patient.

In fact, Striegler said, the board relies heavily on the advice of doctors and tries to expedite any treatment deemed necessary.

With regards to the letter sent months following Scheunert's death explaining her claim had been denied, Striegler said that when a claimant dies prior to a decision being made on the claim, the WCB must wait until an autopsy has determined whether the death is related to the cause of the claim.

A letter is then usually sent to the claimant's estate executive. She noted there are times when it's difficult to find that person though, suggesting this may have been the reason why the letter was sent to Scheunert's previous address.

"We acknowledge that we probably need to do a better job in that area so this doesn't happen again,” she said.

Scheunert's family also wants an inquiry into her death.

Comments (1)

Up 5 Down 3

Groucho d'North on Nov 21, 2013 at 10:40 am

What do you do when you have a serious situation where you work?

Is there a process to correct the problem and is it documented to ensure clarity and the proper chain of action was followed? Most of the shops I have worked in do, the insurance companies and the safety folks pretty much insist on it. So why then is there such a mystery hanging over the unfortunate death of the nurse who died in the hospital where she worked in Watson Lake?

The minister says everything is working according to a system of some description, and recognizing there were problems, various reviews and examinations of these systems have been conducted to correct the identified problems. I'm curious; what were the identified problems?

The more I read about this case, the more I believe there is a snake in the woodpile.

Add your comments or reply via Twitter @whitehorsestar

In order to encourage thoughtful and responsible discussion, website comments will not be visible until a moderator approves them. Please add comments judiciously and refrain from maligning any individual or institution. Read about our user comment and privacy policies.

Your name and email address are required before your comment is posted. Otherwise, your comment will not be posted.