Cynthia Blackjack died while being medevaced to Whitehorse from Carmacks on Nov 7, 2013.
Blackjack had gone to the Carmacks health centre on Nov. 6 because of dental pain. She was given a painkiller and an anti-nausea drug, and told to come back if she could not find a ride to Whitehorse General Hospital.
The next day, a family member called the health centre, saying Blackjack was disoriented and yelling out in pain. Blood was taken for tests, but the samples had to be sent to Whitehorse for analysis and the results weren't available until after Blackjack died.
A decision was made to have her sent by medical evacuation to Whitehorse.
The medevac team from Whitehorse brought blood for a transfusion but had brought the wrong type of IV tubing due to a stocking error at the warehouse in Whitehorse. There was also a complication as the health centre's ventilator wasn't working properly at first when the medical staff tried to intubate Blackjack.
Blackjack was eventually airlifted but died about 10 minutes before landing in Whitehorse.
The cause of death was reported as multi-organ failure secondary to liver failure. A dental examination also found she had 10 abscessed teeth and rampant tooth decay.
In her report, Yukon Coroner Kirsten Macdonald says Blackjack was well known to medical staff in Carmack,s and triage, assessment and management of her case was reasonable given the presenting symptoms and medical and social history.
Blackjack's use of ibuprofen and acetaminophen on a regular basis for her dental pain in conjunction with chronic alcohol consumption may have led to her liver failure, the report says.
Meanwhile, the coroner says equipment has to work and medevac staff must ensure they have proper equipment before departure. She also suggests blood test analyses available in rural centres be expanded.
"I find things like having equipment that doesn't work surprising," said Jan Stick,Yukon NDP's health critic. "I find having pieces of equipment that are not the pieces of equipment you need, or the tubing you need, I find that startling."
She says she wants to know who is going to follow up on the coroner's recommendations and ensure they're put in place.