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Inquest into woman’s death is set for two venues

The inquest into the death of Cynthia Roxanne Blackjack will start on Jan. 20, as previously scheduled, and take place in two communities.

By Whitehorse Star on January 9, 2020

The inquest into the death of Cynthia Roxanne Blackjack will start on Jan. 20, as previously scheduled, and take place in two communities.

The first two days (Jan. 20-21) will take place in Carmacks at the village’s community centre (weather permitting), it was announced Wednesday.

The proceedings will resume Jan. 22 at the Kwanlin Dun Cultural Centre in Whitehorse.

In October 2018, Justice Gail Dickson of the Yukon Court of Appeal upheld a Yukon Supreme Court order to hold the inquest.

This dismissed the appeal that had been launched by Kirsten MacDonald, who was then the Yukon’s chief coroner. She had challenged Justice Ron Veale’s March 6, 2017 decision to hold the inquest into Blackjack’s death.

The Little Salmon-Carmacks First Nation and Blackjack’s mother, Theresa, had wanted the inquest.

Both parties cited concerns over systemic problems in the delivery of health care to First Nations.

The First Nation argued the coroner’s original investigation had been wholly inadequate, failing to explore “systemic racism” as a possible role in Blackjack’s death.

It also said MacDonald had not addressed the stereotypes that impact the delivery of health care to First Nations.

MacDonald had argued that a judge did not have the jurisdiction to order an inquest.

The younger Blackjack, 29, died on Nov. 7, 2013 while being transported from the Carmacks Health Centre to Whitehorse General Hospital by air.

She had been experiencing toothaches, abdominal pain and vomiting in the four days leading up to her death.

Blackjack called and visited the health centre multiple times during that time.

On Nov. 6, 2013, she went to the centre, and was tentatively diagnosed with alcohol induced gastritis and discharged.

She was told to go to Whitehorse for medical attention and advised to return to the centre the next day if she had no ride.

A friend called the centre the next day at 9:40 a.m. Blackjack was reported to be screaming in pain and needed an ambulance – which was not ready.

The friend was advised to bring Blackjack to the centre. This was impossible, as the friend did not have a vehicle.

An ambulance was eventually available, and Blackjack was brought to the centre at 11 a.m.

Staff decided she needed to be sent to Whitehorse by aeromedical evacuation.

The transport was delayed, as the medevac team experienced technical difficulties. They had brought the wrong tubing for a blood transfusion – and the ventilator equipment failed.

She was put on the aircraft at 5 p.m. Blackjack’s vitals were lost just before the aircraft landed in Whitehorse, and she was pronounced dead at 6 p.m.

MacDonald took over the investigation and submitted all information to the Ontario Patient Safety Review Committee.

The likely cause of death was ruled as multi-organ failure caused by hyper-acute liver failure.

It was not determined why her liver failed. On Aug. 4, 2014, the death was deemed natural.

Judge Dickson said any death that causes reasonable concern should be subject to an inquest.

She said the Ontario Law Reform Commission determined that inquests are valuable, as they can address family and community concerns. This can include questions on the quality of care delivered to the deceased.

“That there is good reason to believe a deceased person received substandard care in and around the time of death could be a matter of legitimate public concern which involves systemic failings and may warrant public scrutiny regardless of precisely what caused the death from a purely medical perspective,” Dickson said in her written decision.

She added this includes Blackjack’s case.

She also addressed the issue of whether Veale had been wrong to order the inquest.

Dickson saw nothing wrong with that determination. She said Veale had used his discretion – as he had been entitled to do so.

She concluded the judge’s order would best serve public interest, as it could help assure Blackjack’s loved ones that there was a proper investigation into her death. This would also address community concerns.

This was important, Dickson added, considering Blackjack may have been vulnerable due to her Indigenous ancestry.

Comments (1)

Up 10 Down 17

Why does this take so long? on Jan 10, 2020 at 12:54 am

Why does this take so long? She was 29 and died a preventable death. Inquest must happen.

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