Whitehorse Daily Star

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Photo by Gabrielle Plonka

SERIOUS MISGIVINGS EXPRESSED – Teresa Blackjack (left) told media she was unhappy with the inquest characterizing her daughter, Cynthia, as an alcoholic. She is seen here Friday afternoon with family friend Darlene Jim at the Kwanlin Dün Cultural Centre immediately after the jury’s decision. Inset Cynthia Blackjack

Jury suggests improvements to rural health services

Cynthia Blackjack’s 2013 death was unanimously ruled “an accident” Friday afternoon,

By Gabrielle Plonka on February 3, 2020

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.

Comments (20)

Up 2 Down 0

Lou P. Somme-Schmidt on Feb 9, 2020 at 9:21 pm

@ U R Full of It - What people are saying is that there is no right by any person to abuse another regardless of what may be in their past or present regardless of race: Caucasian, Indigenous, African, Asian... Whatever...
What the government has done and is currently doing is absolutely hateful. It has weaponized race, culture and gender to use as a diversity hammer. Not only are these categories presumptive and prescriptive but they are divisive, malleable, conflict generating and false.

This has given license to individuals to abuse the power they are given under these diversity programs to harass, bully and intimidate others with immunity. They are making things worse for everyone.
This is well documented and it is the root evil of Liberalism - fascism and racism and whatever-ism. This evil lies in the fact that people are no longer individuals they are whatever construct the person with authority wants them to be. There is no honest inquiry. There is no honest engagement because there cannot be - You are! There is no context.

This is the derangement we find ourselves in. The inability to see the other person as anything but our fears and biases. The Federal Government, The Yukon Government, the Union and the RWO should be absolutely ashamed of themselves... As should anyone who treats another as anything other than an individual.

Is there an impeachment process in Canada or the Yukon? Perhaps we should put it to a referendum!

Up 9 Down 2

@ Nicky on Feb 8, 2020 at 10:58 am

@ Nicky Thank you for saying out loud that which many of us have experienced and believe.
Those poor nurses in those communities take the brunt of it and I sympathize with them all the way.

Up 3 Down 17

U R Full of it. on Feb 7, 2020 at 5:09 pm

What has this forum lowered itself to? Now the dominant race is crying foul??!
Let's see, not mentioning any races specifically. Since the time of contact if they didn't wipe us out by genocide and disease, they penned us up in reserves which had no economic potential and allowed FNs to barely squeak out an existence on limited game. Then they marginalized FNs in health care, education, justice and every other system set up for the new comers. Last year I had one of the preferred races ask "why don't you go back to your reserve?" in 2019!! FNs have been dumped on since the time of contact and they will not put up with it anymore. Yes we are a getting a fair shake from most judges when it comes to aboriginal title, thank god cause we don't from most elected governments. Yes, we do have preferenial hire, because most jobs are held for and by the new comers and most responsible governments etc. recognize that now. So yes FNs are making advancements in Yukon society and that is a good thing on many fronts. Of course there will be those that yearn for the good old days, fortunately they are in the minority and comment frequently on this site.
This inquest has been a good thing, no one should have to live the life this young lady lived and there are more FNs that now will not accept it. Get used to it folks this is just the tip of the iceberg.

Up 30 Down 5

Yu Krappen-Hu on Feb 6, 2020 at 8:24 pm

Bang on Nicky - However, lots of people are talking about it but society is currently structured in a manner that actively suppresses any dissent. Racism has been legally codified as a right of the state and of non-dominant groups to dominate an asserted dominant group, usually, white middle class males. The irony of this doublespeak duplicity is that it is advanced by predominantly white upper class males as a psychological balancing of the scales.

Consequently you will see job advertisements that say aboriginal or indigenous preference hire. You will see advertisements such as female preference hire. You will never see a white male preference job posting though.

Up 63 Down 8

Nicky on Feb 6, 2020 at 1:20 pm

The 'racism' nobody wants to talk about is the disrespect and abuse directed at many health professionals by members of a different race who believe their ancestor's time of arrival in the Yukon denotes some special status and the 'right' to be abusive to others. Some people actually believe that abusive racism directed at later immigrants is somehow acceptable.

Up 46 Down 7

Charlie's Aunt on Feb 5, 2020 at 4:48 pm

Community education on health and dental care! Spare me on this one please. Cynthia was of an age when she would have been in school when the Yukon Children's Dental Program provided excellent care along with oral hygiene instruction. As well as routine treatment the children received free toothbrushes and shown how to use them. Earlier a report said her teeth were blackened stumps, I don't think health care personnel can be thought to be negligent over that. Sometimes it takes convincing family members of importance of oral health, but you can lead a horse to water - you know the rest.
Communities used to have Community Health Reps who often were members of the local community & acted as liaison between families and health workers, what happened to that program? I have worked alongside CHRs & Community Health Nurses in many communities and as a group they are dedicated to, what can be at times, a difficult job. Never have I witnessed racism, frustration yes, but racism no.

Up 69 Down 7

Salt on Feb 4, 2020 at 7:42 pm

@ Antianie
The irony is mind-numbing. Maybe you should walk a mile in the shoes of the health professionals that provide their services in the communities. Without a doubt a challenging and often thankless job. Trying to pin this death on them and slandering them as racists is the disgusting bit of cognitive dissonance that got this ball rolling.

Up 52 Down 7

drum on Feb 4, 2020 at 6:59 pm

Complaints - just get all first responders and nursing staff in the mostly First Nations communities be First Nations. That solves it all.

Up 51 Down 7

JC on Feb 4, 2020 at 4:54 pm

Antianne: Most of us lived among and even side by side with the FN people most or even all of our lives. We aren't ignorant. Perhaps you might want to walk in the shoes of a non FN person for awhile. Now, I am sure you are referring to the white race, but by the way, for some time now, the Yukon has been made up with every race on the planet. And one more thing, racism comes in all colors and races - even yours.

Up 34 Down 8

Obi on Feb 4, 2020 at 3:56 pm

Dear Antianie,
I agree that you should walk a mile in some ones shoes before you say something critical about them. That way you will be a mile away when you say it, and have a nice pair of shoes.....

Up 20 Down 15

YukonMax on Feb 4, 2020 at 7:13 am

Excuse me here! A nurse at the community health center insisted I book an appointment with the doctor after she saw me. She knew me well and knew I wasn't getting anywhere with the doctor and said she would act as my patient advocate. I booked my appointment, showed up for it. The nurse was there, on duty. But the doctor told her to stay out of it. That was the last time I saw a doctor in my community and I will only go there for acute emergencies. And on another note, I can drive or be driven to Whitehorse much faster then by medevac. I know, I was taken out 4 times so far.

Up 80 Down 9

Joe on Feb 4, 2020 at 1:47 am

How about we recommend an apology to the nurses, medi vac team and all support groups involved. Everyone knows the truth but too respectful to spit it out. It isn’t about the day this happened, it’s about the past ten years and the choices made. It is very sad for family and friends.

Up 59 Down 8

Salt on Feb 3, 2020 at 10:36 pm

The outcome wasn’t as bad as it could have been, but still it is blatantly dysfunctional. Our society is held captive by irresponsible, childish adults and their willing enablers. By no means am I referring to one particular ethnicity. Selfish, magical thinking is everywhere.

Up 10 Down 74

Antianie on Feb 3, 2020 at 10:15 pm

I would bet dollars to donunts that not one of the people providing negative comments regarding this article are First Nations. How can you be critical or negative about something to do with First Nations when you have never spent a day in the shoes of a First Nations person? You have lived your whole life never having experienced what First Nations people have endured since the time of contact. Instead of making ignorant comments, take some time out of your busy life and try to get to know a FNs person, you might be enlightened.

Up 50 Down 9

SheepChaser on Feb 3, 2020 at 7:37 pm

"A friend testified they provided Blackjack with Tylenol for the pain."
That's gotta be the accidental bit, right? Cause otherwise I'm starting to feel like a lunatic that has lost all understanding or connection with the 'common sense'.

Up 54 Down 6

Anon on Feb 3, 2020 at 6:14 pm

I wonder how many people from each of the communities are in nursing school, and have an end goal of returning to their home communities to work?

Up 51 Down 7

JC on Feb 3, 2020 at 5:15 pm

They forgot or deliberately left out co-operation between medical team and patient. And keep your appointments. And I don't want to sound mean here, but if a member of the FN has no, or has little trust in the local medical team, there are native healers there. They practice herbal medicine as well other methods. Perhaps they would be more comfortable with them.

Up 70 Down 11

Hu Krappen-Yu on Feb 3, 2020 at 4:57 pm

Chisholm: This is not a fault-finding process.
Jury: Uh yah, about this fault-finding, how do we account for “societal negligence”?

Chisholm: You can’t. It’s not an option. This is not a fault-finding process.
It is apparent the jury did not understand its role. Perhaps there should be some minimum IQ requirement for jury membership - They should be able to understand basic instructions - No?

Notwithstanding the no-fault process the jury made it clear that racism played a big roll in Ms. Blackjack’s death. This blame is embedded in the recommendations.
Notably absent in the recommendations was any reference to personal accountability or any expectations of the community at large.
Develop a curriculum on cultural safety? WTF! If you want cultural safety stop drinking, drugging and committing violence.

Advocates, fully staffed wellness hub, lights on the runway, cultural safety, racialized language training, a dedicated ride program for the not-sure cases... Wow! That will cost an awful lot without addressing the root problem - Personal choice needs personal accountability.
You can’t just do this for one community though. There are 14 FNs and their associated communities. Now that the liability cat is out of the bag... Get building!

Up 14 Down 65

Karen Riemer on Feb 3, 2020 at 3:59 pm

I understand that an inquest does not search to lay blame however, this inquest did nothing but blame Ms. Blackjack for her untimely death. Was her disease self inflicted - yes, but there most definitely were underlying events that led to her illness as there is with every individual who abuses drugs and alchohol.
Was her death the result of her disease - yes. Could she have lived longer - yes. Was her treatment/diagnosis the same as it would have been for a non-First Nation individual? Only the Nurse can answer that. If she had been sent to and treated in Whitehorse after her initial visit to the Health Center I sincerely believe she could have lived. Of course treatment and possibly a transplant would have been needed but we will never know now if she could have been a success story.
Is there blame? Absolutely. Where does it lay? With the Nurse? With the Community? With the Government?
The Jury recommends that a Nurse Practitioner be installed in the Community. I feel that is a terrific idea though there should be appropriate training to reflect their understanding of First Nations history, culture and traditions. I don't believe that the individual needs to be First Nation, but it most definitely would be the best option.

Up 80 Down 10

Anie on Feb 3, 2020 at 2:54 pm

"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;". Carmacks only? And what the heck is a "curriculum on cultural safety"? Did a jury really write this bafflegab or were they coached? And how can liver failure be an accident?

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