Whitehorse Emergency Shelter understaffed and staff lacked training - inquest reveals

They said at the time of the incident, there was no clear policy or training available to staff on how to deal with overdose incidents nether were they trained on how to monitor intoxicated guests.

Staff testimony about the deaths at the Whitehorse Emergency Shelter of Cassandra Warville, 35, and Myranda Tizya-Charlie, 34, continued this week before presiding Coroner Michael Egilson. It is expected to take a total of three weeks and examine four deaths.

The three staff members on duty when Tizya-Charlie and Warville died on January 19, 2022, said they were only trained on basic CPR and how to administer naloxone, a medication that rapidly reverses an opioid overdose. No clear policy was in place or training made available to them on how to deal with overdose incidents, they said, nor were they trained on how to monitor intoxicated clients.

That evening's supervisor, who was also questioned by the Coroner, lawyers, and the six-member jury, said he was overwhelmed by the incident, and that it has negatively affected his state of mind.

The night Warville and Tizya-Charlie died was chaotic and they were understaffed, he said, noting he sent an email to his manager about the unacceptability of staffing numbers earlier that night. No clear policy was in place at the time about how many people could go into the shower rooms together, nor was there any policy about how often staff should check on people. The two women, the Inquest heard, were in the shower room with the door locked for three hours before being discovered unconscious.

A paramedic, who responded to the 911 call after the women were discovered, said Tizya-Charlie had a weak pulse when the ambulance arrived. However, when they were ready to administer naloxone, she had no pulse and was treated for cardiac arrest because naloxone isn't useful once the heart has stopped, he said. Having paramedics already on site may have prevented the deaths, he testified.

The Government of Yukon was running the Whitehorse Emergency Shelter at the time. The inquest learned that it changed some shelter policies after the women's deaths by sending an internal email. In the email, the government introduced new procedures about the shelter's main floor shower rooms specifying that only one guest could be in there a time and that the name of the client using the room should be communicated over radio to on-duty staff, and that the client should be checked every 20 minutes.

After that night, the government also installed sensors in the shower rooms which would send an alarm after detecting no movement for five straight minutes. A minimum of four people per night shift was also a new policy implemented by the government after January 19, 2022.

The Coroner's Inquest continues for the next few weeks, examining the circumstances around four deaths associated with the shelter, including Josephine Elizabeth Hager 38, and Darla Skookum 52, who both died in early 2023, after the Government of Yukon had stepped away form managing the shelter and had the Council of Yukon First Nations (CYFN) take over.

The public inquest continues at the Gold Rush Inn in Whitehorse. You can also watch it via Zoom by going to this page: https://yukoncoronerservice.ca/inquests#notice-of-inquests

In-person and virtual rapid access counselling appointments can be made by calling 867-456-3838, or toll-free at 1-866-456-3838. In-person counselling will be available in Whitehorse, as well as in Carmacks from April 17-19 and April 22-23, and Pelly Crossing from April 10-12.

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