After nine days of testimony, a Yukon coroner’s jury determined that Cynthia Blackjack’s death during a medevac flight to Whitehorse was accidental.
The 29-year-old died of multiple organ failure due to hyper-acute liver failure, likely caused by acetaminophen poisoning.
The jury heard Blackjack went to the Carmacks Health Centre several days in a row leading up to her death and was treated for gastritis and instructed to find a ride to Whitehorse General Hospital.
When she returned to the health centre on Nov. 7, 2013, her condition had worsened and she was flown to Whitehorse but died in transport.
The coroner had originally decided not to call an inquest but a Yukon judge ordered the inquiry when the Little Salmon Carmacks First Nation went to court alleging systemic discrimination when providing health care services to Indigenous people.
The jury made eight recommendations late Friday, including that the centre hire a nurse practitioner, that there be dedicated transportation for those who aren’t sick enough to be flown to hospital and that medical chart terminology be reviewed to eliminate stigmatizing language.
Several witnesses told the inquest that they were discriminated against while seeking medical care at the same centre.
Medical notes on Blackjack presented at the hearing described the woman as “dramatic” and “on a bender.”
Robert Saunders, an expert in emergency medicine, testified that Blackjack was already too sick for treatment when she appeared at the Carmacks Health Centre before her death.
Saunders said Blackjack’s rapid decline was very rare and that she may have been vulnerable to liver damage from acetaminophen because of her alcohol usage.
Matt Lewis, the nurse who treated the woman in Carmacks, testified he wasn’t aware that Blackjack had taken any Tylenol leading up to her death and she was seemingly stable when she left on Nov. 6.
Lewis told the inquest Monday he was extremely surprised to see how seriously Blackjack had declined when she returned to the health centre Nov. 7.
Blackjack suffered cardiac arrest aboard the flight and was pronounced dead shortly after landing.