Cynthia Blackjack’s 2013 death was unanimously ruled “an accident” Friday afternoon, triggering eight recommendations to improve community health services and bringing the two-week inquest to a close.

The jury listened to nine days of testimony from Blackjack’s friends and family, nurse practitioners and experts before making the decision.

Blackjack’s mother, Teresa, told media she was unhappy with how the inquest characterized her daughter.

“I think they misjudged her bad,” Teresa said. “They called her an alcoholic, and she’s not; she’s my daughter and I know her.”

Teresa said Cynthia often phoned and complained about the medical care in Carmacks.

She added the sentiment is reflected, anecdotally, by many people she knows in the community. Teresa said she hopes the inquest will trigger better support for First Nations members.

“We’ve lost a lot of First Nation (people), and it’s hard for all of us to keep together. I’m glad my daughter opened up everybody’s eyes,” she said.

“I hope they have a lot of support around their communities, too, and help out all the people who’s (sic) hurting.”

The inquest was spurred by calls from Blackjack’s family to investigate whether systemic racism in the health system played a part in her death.

Jury members heard testimony on both sides of the issue: Carmacks residents, who said they received insufficient treatment at the centre, as well as Carmacks nurses, who said they provided care without bias.

The jury was charged on Friday with ruling Cynthia Blackjack’s death one of five categories: natural causes, homicide, suicide, accident or unknown.

On the day of decision, jury members asked how to categorize personal and societal negligence.

They were advised by Peter Chisholm, the territorial judge acting as the presiding coroner, that negligence does not fall under any of the five categories.

Chisholm reminded the jury that the objective of the inquest was not to assign blame to any person nor agency.

The jury members deliberated for approximately six hours before coming to agreement.

They ruled that Blackjack’s death was an accident as a result of “multi-organ failure due to hyper-acute liver failure likely triggered by toxicity to a drug or other substance”, a reflection of the expert medical testimony.

Last Wednesday, two experts suggested that Blackjack’s death was likely caused by acetaminophen (Tylenol) poisoning, because that was the only potentially toxic substance in her system at the time of death.

The jury made eight recommendations:

“1. Prioritize the hiring of a Nurse-Practitioner in Carmacks;

“2. Develop a framework addressing patients with no advocates by having a Community Health Representative at the Carmacks Health Centre. This role should be carried out by a local First Nation;

“3. Dedicated medical transportation to Whitehorse for Carmacks residents who are not sick enough for medevac but who are deemed to require a level of medical care that Whitehorse General Hospital can provide;

“4. Review of terminologies used in charting. Take steps to eliminate the use of stigmatizing language;

“5. Fully staff a wellness hub in Carmacks that focuses on alcohol and drug dependency. The hub should address issues of social, mental, psychological health and child development;

“6. Community education on health and dental care, available resources and how to access available services and funding;

“7. Develop a curriculum on cultural safety specific to Little Salmon-Carmacks First Nation;

“8. Investigate the possibility of lighting at community landing strips to extend flight hours for medevac.”

A timeline was not set out for any of the recommendations.

Blackjack died on Nov. 7, 2013, while being medevaced from Carmacks to Whitehorse. Her time of death was pronounced just before 6 p.m.

Two medevac practitioners testified that they spent most of the day in Carmacks trying to bring Blackjack into a stable state before evacuating her.

They were prompted to start the evacuation late that afternoon when faced with loss of light for take-off.

On the day before her death, she visited the Carmacks health centre complaining of abdominal pain. She was advised to find a ride to Whitehorse General Hospital or return to the health centre.

Two nurses testified that patients are often advised to find their own ride, because Carmacks has only one ambulance.

The inquest included an extensive review of the medical notes made in Blackjack’s file the week of her death. There was the suggestion that terms describing Blackjack as “dramatic” and “on a recent bender” might signify bias against her.

Dr. Robert Saunders, an expert medical witness, described her death as “hyper, hyper acute liver failure” because of the speed at which her health declined.

He suggested the cause may have been Tylenol mixed with alcohol, known to be a toxic combination.

Blackjack had called the health centre after-hours twice in the week before her death, complaining of tooth pain. It was made known to the jury that Blackjack had recurring dental issues. A friend testified they provided Blackjack with Tylenol for the pain.

Another friend of Blackjack’s testified that she was reluctant to visit the health centre on the week of her death.