The family of a woman who died last year at the Watson Lake hospital wants a public inquiry into the circumstances that led to her death.

Teresa Ann Scheunert was 47 when she died on June 21, 2012 of mixed drug toxicity.

Scheunert's two daughters, Crystal Thomas and Chandre Burchell, and her sister, Wanda Zimmerman, made the call for a public inquiry today during a press conference hosted by the Yukon NDP.

Thomas explained the family travelled to Whitehorse with the intention of filing for a judicial review of the coroner's report, but was unable to secure legal representation.

The family also released the first coroner's report they received following Scheunert's death.

That report, dated June 14, 2013, was never made public.

Instead, the chief coroner, Kirsten Macdonald, released a second report dated July 9, 2013.

The second report was "substantially different on several points,” Thomas said this morning.

Two recommendations were missing from the second public report that were present in the first report provided to the family.

The first report included recommendations that the Yukon Hospital Corp. "ensure that "Patient Own Medication” policy is followed consistently across all Yukon hospitals.”

It also recommended that "any time a patient is permitted under the "Patient Own Medication” policy to self-administer medications, documentation should be made in the patient records what medication was taken, what the dosage was, and when it was taken.

"Patients who self-administer medication require supervision and guidance.”

As noted in the conclusion of the first coroner's report, "prescriptions for Ms. Scheunert were filled in the days preceding her death and the patient self-administered these medications.

"The ‘Patient's Own Medication' policy of Yukon Hospital Corporation was not followed.”

There was no discussion of the "Patients Own Medication” policy in the conclusion of the second report.

More differences are evident in the concluding section of the reports.

Macdonald noted in the first report that Scheunert was a medical professional and that a colleague was managing her care.

"Ms. Scheunert was permitted to leave the hospital during the day, returning at night. There is a lack of clear rationale why this was permitted.

"One would wonder if the same permissions would have been granted to another patient who was not a colleague of the primary clinical decision-maker or a health care professional,” Macdonald questioned in the first report.

The second version included no mention of that issue in its conclusion.

In an earlier section of the second report, Macdonald refers to Scheunert as a voluntary patient, who was able to leave during the day and return at night.

During a brief interview this morning, Macdonald explained that she completed and released the second report because "new information came to light.

"The first one was inaccurate. It's just as simple as that,” she said.

"The second one reflects what happened in the case and the toxicologist confirmed the levels and the history and it was more accurate.”

Macdonald would not expand on the inaccuracies in the first report, but did caution the public against "putting too much weight in that first report.”

In a statement released early this afternoon, following the late-morning interview, Macdonald commented that the substantial difference between the two reports regarded whether a subsequent dose of one medication could have been taken by Scheunert.

"The Coroners Service worked closely with a forensic toxicologist who determined that a subsequent dose was not likely,” she said in the statement.

"New facts regarding this investigation came to light after the report had been written. Once the new information was realized, the chief coroner called the family immediately and advised them that an error had been made and that the report was retracted so that the facts could be appropriately amended.”

Jan Stick, the NDP's Health and Social Services critic, noted, as the coroner's reports say, that the system let Scheunert down.

"After their mother, their sister was let down by the system, (Scheunert's family) also had to struggle with the same system to have their questions answered,” Stick said.

Now the NDP is asking for accountability from the government and the Yukon Hospital Corp., she said.

"We have a responsibility to acknowledge when the system fails and to fix identified gaps,” Stick continued.

In the legislature, the NDP has raised several questions about the failings of the system in Scheunert's case and the implementation status of the coroner's recommendations.

More questions were planned for this afternoon during question period.

Today, Thomas, Burchell, and Zimmerman all offered brief, heartfelt comments explaining how Scheunert's death has affected them and their families.

Now, they are looking for clear answers to the questions they've had for the past year and a half.

"What has made her death even more difficult is not understanding what went wrong and if and how it will get fixed,” Thomas said.

See commentary.