Mary Johnny’s death was a homicide, a jury has ruled after a four-day inquest.

After five hours of deliberation on Friday, the six-person jury determined she died of hypovolemic shock secondary to intravascular volume depletion and multi-organ failure.

Hypovolemic shock results from severe fluid loss in the body.

The 60-year-old Johnny died the morning of Aug. 9, 2012, at Whitehorse General Hospital. She’d been medevaced the day prior out of Watson Lake, after spending six days in hospital there. She was admitted with nausea, vomiting, dehydration, diarrhea and stomach pain.

The doctor who cared for her in Whitehorse determined at the time she died of hypovolemic shock due to a bowel obstruction.

The inquest into Johnny’s death, called by the Yukon’s chief coroner Kirsten Macdonald last November, heard from 20 witnesses, including her doctor, Said Secerbegovic, her mother and son, nurses who cared for her in Watson Lake, and several doctors from across Canada who provided expert testimony.

“Mary’s mother, Eva, knew something was terribly wrong with the care she was receiving at the Watson Lake Hospital,” said Eva Johnny’s lawyer, Jennie Cunningham, via email this morning.

“She is happy that it is public information now, and hopes that the verdict will instigate urgently required changes to the health care system so that community members are treated with the care and respect that they deserve.”

Johnny was a Kaska woman and survivor of the residential school in Lower Post, B.C.

“She lived with her difficult past and she experienced a tragic and preventable death,” Cunningham said. “She was deeply loved and she is deeply missed.”

The jury made four recommendations for the Yukon Hospital Corporation:

• have routine audits to ensure standards for adequate and timely documentation of patient care are adhered to;

• conduct a review of policies and procedures for the transfer of patients from rural Yukon medical centres to regional/tertiary care centres;

• develop a standardized process to address and formally document DNR (do-not-resuscitate) orders;

• require physicians working in rural communities to have completed up-to-date Advanced Trauma Life Support and Advanced Cardiac Life Support courses or their equivalent.

Secerbegovic testified that he had a conversation with Johnny on her second or third day in hospital about a DNR order, which means a doctor won’t go to extraordinary measures to save a patient’s life if his or her heart stops.

This was what Johnny requested, he told the inquest. But he didn’t note the order in her file until days later, in the early-morning hours of Aug. 8, when her condition was worsening rapidly.

Dr. Robert Saunders, of Burnaby, B.C., testified Friday that at the hospital he works at, it’s necessary to document a DNR order with an end-of-life care form. It must be signed and dated by either the patient or a family member, if the patient is incapable of doing so.

Secerbegovic also testified he hadn’t taken the Advanced Trauma Life Support and Advanced Cardiac Life Support courses in about 15 years.

Yukon Hospital Corp. CEO Jason Bilsky said in a release this morning that the organization fully respects the jury’s verdict and will “carefully look” at each recommendation.

“There will be a role for Yukon’s hospitals, physicians and other system partners as we undertake a review and work together to make improvements,” he said.

“We are committed to this process as 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 intention is that nothing like this happens again.”

Bilsky said Johnny’s death was “an outcome no health care provider ever wants to see.”

During the course of last week’s inquest, doctors and medical experts who reviewed Johnny’s file and nurses’ notes said she should have been medevaced sooner – that her condition was serious and she needed more urgent care than the Watson Lake hospital and its equipment could provide.

Some also criticized the quality of care Johnny received, pointing to Secerbegovic’s lack of notes, his “conservative” approach to rehydrating her, the infrequency with which her bloodwork was done, and the fact that an X-ray wasn’t taken until three days after it was ordered.

They disagreed on her cause of death, some speculating she had a secondary diagnosis, like a pulmonary embolism or congestive heart failure.

The inquest heard Johnny had struggled with alcohol addiction for decades.

She was a patient of Secerbegovic’s for 35 years, and he said that, during that time, she made hundreds of visits to hospital, many times to detox.

Johnny was petite and frail – though she was 60, she had the body of a 90-year-old, he said. In the last 20 years, she’d had several bone fractures. A few years ago, she was in a serious car accident, and was thrown from the vehicle, fracturing her pelvis.

Represented at the inquest were the Yukon Hospital Corp., the physicians involved, Eva Johnny, and the coroner, whose lawyers questioned the witnesses.

The purpose of these proceedings is not to find guilt or place blame, but rather to determine the circumstances of a person’s death and prevent future deaths, presiding coroner Norman Leibel told jurors last week.

It’s not mandatory for the jury to make recommendations.

In addition to determining cause of death, they also must decide whether a death is accidental, natural, homicide, suicide, or undetermined.

The finding of homicide means Johnny’s death was a result of the “culpable actions of another person,” according to the Yukon Coroner’s Service. It’s not synonymous with murder, and doesn’t determine legal responsibility.

Following an inquest earlier this year into the death of Teresa Scheunert, a woman who also died in the summer of 2012 after receiving treatment at the Watson Lake hospital, the jury determined the death was accidental, caused by mixed-drug toxicity.

This is not the first time this year a review of the medevac process has been urged.

In her inquiry into the November 2013 death of Carmacks woman Cynthia Blackjack, completed in August, coroner Macdonald recommended the Yukon government review its policies and procedures for transporting patients at community health centres to hospital in Whitehorse.

Blackjack died at the Erik Nielsen Whitehorse International Airport of multi-organ failure as a result of hyperacute liver failure.

A spokesperson for the Department of Health and Social Services said at the time guidelines for medevacs would be reviewed to ensure they were “timely and appropriate.”