Inquest ordered into Yukon First Nations woman's death

A Yukon Supreme Court judge has overruled the territory's chief coroner, saying an inquest is needed to examine allegations of systemic racism as factors in Cynthia Blackjack's death in 2013.

Coroner KirstenMacdonaldhadearlier rejected the need for an inquest.

• First Nation wants inquest into Yukon woman's death, cites 'systemic racism' in health care

Justice RonVeale'sdecision cites evidence that Blackjack, 31,received inadequate ambulance service in the hours before her death on Nov. 7, 2013, and says an inquest should consider "alleged systemic failures of theCarmackshealth services to First Nation citizens."

Vealesaid the coroner's original judgement of inquiry, which reported the cause of death asmulti-organfailure secondary to liver failure, was too narrow in its focus.

"The Judgement of Inquiry focussed to a great degree on Ms. Blackjack's medical issues and did not address underlying reasons for the inadequate ambulance service, which on its own, is sufficient for this court to order an inquest," his decision reads.

According to the Yukon Coroners Act, the coroner can order a formalinquest if there's reason to believe someone died "as a result of violence, misadventure, or unfair means or as a result of negligence, misconduct or malpractice on the part of others."

Sent home after initialtreatment

Blackjack visited theCarmacksnursing station on Nov. 6, 2013, the day before she died, complaining of toothache, abdominal pain and vomiting.She was given a tentative diagnosis and treatment, thensent home and told to find her way to the Whitehorse hospital, a two-hour drive away or come back at the end of the day.

Blackjack did not go to Whitehorse or return to the nursing station that day. The next morning her health had deteriorated.

Her family called for an ambulance, but according to SusanRoothman, the lawyer for Blackjack's family,it took about 90 minutes before aCarmacksambulance was eventually sent to bring Blackjack to the local nursing station.

She was eventuallymedevacedto Whitehorse but court documents say her vital signs were lost before the plane landed.

'Questions unasked and unanswered'

The Little SalmonCarmacksFirst Nation and Blackjack's family have argued that her death illustrates systemic racism at work in Yukon's health care system. They believeFirst Nations people are not always getting the care they need, especially in remote northern communities.

In 2015, they pushed for a inquest, but coroner KirstenMacDonaldrefused.TheFirst Nation then applied to the court and the coroner argued the First Nation has no standing.

In an affidavit filed in court in 2015, Blackjack's mother TheresaAnne Blackjack described her family's despair and confusion over what happened, and why.

"I feel that the Chief Coroner's inquiry left many questions unasked and unanswered," the affidavit reads.

"Why did it take so longto get [Cynthia] to Whitehorse General Hospital for treatment? Why did the nurse wait until the last minute?

"Why is it that First Nation people are treated this way? Why did my mother have to threaten with legal action before the ambulance picked her up on Nov. 7, 2013? Why are we as First Nation people not treated equally by nurses at the nursing station?"

First Nation, family, should be included, judge says

Vealedecided those questions are worth exploring through an inquest, the coroner was wrong to refuse.

He also noted that the coronerin her original investigationdid not identify Blackjack as a First Nation citizen, and "this is the very issue that is raised by her relatives who allege discriminatory treatment.

"In my view, it is always advisable, in any community that provides services to a First Nation, to include the First Nation, the family members of the deceased and the Director of Health and Social Program in any investigation under theCoroners Act,"his decision reads.

Inquests are normally conducted by the chief coroner and a six-person jury, butVealeis recommending against that. He wants a territorial court judge appointed to preside, instead ofMacdonald.

He says it's a reasonable practice, "particularly when a proceeding is considering the possible contributory role of the chief coroner's fellow employees at the Government of Yukon."

It's not clear when an inquest would begin. The coroner's office has 30 days to appeal the decision.