A six-person jury has determined that Teresa Scheunert died accidentally of mixed-drug toxicity.

Scheunert died on June 21, 2012 after a two-week stay at the Watson Lake hospital, where she also worked as a nurse.

She was admitted to hospital on June 7 that year for pain management after she hurt her back in April during a CPR training course.

A coroner's inquest investigating her death began last Monday, hearing testimony from 18 witnesses over five days.

The jury was charged Saturday morning and tasked with reading the written testimony of a 19th witness before ruling on Scheunert's cause of death and delivering recommendations.

By mid-afternoon, the all-female jury had returned with its verdict.

The ruling that Scheunert died from a deadly dose of a combination of narcotic medications is consistent with the original findings of the forensic pathologist who performed the autopsy on Scheunert.

Her findings were later challenged by a review of the death, completed for the Yukon Hospital Corp., which suggested Scheunert may have died as a result of sleep apnea.

The jury's ruling that the death was accidental means it was an unfortunate and unintentional incident.

Along with its verdict, the jury made six recommendations, including that the hospital corporation implement 19 recommendations from the Institute for Safe Medication Practices Canada.

Those deal with pain management practices, patient monitoring, medication administration, resuscitation efforts, training, telepharmacy services and consultations.

The jury further directed the hospital corporation to develop a formal process for providing a consistent level of care for medical peers in the community hospitals and possible transfers to the Whitehorse General Hospital.

The corporation was urged to review and simplify its monitoring and reporting forms to make them more user-friendly and ultimately to create more complete and better organized patient files.

The jury recommended that the hospital corporation provide mandatory in-service training annually and on an as-needed basis on all hospital policies and procedures.

It further recommended that the hospital corporation work with the Yukon Workers' Compensation Health and Safety Board to avoid delays in receiving the necessary medical diagnosis and treatment regarding work-related injuries.

Finally, the jury recommended that the Institute for Safe Medication Practices Canada and the office of the chief coroner work collaboratively to share the lessons learned from this case in a national safety bulletin.

Scheunert's family released a statement Friday calling her death a matter of public safety.

They expressed hope that the recommendations would be enforced.

The statement outlined several areas where changes could be made to improve public safety, noting there was no clear care plan for Scheunert, poor charting, poor monitoring, no review of the prescribed medications by a pharmacist, and apparently little awareness of relevant policies governing some of those medications.

"All Yukoners are entitled to consistent, safe care that this inquest shows Teresa Scheunert did not receive in Watson Lake Hospital,” it says.

The hospital corporation released a statement today saying it will carefully review the inquest verdict and recommendations in the coming days.

"We are fully committed to this process,” the corporation said.

"It is our opportunity to learn from all of the circumstances in this case. For us, safe and excellent patient care is paramount, so our organization will address any areas for improvement,” it says.

See related story below; family's full statement in Opinions.