Institutional Betrayal Number One
HUMBER RIVER HOSPITAL STILL
COVERS UP MEDICAL NEGLIGENCE(Dr. Laz Klein)-, CEO B. Collins
Humber River Hospital -North York, Toronto
SHOULD YOU WORK FOR THIS HOSPITAL, KNOW SOMEONE WHO DOES OR PROSPECTIVE PATIENTS, PLEASE HAVE THEM SEE THIS POST AS HUMBER RIVER HOSPITAL DEFINITELY DOES NOT WANT THEM TO SEE THIS. PLEASE SHARE THIS POST especially to those in Toronto.
A PRIMER ON THE LAW OF DEFAMATION IN ONTARIO:"Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words)
Proving a Claim in Libel and/or Slander
"the statement must be false!"
Defences to Actions in Libel and Slander
TRUTH--
"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefore there was nothing false about the statement, meaning therefore, that the statement was not defamatory."
FAIR COMMENT--
"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."
QUALIFIED PRIVILEGE--
"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate.
My twelve year struggle resulting in failure to bring about the truth, protect Ontario citizens and open up true transparency and accountability.
Will the Patient Ombudsman's Office be another failed institution?? WELL, I WAS RIGHT--ANOTHER WASTE OF TIME.
Should you be an Ontario citizen and care about Health Care in Ontario, this should be of interest to you. Please pass this on to all of your social media contacts especially family members.LIBERAL GOVERNMENT REFUSES TO IMPROVE HEALTH CARE TRANSPARENCY AND ACCOUNTABILITY.
SHOULD YOU OR A FAMILY MEMBER SUFFER AN ADVERSE EVENT IN AN ONTARIO HOSPITAL---THE TRUTH WILL NEVER BE REVEALED, INSTEAD NEGLIGENT MEDICAL CARE WILL BE COVERED UP BY ALL INSTITUTIONS UNDER THE AUTHORITY OF THE PRESENT LIBERAL GOVERNMENT.
THE NEWLY CREATED PATIENT OMBUDSMAN'S OFFICE IS A COMPLETE WASTE OF OUR TAX DOLLARS AND PORTRAYS A FALSEHOOD THAT A CITIZEN CAN TURN TO SHOULD THEY FEEL A HOSPITAL HAS MISTREATED THEM.
I DON'T BELIEVE THERE IS A PROVINCIAL PARTY, AT PRESENT, THAT WILL GO UP AGAINST THE CPSO AND CMPA.
Regardless of the friendship between Ms Elliott and Ms Collins, I feel she should be fully engaged in the investigation as this is far to important to disqualify herself! As the Patient Ombudsman, how can she investigate if she has friendships with the administrators of Ontario hospitals and disqualifies herself?
I met with the Patient Ombudsman, Christine Elliott, my MPP, Steve Clark and a patient ombudsman investigator, Marie-Claire Muamba with regard to HRH and Dr. Klein. This occurred several months ago, September 22/2016. I was told not to post anything until they had been in touch with HRH. This has occurred.
Marie, I am a little hesitant with regard to the coming phone call today, January 11, 2017, as I have had so many from so many investigators who merely want to inform me that there is nothing to be done! All these phone calls do is raise my blood pressure and anger me. They ignore the evidence and do a lame job of trying to explain why they find nothing to my concerns, which of course, is absolutely ludicrous!
HRH has an opportunity to bring forth the truth after concealing it for over ten years. The patients of Humber River Hospital should have the assurance that should an adverse event occur, this hospital will not conceal the truth by remaining silent. I and all of whom are aware of Terra Dawn's hospitalization and death would certainly not go to this hospital nor recommend Humber River Hospital to anyone. The problem is most Ontario citizens are completely unaware!
Ms Collins, knowing that my complaints with regard to Terra's care or lack thereof has been ongoing for ten plus years, one would feel compelled to reopen my file when the Excellent Care For All came it effect.
Keep in mind, I met with five HRRH administrators in May of 2008 whereby they didn't respond to a single question/concern of mine. This was before I actually had the hospital records. Once studying the records, I often sent my new concerns to Ms. Collins.
Excellent Care For All
- Have practices in place for handling patient complaints as part of the organization's overall patient relations process. As part of these practices, health care organizations are be required to:
have processes in place for reviewing and resolving complaints made by patients and caregivers record, monitor, and analyze key information about each complaint, including the name of the person who made the complaint (except in the case of an anonymous complaint), the date the complaint was made, the subject matter, whether the complaint was resolved, and if so, when and how the complaint was resolved
- inform the person who made the complaint of its review status, within five days of the date the complaint was made and whenever the person who made the complaint reasonably requests further information
Remember this is after Terra's death--considering this surgeon has multiple deaths, and the fact that his department was temporarily shut down due to multiple deaths in 2009 up to Feb of 2010, the CEO and COO should have realized there was a serious problem present. Let's not forget the death of Crystal Rose in Dec of 2012. Perhaps, HRH's lack of action led to these deaths and continue to do so.
Duty where serious problem exists CEO and COO were well aware of a serious problem! But ignored it for the years.
(3) If an officer of the medical staff who is responsible under subsection (1) or (2) becomes aware that, in his or her opinion a serious problem exists in the diagnosis, care or treatment of a patient, the officer shall forthwith discuss the condition, diagnosis, care and treatment of the patient with the attending physician. 2006, c. 4, s. 52 (12).*************************
Should they not, the Ontario Citizens should be able to access a public document from the Patient Ombudsman's Office indicating HRH's lack of transparency and accountability and their excuse to hide behind the "Excellent Care Act" and conceal the truth with regard to a surgeon's negligence which resulted in many more deaths after Terra Dawn Kilby.
Also: If the phone call has to do with what I want from HRH. l doubt they will do the following.. They will not want to put anything on record.
For example-- a written response to some of the following questions. There are many more questions!
1. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to change to an open abdominal surgery to perform a colon resection and removal of a tumor after attempting a colon resection laparascopically without administering the mandatory antibiotic prophylaxis???
2. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide the patient with antibiotics when the abdominal incision became so infected that all staples had to be removed, considering the patient did not receive the mandatory antibiotic prophylaxis at the time of surgery???
3. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide antibiotics to the patient when test results indicated the "presence of many gram negative bacilli" considering the patient had not received any antibiotics whatsoever???
4. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide supplemental nutrition after five days of the patient only receiving a liquid diet and where records indicate the patient was not tolerating current diet???
5. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to keep a patient on a liquid diet for nine days without nutritional supplementation??
6. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to ensure the patient had a solid bowel movement after consuming her only two solid meals just prior to discharge??
7. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to not see the patient the day of discharge??
8. Is it hospital policy and the standard of care for Humber River Hospital take over two years to substantiate my assertion that the mandatory antibiotic prophylaxis was not administered even though the surgeon kept telling the COO that he had done so???? And this was only done so during a phone call I had with Ms Collins.
9. Would HRH not consider all of the above to be negligence on the part of the surgeon and perhaps the hospital???
PLUS SO MANY MORE QUESTIONS WHICH HRH CAN EASILY SEE BY STUDYING THE HOSPITAL RECORDS.
*******************
CPSO's Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. (Laz) Klein in this case.” The CPSO issued a secret written caution to Dr. Klein and stated that PERHAPS he MIGHT want to CONSIDER administering the mandatory antibiotic prophylaxis in THE FUTURE when converting from minimal evasive to open surgery!
*******************
SEE COMMENTS AT END OF POST BY OTHER ONTARIO CITIZENS.
Ms Deborah Dennie, e-mail send to Ms Dennie with no response.Director of Education, Quality Support and Risk Management. HRH
My MPP and I will be meeting with the new Patient Ombudsman.I know you will undoubted run to the new CEO about this however I am hopeful you will bring forth the truth after it has been conceal for such a long time.
Ms Dennie
I understand you conduct in-hospital deaths without consulting with nursing or medical staff who were involved in that incident. And then, quite often, you would go to the program director and get some information from her or him to prepare your report. It is now time to bring forth the truth!
Did you and another party investigate the death of Terra Dawn Kilby when she passed away on July 21st, 2006 less than 12 hours after being discharged by HRRH, Finch Street Site.What was the date of this investigation?
Who else was involved in this death investigation?
Were copious notes kept of this investigation?
What was the result of this investigation? Scott Jarritt stated at a meeting you found no concerns!! I would love to put you on the stand before a Judge/Jury to have you commit purgery!
How many times have you investigated an in-hospital death of one of Dr. Laz Klein's patients? He must have kept you very busy!
Newsflash! 
Dr. Devlin, Congratulations upon your upcoming retirement from
HRH as its CEO. A FEW MONTHS BACK, RUMOUR HAD IT THE MINISTRY OF
HEALTH WAS FORCING RETIREMENT ON YOU AND ON MS COLLINS, AS WELL. So
perhaps the following is not true?And I understand, Ms Collins is applying to take your place as the new CEO.
Perhaps, it is time to come forth with the truth with regard to the negligent care received by Dr. Laz Klein and provide me with a copy of the supposed in-hospital death investigation which you have continued to refuse to grant me.
I wonder if Dr. Devlin's religious commonality with Dr. Klein prevented the truth from coming out concerning the death of a common Gentile? One must also wonder if Terra's care would have been far superior that it was had she been Jewish? I believe should the Hospital and the CPSO compared patient hospital charts for those of different faith, they would certainly discover a tremendous difference with respect to post operative care provided by Dr. Klein!
Dr. Hoskins won't be Health Minister in less than two years and the Liberals have no hope of forming another Liberal government.
Mr Clark sits right beside Conservative Leader Patrick Brown at Queen's Park. I know Dr. Devlin has supported the Conservative in the past. Perhaps, you Mr Devlin are ready to make some amends to those you have lied to in the past. The victims of hospital neglect -- ie- Jerry and Terry Rose regarding the death of their daughter, Crystal. And perhaps grant them the meeting they requested that the hospital cancelled.
bcollins@hrh.ca rdevlin@hrh.ca
******************************************************************Be Forewarned --If the CEO and COO covers up negligence, should you or a loved one consider going to the newly built hospital. THINK HARD.
Interested in connection with others in Ontario with similar feelings and/or who have dealt with Humber River Hospital, the College of Physicians and Surgeons of Ontario, the Chief Coroner's Office of Ontario, the Death Investigation Oversight Council, the Ministry of Health and the Ministry of Community Safety and Corrections.
THOSE WHO VIEW THIS POSTING, PLEASE SHARE WITH YOUR CONNECTIONS.
SHOULD THERE BE A LAWYER OR LAW FIRM WHO WOULD BE WILLING TO BRING FORTH A LAWSUIT, ALL FINANCIAL AWARDS YOU CAN KEEP. I DON'T WANT MONEY, I WANT JUSTICE!
Sadly, a deceased woman is less valued than one who remains alive in a vegetative state-- one reason why a malpractice suit is rejected by law firms. But in this case, besides the Surgeon, Dr. Klein, I believe a suit could be filed against all who supposedly looked into this death--- Humber River Regional Hospital, Chief Coroners Office of Ontario, the Death Investigation Oversight Council, the Ontario Ombudsman's Office, the Ministry of Health, the Ministry of Community Safety and Corrections, the Health Professions Appeal and Review Board. A knowledgeable Law Firm would know the exact reasoning for a suit against the above publicly funded institutions But "Breach Of Trust" would not in the least bit be difficult to prove.Message from beyond:
"I want you all to know how much I love you and miss you. But I am content and watching over all of you. Until we meet again, please remember all of the good experiences we shared and the fun times we had together as a family."
“ Continue the fight, Dad, so changes are made to protect others”
*********************************************************
College’s Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. Klein in this case.”
The College recommended to the surgeon that perhaps "he might consider the use of antibiotic prophylaxis in the future when converting to open surgery"
HE MIGHT CONSIDER???????
The Chief Coroner's Office, the College of Physicians and Surgeons of Ontario, the Health Professions Appeal and Review Board, the Death Investigative Oversight Council, the Liberal government and Liberal Health Ministers and Premier Wynne apparently agree that it is perfectly within the accepted Standard of Care to:
--have open abdominal surgery without the mandatory antibiotic prophylaxis
--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed An example of something purulent is an open wound that's not healing properly.
--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics
A VERY DANGEROUS PRECEDENCE HAS BEEN SET BY ALL OF THE ABOVE AS THIS DECISION CAN NOW BE USED TO JUSTIFY SIMILAR COMPLAINTS. EVEN THOUGH, IT WAS AN OBVIOUSLY WRONG DECISION.
******************************************************
From: Arnold Kilby awkilby@hotmail.com>
Sent: September 15, 2009 11:49 AM
To: barbara collins Subject: Dear Ms Collins, I am still requesting a copy of ...
Dear Ms Collins,I am still requesting a copy of the internal investigation to my complaints which I ask for in a letter sent around Oct 22 of 2008. I would also suggest that you review your internal investigation as it would appear that it was not very thorough, even though I have not seen it. I presented a very strong case to the HPARB panel this week. With respect, Arnold W Kilby
**********************************
Subject: FW: Terra Dawn Kilby's Death HRRH
From: Arnold Kilby awkilby@hotmail.com>
Sent: July 5, 2010 12:14 PMTo: barbara collins; rdevlin@hrrh.on.ca; steve clark; a horwath; andre marin; bentley; central health integrated network; Christina Blizzard; Collette Gooden; d matthews; dmcguinty.mpp.co@liberal.ola.org; domonique Pierre; Elizabeth Witmer; rbartolucci.mpp@liberal.ola.org; Rick Bartolucci; Talia Talaga; Tim Hudak; Toronto Star; w 5; laz Klein
Dr Devlin & Ms Collins Just wondering whether you are following your lawyers advice not to communicate with me again? There is no lawsuit so I'm not sure why the lack of transparency on the hospital's part? I will be distributing Terra Dawn's flyers shortly after the fourth anniversary of Terra's death. Still waiting patiently for a response. I would still, after several attempts made to you, request a copy of your internal investigation which took place in the 2008 year. I believe I am entitled to this as it pertains to my complaints I submitted to you, and tried to address during the May 2008 interview with your five administrators who sat by deaf and muted. I am re-sending the previous e-mail as I did not receive a response.
Respectfully yours, Arnold W Kilby
From: Arnold Kilby awkilby@hotmail.com>
Sent: June 26, 2013 10:02 PM
To: barbara collins
If there is no cover-up then could I have a copy of the internal death review that was done after Terra's death, which I have asked for on numerous occasions. And how can a patient, regardless of it changing from laparoscopic to open, for removal of tumour and a colon resection be done with no antibiotic given at all, at any time --prior, during and after. I still remember that meeting when it was said that the hospital found no issues???? How in depth was this investigation? Certainly this aspect should be noted in the review as a concern. It is very difficult to believe that the hospital feels Dr. Klein acted in a knowledgeable, professional, ethical etc manner with respect to all aspects of Terra's care, prior, during and after her operation.
**********************************************************************
Twelve Attempts made with no response:
a letter sent around Oct 22 of 2008 September 15, 2009 11:49 AM
Sat 2015-12-12 6:28 PM June 26, 2013 10:02 PM
Sat 2016-01-02 9:03 PM Mon 2016-01-11 4:45 PM
Thu 2016-01-21 9:52 AM Fri 2016-02-05 3:15 PM
Wed 2016-02-10 11:14 PM February 11, 2016 6:25 PM
Feb 23, 2016 March 4, 2016
--- MS COLLINS AND MR DEVLIN IT IS NOW FEBRUARY 23, 2016. PERHAPS YOU THOUGHT OF CRYSTAL ROSE YESTERDAY, AS IT WAS HER BIRTHDAY. PERHAPS, I WILL GET A RESPONSE BEFORE TERRA'S BIRTHDAY, APRIL 22 --- WHICH IS EARTH DAY AND WE NAMED HER TERRA DAWN NOT KNOWING ABOUT EARTH DAY.
I AM VERY SURE CHRISTINE ELLIOTT WILL BE EXTREMELY INTERESTED IN YOUR CONTINUED LACK OF A RESPONSES, EVEN A SIMPLE ACKNOWLEDGE OF RECEIVING MY MANY E-MAILS SHOULD BE EXPECTED.
*****************************************************
Oh, and I forgot the Ombudsman's Office inquired and yes I know they did so, not officially since they do not have the authority and the answer was HRH did one but will not reveal it to them.
Ms. Collins told me the following about your request for a copy of "the report":
- you are asking for a copy of their "internal investigation report"
- you were told that the hospital investigates all deaths in the hospital and that they do a complete review of each case
- she has been in communication with you since a week after your daughter died
- they have provided you with all of the information that they can provide to you - everybody has tried to be understanding but there is nothing more that she can give you
- you have the entire health record - you cannot have all of their internal documents as you are asking for private and confidential information
- there is NO REPORT, she emphasized, but only internal notes and documents
- you have appealed to the Privacy Commissioner to get all of the information from the hospital and the Privacy Commissioner is currently investigating
- the Privacy Commissioner will decide if you can get any further information This is the information that was provided to me.
The last two comments above are incorrect, what I went for dealt with the Chief Coroner's Office, not the hospital.
I appreciate your comments about our lack of jurisdiction over the hospital sector and, I think you know, our Ombudsman is working very hard to try to get his jurisdiction expanded to include the hospital sector as well as the other sectors which our province does not allow him to oversee. I share your optimism that this will be "coming sooner than later" but, sadly, it is not in place now. Unfortunately there is nothing further that I can do to assist you with this issue. I think it is good news that you have taken your concerns to the Privacy Commissioner and given that she is investigating your complaint at this time perhaps you will be satisfied when she has finished her review and can report back to you. I am going to close your complaint on this issue to our office as there is nothing further that I can do. Having said that you know that you can contact me again, directly, at any time, if there is anything you want to discuss.
Fran Cappe Investigator Office of the Ombudsman of Ontario
One wonders what HRH's response will be when Ontario's Patient Ombudsman, Christine Elliott, asks?? I am sure HRH's lawyers are preparing for numerous requests from Ms Elliott.
COO Ms B. COLLINS AND CEO, DR. DEVLIN OF HUMBER RIVER HOSPITAL IN TORONTO. bcollins@hrh.ca rdevlin@hrh.ca
It is now February 18, 2016 and still no response. This will prove to be beneficial in the future.
I, once again, am requesting a copy of HRRH's internal death investigation of Terra Dawn Kilby. I am the father; I deserve this report. We all know who the surgeon is so you can omit his name for privacy reasons. But the facts must become public, for the interest of patient safety, accountability and transparency!
I am still asking for a copy of the supposed internal death investigation done after Terra's death. I kind of suspect that you don't have one. Actually I know you didn't at the time but may have come up with one several years after the fact. I would like to see that one.
I'm sure your death investigation would have dealt with these concerns even though for two years you maintained Terra had received the mandatory antibiotic prophylaxis prior to surgery simply because you asked Dr. Klein and he said yes. Two years to finally look at the records to discover he lied! Remember, I have Dr. Phillip Hebert's questions that were answered by HRRH in the fall of 2008.
The following is the answer to the first question:
Dr Hebert's first question: a. Was antibiotic surgical prophylaxis done at the proper time before time of operation?
HRRH's Response: Dr. Klein has advised that Terra was given the appropriate pre- operative antibiotics.
Why didn't you look at the operation chart to see he attempted a colon resection without the mandatory antibiotic prophylaxis being administered? Then he lied and said he didn't know he had to do a colon resection until after he converted. This charts shows the opposite--- Look at the first Procedure. Why do you continue to cover up negligence when this surgeon is responsible for so many deaths? WHICH WAS A COMPLETE LIE TO YOU AND TO EVERYONE
It is so wrong to think this, but I am convinced in a hospital setting a surgeon/doctor could actually commit a murder and get away with it. They are getting away with negligence contributing to adverse events and deaths taking place in hospitals with no fear of being reprimanded or held accountable. The record of Terra’s surgeon remains spotless although there are more deaths associated with him, and there is no way for citizens to be aware of his past. This is the reality within Ontario. Humber River Hospital by concealing the truth contributes to the above.
HRH has never addressed any of the medical concerns I have sent to you via numerous e-mails in the past. All of which dealt with Terra's pre and post care!
If you recall, often you had mentioned that we could meet, and I had said that unless some measure of acknowledgement that Terra's care should have been better then there was no point in meeting. You never commented on this. Considering the numerous unquestionable issues this was not an unreasonable request. If you recall I met with five administrators in May of 2008 whereby not a single issue was address by Dr. Barkin. So really, how does one expect that a meeting with HRRH would be any different?
The first meeting assessment written by Terra's Aunt who attending this meeting:
HRRH’s Communication Efforts?
“The general attitude of senior staff at HRRH (we met five senior staff members, including Dr Jack Barkin, Chief of Staff, at our meeting of May 15, 2008) appears to be one of complete haplessness: as they have been cleared (by the College of Physicians/Surgeons) of not meeting standards in Terra’s post-operative care, they have expressed a lack of interest in further discussion and have given us the impression that they consider Terra’s death to be a fluke/bad luck/ “just one of those things” / a medical mishap for which there is no explanation and show absolutely no inclination to conduct their own inquiry.
Their truculence to say anything at all, indicates to us that any discussion initiated by them may be taken as an admission of culpability. Is it not incumbent upon hospitals, when these types of totally unexpected deaths occurs, to conduct an investigation, to shed some light on the situation (in Terra’s case, the cause of death was DIC) as some measure of solace to relatives, and also to educate other medical professionals and to advance the body of knowledge on the subject - in other words, perform a public service?
Our family expected HRRH would provide this kind of service to us - that they would tell us what happened/may/could have happened. On the contrary, we have had to conduct our own research, much of it via the internet, via journals, but it can be accessed only by subscribing and paying a fee.
This state of affairs should be unthinkable in our province. Our family knows the CAUSE of Terra’s death - what should be investigated are connections between the events of Terra’s hospital stay and their connections to the onset of DIC. This is the heart of the matter. Terra’s father, has done a meticulous job, researching medical records, organizing documents etc. while at the same coping with his overwhelming grief. He deserves credit for this.”
“It is common knowledge that on very rare occasions, a patient, even a young healthy patient dies after surgery. However, until every detail of the surgery/post-operative period in HRRH have been examined by specialists in the field, we are not prepared to accept the fact that Terra’s death has no explanation.”
Note: Terra's Colon Resection broke down and she bled to death. We had been told that she had DIC which the Chief Coroner later retracted.
**************************
As well, when the parents of another of Dr. Klein's patient (who died in Dec of 2012, Crystal Rose), requested a meeting with the hospital, HRRH agreed to meet. HRRH asked Mr & Mrs Rose to submit the questions/concerns they wanted addressed at the meeting. Then, upon receiving Mr Rose's questions/concerns, HRRH cancelled the meeting! But later in 2016 they met and nothing was resolved.
So, things have not really changed at all!!! REAL CLOSURE WILL NEVER COME ABOUT FOR US AS LONG THE TRUTH CONTINUES TO BE CONCEALED.
HOW RESPONSIBLE IS DR. LAZ KLEIN FOR TERRA'S DEATH AND THIS HOSPITAL FOR CONCEALING THE TRUTH? DR. KLEIN CAN ANSWER THIS.
Dr.John Hagen, Dr. Klein's partner in MIS surgery operating out of Humber River Regional Hospital, delivered this presentation during May 2010 in Montreal as part of a symposium on diabetes.
IN 2010, "With the help of the Coroner's Office, the program was shut down while an external review was done by a well-known expert." (according to this power point display which mentions 5 deaths within 30 days of operation of patients) My sources say it is higher.***************************
From letter sent to the College by Dr. Klein which I had not previously seen.
July 13, 2011
Ms. Angela Bates Manager, Committee Support Area Investigations and Resolutions
College of Physicians and Surgeons of Ontario 80 College St. Toronto ON M5G2E2
RE: Ms. Terra Dawn Kilby - Your File #77429
Antibiotics
"The independent assessor is correct that Ms. Kilby did not receive preoperative antibiotics. I agree with the independent assessor's opinion in response to your subsequent letter that preoperative antibiotics would not have been a contributing factor to the anastomotic leak. Antibiotics are used to prevent or treat an infection. They have no preventative or beneficial effect for an anastomotic leak."
"Furthermore, it is not my practice to prescribe antibiotics for a planned laparoscopic surgery with possibility of conversion to an open procedure."
"As I have explained in my initial response, Ms. Kilby did develop a superficial wound infection postoperatively that was treated appropriately. I do not feel that the wound infection 'was in any way related to the outcome of this case."
L Klein
**********************************
Oh, my God!!!! Dr. Klein has not learned a thing from Terra's death and is obviously going to continue as he did!
This is detrimental to the safety of patients that are under his care!!!!!!
I have not seen this prior to receiving this from HPARB and Humber River Hospital refuse to comment on the concerns I point out regarding Dr. Klein's letter to the CPSO.Dr. Klein’s letter to the College:
July 9, 2010
Ms. Sandra Keough Investigator
College of Physicians and Surgeons of Ontario
80 College St. Toronto ON M5G 2E2
Dear Ms. Keough:
Re: Dr. Lazar Klein
Your File No. 08-CRV-0097
I understand that this matter has been referred by the Health Professions Appeal and Review Board ("HPARB") back to the Inquiries, Complaints and Reports Committee ("ICRC") for further consideration and the issuance of a new decision. I write to clarify my response to Mr. Kilby's initial complaint and to address the specific aspects of the HPARB decision.
Committee's Findings
The Committee had found that:
Ms Kilby's cause of death was determined to be intra-abdominal haemmorrhage with coagulopathy [i.e. DIC]. It is very odd that Ms Kilby had no signs of coagulopathy while in hospital, and that it affected her so suddenly and fatally. Overall, Ms Kilby's case is an extremely unusual one, and the Committee could find no information in the hospital chart or other medical records to predict the horrific outcome, nor any information to suggest that there were flaws in surgery performed by me or the care that I provided that directly or indirectly resulted in Ms Kilby's untimely death. It is an unfortunate fact that the delivery of appropriate and adequate medical care does not guarantee positive results, and that sometimes it is not possible to avoid a tragic outcome, particularly when an unpredictable clinical presentation occurs and when a patient's symptoms do not coincide with the underlying pathology.
With respect to the postoperative care, the Committee found that:
Dr Klein's account of the visits paid to Ms Kilby and attention to her wound are supported by information in the hospital chart, which contains my post-operative notes, documenting that Ms Kilby was seen daily. While the Committee cannot tell from the chart whether Ms Kilby's wound was assessed daily, the record does contain my diagnosis and treatment of a minor wound infection that developed post-operatively.
AWKILBY’s Response: Take a good look at Dr. Klein’s notes, lacking thorough examination on various issues. Also, important to note, the College does not require the length of time to be noted, for obvious reasons. So, a ten second visit counts-----how on earth can one truly care for a patient in ten seconds, and the Wednesday prior to her release she was asleep when he was in the room? On one other occasion I waited in the TV room four doors down from Terra’s room, counted “ten steamboats” and then went to my daughter’s room. Dr. Klein was not only gone from the room but also the floor, as I had asked the nurse to locate him. She couldn’t find him.
Issues Raised by Mr. KilbyThe HPARB panel noted that the Committee did not specifically address in its Reasons certain concerns of Mr. Kilby related to his daughter's postoperative wound infection that he believed to be relevant to his complaint.
In particular, Mr. Kilby:
• pointed to observations in the nursing notes regarding the odour and oozing from Ms. Kilby's wound, as well as abdominal distension;
• questioned whether Ms. Kilby should have been ordered antibiotics;
• queried whether her wound infection may have been related to DIC; and
• questioned whether a CAT scan would have been warranted in the circumstances.
As I stated in my initial response letter, Ms. Kilby did have a superficial wound infection postoperatively.
Postoperative wound infections such as the one experienced by Ms. Kilby are common after bowel surgery. I treated Ms. Kilby's infection promptly by opening the wound and draining the fluid on the fourth postoperative day. As this was a superficial wound infection, antibiotics would not have been necessary. Further, there would have been no need to perform a CAT scan since Ms. Kilby did not have any signs of a systemic infection. As stated in my response letter, she had no fever, no tachycardia, no elevated white blood cell count and normal bowel function.
AWKILBY’s Response: It was on Saturday, Day five after the surgery not Day 4 and the infection spread to the entire incision by Tuesday. Thus her entire incision was now opened up. Since she was given no antibiotic prophylaxis, wouldn’t one think that for this incision infection, an antibiotic would be warranted? Also, what about the gram negative bacilli—left untreated. Gee, an enlarged abdomen doesn’t warrant a cat scan or further investigation? Also when the nurse asked about antibiotics Dr. Klein’s response was “The Body Will Heal Itself” --- Well just maybe, Terra’s body needed a little help.
(Pulse Rates >90) (tachycardia) Please go back and see Terra’s pulse rates. Again, I believe this is proof the Dr. Klein paid no attention to the nursing records.
34/38 of Terra’s recorded pulse rates were above 90 during her stay
Please refer back to comments made by the surgeons I contacted with regard to the incision.
Concerns of abdominal distension were not communicated to me at any time during my daily assessments of Ms. Kilby. As I stated in my response letter, Ms. Kilby continued to recover well after surgery, and the time of discharge she was feeling well and had no complaints. In any event, abdominal distension is not uncommon after abdominal surgery and in my view, would not have given any indication of DIC.
AWKILBY’s Response: Again, did Dr. Klein not look at the nursing records? See description of abdomen. As well, how on earth can a nurse communicate with Dr. Klein when his visits are timed in seconds. Who knows whether the nurse was present in the room while Dr. Klein was temporarily there or not.
As I stated in my initial response letter, Ms. Kilby did not show any signs that would have alerted to me to any cause for concern. Her death was extremely unusual and tragic.AWKILBY’s Response: So none of the following are a concern requiring further investigation????
Did Dr. Klein look at the nursing records and test results??
THE INCISION from July 15 to release from hospital, incision was infected
ABDOMINAL SWELLING from July 13 to release from hospital With significant nausea, vomiting, or abdominal distension, x-rays of the abdomen should be obtained.
MANY GRAM NEGATIVE BACILLI SEEN as stated in hospital records
MANY PMN’S Polymorphonuclear Neutophils greater than 15/LPF as stated in hospital records
Pulse Rates 34/38 of Terra’s recorded pulse rates were above 90 during her stay
Temperatures 23 out 38 recorded temperatures were not in the normal range
Breathing It should be noted that Terra’s breathing to the most part indicated concern. (see hospital records)
All Five Hemoglobin test scores below normal range.
All Five Hematocrit test scores below normal range.
Red Blood Cell Count test scores---one at lowest of normal and other four below
All five Absolute Lymphocytes well below normal range.
All four UREA Blood Urea scores well below normal range.
Breathing It should be noted that Terra’s breathing to the most part indicated concern. (see hospital records)July 11
1133 short of breath on exertion, occasional cough
July 12
0000 eupnea, air entry decreased, occasional cough
800 eupnea, air entry decreased, short of breath on exertion
1300 eupnea, air entry decreased,
1605 nutrition—probably inadequate
1605 eupnea, air entry decreased,
July 13
820 short of breath on exertion, occasional cough
1130 eupnea, air entry decreased, short of breath on exertion
0415 not tolerating current diet, shortness of breath on exertion
1615 eupnea, decreased air entry – lower lobes
1730 not tolerating current diet, nauseated
July 14
0500 eupnea, decreased air entry – lower lobes, shortness of
breath on exertion
815 eupnea, decreased air entry – lower lobes, occasional cough
1200 eupnea, decreased air entry – lower lobes, cough in am
1338 ate about half of what was served
1856 eupnea, decreased lower lobe
2000 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes, oxygen delivered nasal
July 15
0530 eupnea, decreased air entry – lower lobes, oxygen
delivered nasal,
0910 air entry decreased – lower lobes, not able to clear airway of secretion,
1300 air entry decreased – lower lobes, not able to clear airway of secretion,
eupnea --normal, good, unlaboured ventilation, sometimes known as quiet breathing or resting respiration
July 16
0530 oxygen delivery – room air
0830 not tolerating current diet, nausea, save tray to try and eat later
0835 eupnea, decreased air entry – lower lobes
1310 eupnea, decreased air entry – lower lobes
2000 unable to clear airway of secretion, oxygen delivery – room air
July 17
0700 oxygen delivery – room air
0800 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes,
0900 not tolerating current diet, does not nomally eat in morning, save tray to try and eat later
1400 eupnea, decreased air entry – lower lobes
According to the records from 2200, July 17 through to Terra’s release, it appears there was no difficulty with her breathing and eating
What Complications Can Occur with a Colon Resection?
These complications include:- Bleeding
- Infection
- A leak where the colon was connected back together.
- Injury to adjacent organs such as the small intestine, ureter, or bladder
- Blood clots in deep veins in your legs that may travel to your lungs.
When to Call Your Doctor
Be sure to call your physician or surgeon if you develop any of the following:- Persistent fever over 101 degrees F (39 C)
- Bleeding from the rectum
- Increasing abdominal swelling YES
- Pain that is not relieved by your medications YES
- Persistent nausea or vomiting YES
- Chills YES
- Persistent cough or shortness of breath YES
- Purulent drainage (pus) from any incision YES
- Redness surrounding any of your incisions that is worsening or getting bigger YES
Gee, why did Dr. Klein discharge her?
- You are unable to eat or drink liquids YES
Lazar Klein
************************************************
From July 11th after her operation up to July 20th lunch, Terra was on a liquid diet with no nutritional supplementation. A liquid diet should not go more than five days. As well, records show she was not tolerating current diet. Her dinner on the 20th and breakfast on the 21st were regular meals. So, this was the first time she ate regular food. She did not have a bowel movement prior to discharge at noon on the 21st. Gee, one would probably think that the colon resection should have been tested to see if she could pass a solid bowel movement. But not this hospital. She was not seen by any doctor on the day of her discharge. The day prior to her discharge she was seen my Dr. Klein while she was sleeping???? So really, the last time Dr. Klein spoke to her was on two day prior on the 19th when I though my hissy fit about the infected incision. It took quite some time to locate him that day.
USDA National Nutrient Database for Standard References 2004
1. Iron Deficiency = The recommended dietary allowance required by an adult female for Iron is 18 mg/day
Terra’s diet contained: Jello .01 mg Tea .02 mg Broth .06 mg Juice .92 mg
Terra would have received 3.03 (16.8%) mg per day in the course of her 3 daily meals. This means she was lacking 14.97 mg per day!
LACKING 83.2% OF TOTAL DAILY IRON INTAKE!
2. Potassium Deficiency =The recommended dietary allowance required by an adult female is 90 micrograms of Vitamin K per day.
Terra’s diet contained: Jello 0 mcg Tea 0 mcg Broth 0.2 mcg Juice 0 mcg
Terra would have received .6 (point 6) (.7%) mcg in the course of her 3 daily meals. This means she was lacking 89.4 mcg daily!
LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE!
3. Magnesium Deficiency =The recommended dietary allowance required by an adult female is 255 mg/day (milligrams) of Magnesium per day.
Terra’s diet contained: Jello 1 mg Tea 5 mg Broth 0 – 3 mg Juice 12 mg
Terra would have received 63 (25%) mg in the course of her 3 daily meals. This means she was lacking 192 mg daily!
LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE!
4. Vitamin E Deficiency =The recommended dietary allowance required by an adult female is 15 mg (milligrams) of Vitamin E per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .13 mg Juice .02 mg
Terra would have received .45 (.03%) mg in the course of her 3 daily meals. This means she was lacking 14.55 mg daily!
LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE!
5. Calcium Deficiency =The recommended dietary allowance required by an adult female is 1000 mg/day (milligrams) of Calcium per day.
Terra’s diet contained: Jello 4 mg Tea 0 mg Broth 4 mg Juice 20 mg
Terra would have received 73 (.73%) mg in the course of her 3 daily meals. This means she was lacking 927 mg daily!
LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE!
6. Vitamin A Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Vitamin A per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.5 mg
Terra would have received 7.5 (.01%) mg in the course of her 3 daily meals. This means she was lacking 682.5 mg daily!
LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE!
7. Vitamin C Deficiency =The recommended dietary allowance required by an adult female is 75 mg/day (milligrams) of Vitamin C per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.2 mg
Terra would have received 6.6 (9%) mg in the course of her 3 daily meals. This means she was lacking 68.4 mg daily!
LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE!
8. Dietary Fibre Deficiency =The recommended dietary allowance required by an adult female is 25 mg/day (milligrams) of Dietary Fibre per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice .5 mg
Terra would have received 1.5 (6%)mg in the course of her 3 daily meals. This means she was lacking 23.5 mg daily!
LACKING 93% OF TOTAL DAILY FIBRE INTAKE!
9. Phosphorus Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Phosphorus per day.
Terra’s diet contained: Jello 30 mg Tea 2 mg Broth 19 mg Juice 17 mg
Terra would have received 204 (29.1%) mg in the course of her 3 daily meals. This means she was lacking 496 mg daily!
LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE!
10. Zinc =The recommended dietary allowance required by an adult female is 8 mg/day (milligrams) of Zinc per day.
Terra’s diet contained: Jello .01 mg Tea .04 mg Broth .36 mg Juice .05 mg
Terra would have received 1.38 (17.3%) mg in the course of her 3 daily meals. This means she was lacking 6.62 mg daily!
LACKING 82.7% OF TOTAL DAILY ZINC INTAKE!
11. Copper =The recommended dietary allowance required by an adult female is 900 µg/day (microgram mcg) of Copper per day.
Terra’s diet contained: Jello .032 µg Tea .018 µg Broth .246 µg Juice .030 µg
Terra would have received .978 µg (microgram) in the course of her 3 daily meals. This means she was lacking 899.022 µg daily!
LACKING 99.9% OF TOTAL DAILY COPPER INTAKE!
12. Manganese=The recommended dietary allowance required by an adult female is 1.8 mg/day (milligrams) of Manganese per day.
Terra’s diet contained: Jello .003 mg Tea .390 mg Broth .366 mg Juice .184 mg
Terra would have received 2.89 mg in the course of her 3 daily meals. This means she was not lacking manganese daily!
13. Selenium =The recommended dietary allowance required by an adult female is 55 mg/day (milligrams) of Selenium per day.
Terra’s diet contained: Jello 1.5 mg Tea 0 mg Broth 1.7 mg Juice .2 mg
Terra would have received 10.2 (18.5%) mg in the course of her 3 daily meals. This means she was lacking 44.8 mg daily!
LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE!
14. Thiamin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Thiamin per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .004 mg Juice .052 mg
Terra would have received .168 (15.3%) mg in the course of her 3 daily meals. This means she was lacking .932 mg daily!
Thiamine is an essential coenzyme in carbohydrate metabolism. Because of its constant demand and limited storage thiamine is required daily.
LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE
15. Riboflavin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Riboflavin per day.
Terra’s diet contained: Jello .008 mg Tea .025 mg Broth .015 mg. Juice .042 mg
Terra would have received .09 (8.2%) mg in the course of her 3 daily meals.
This means she was lacking 1.01 mg daily!
LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE!
16. Niacin =The recommended dietary allowance required by an adult female is 14 mg/day (milligrams) of Niacin per day.
Terra’s diet contained: Jello .001 mg Tea 0 mg Broth .711 mg Juice .181 mg
Terra would have received 2.679 (19.1%) mg in the course of her 3 daily meals. This means she was lacking 11.321 mg daily!
LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE!
17. Vitamin B-6 =The recommended dietary allowance required by an adult female is 1.3 mg/day (milligrams) of Vitamin B-6 per day.
Terra’s diet contained: Jello 0 mg Tea .002 mg Broth .024 mg Juice .045 mg
Terra would have received .213 (16.4%) mg in the course of her 3 daily meals. This means she was lacking 1.087 mg daily!
LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE!
18. Vitamin B-12 =The recommended dietary allowance required by an adult female is 2.4 mg/day (milligrams) of Vitamin B-12 per day.
Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 0 mg
Terra would have received 0 mg in the course of her 3 daily meals. This means she was lacking 2.4 mg daily!
LACKING 100% OF TOTAL DAILY VITAMIN B-12 INTAKE!
Calorie intake for a Female at Terra’s weight
Daily Requirement
Sedentary 1,816 - 1,982 Carbohydrates 130 grams per day
Low Active 2,016 - 2,202 Protein 46 grams per day
Active 2,267 - 2,477
Very Active 2,567 - 2,807
Jello 84 calories 19.16 g carbohydrates 1.65 g protein
Tea 2 calories .53 g carbohydrates 0 g protein
Broth 29 calories 1.76 g carbohydrates 5.35 g protein
Juice 114 calories 28.2 g carbohydrates .25 g protein
Total = 687 calories 148.95 g carbohydrates 21.75 g protein
Protein = Terra was lacking 21.75 g of protein per day!
Terra was only consuming 687 calories daily. A starvation diet is listed as below 1200.
Nurses: Angella Y Miller Betty Traynor Cheryl Byrnes Gylanne Allen
Jennifer Celio Jennifer Dyce Kalpana Mohammed Linda Lane
Paul Pangilinan Claudia Herod Allan Gylanne Ingrid Nattras
Julie Lazzaro Kwabena Omane-Badu Marlene Sutherland
**********************************************************************
The CEO and COO couldn't run the previous Humber sites and now it they can't run this new facility
Safety of Patients May Be Compromised at Humber River HospitalSame Old, Same Old
Toronto, February 8 2016 — The Teamsters Union would like to inform the public and fellow hospital workers of several serious health and safety problems at the new Humber River Hospital.
Since the hospital’s opening last October, some 900 workers represented by Teamsters Canada Local Union 419 have noticed and documented dozens of hygiene issues such as the failure to use proper disinfectants in rooms and public spaces.
Some of the issues documented by the workers and the Union:
- Traces of blood, urine and other bodily fluids can be found throughout the hospital, usually on the floor.
- Workers had no mops, brooms or adequate cleaning supplies during the first ten days after the hospital’s opening.
- Feces, urine and other bodily fluids can’t be cleaned properly because the microfibre mops aren’t made to wash certain surfaces. Furthermore, there is no vacuum cleaner in some departments.
- Tap water is used to clean some departments because workers lack proper cleaning products.
- Cleaning products used in some departments are not approved for use in hospitals.
- Trays with leftovers are left accumulating in certain areas.
- Meals are occasionally served below 74 degrees Celsius, despite safety standards, which could lead to food-borne illness.
- Patients sometimes cannot get hot meals.
- Mismanagement has created food shortages resulting in some patients not being served bread or milk with their bedside meals.
- Housekeeping workers are extremely overworked in most departments.
- Steaming is done in a way that may not kill all bed bugs. Bed bug removal protocols have been compromised by mismanagement.
- Garbage bags and linen bags don’t fit in the chutes and are left for days piling up in soiled utility rooms.
- The collective agreement is regularly violated because certain tasks are done by the managers and volunteers who aren’t properly trained.
- When the hospital re-opened with even more square footage, management did not hire enough new workers to adequately meet hospital standards.
- The collective agreement is regularly violated as certain tasks are performed by non-bargaining unit members who aren’t properly trained (such as well-meaning volunteers and middle-managers).
- Despite adequate hospital funding, absent workers aren’t always replaced. That puts more pressure on the rest of the staff.
- Robots have priority access to elevators; staff and patients must wait or remain trapped inside the elevator.
- Patients have been observed taking the elevator at the same time as workers with waste bins.
********************************************************************
Family and friends do appreciate the Memorial Garden and sitting area in memory of Terra at the Finch St. Site.
BUT THE TRUTH IS LONG OVERDUE.
TERRA
Some Day Soon We’ll Be Together, Again
April 22, 2012 at Terra’s Memorial Garden 1:00 pm
May visitors wonder why this is here?
Hearing your story they may shed a tear.
Your young life ended with much more to do.
A beautiful soul left us too soon,
Leaving behind in our hearts, a very deep wound.
A symbol of negligence, a reminder to all,
A warning for patients lest they befall.
A Memorial Garden dedicated to you.
For your family and friends, ----this--- a symbol of love,
Thinking of you, looking down from above.
Still hiding the truth are those in the know,
Lacking transparency and not willing to show.
For surgeons and doctors you know what to do.
Your patients require much more than your charm.
Remember “primum non nocere–first, do no harm”!
A sister, a daughter, a niece and a friend.
All her love and friendship both did ascend
To those she met and to those she knew.
Was a compassionate, romantic and intelligent girl.
Enthusiastically giving all experiences a whirl!
The time will come when together we’ll be,
Reunited again with our little “Louie”.
Never more will we ever say “adieu”.
Our caresses and kisses we will certainly regain
Some day soon, ----we’ll be together again!
LOVE YOU FOREVER,
WHY I CAN'T BE SUED?
A PRIMER ON THE LAW OF DEFAMATION IN ONTARIO:
"Defamation
is comprised of two subcategories between libel (libel refers to
written defamatory statements)and slander(broadcasting of spoken
defamatory words)
Proving a Claim in Libel and/or Slander
"the statement must be false!"
Defences to Actions in Libel and Slander
TRUTH--"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefore there was nothing false about the statement, meaning therefore, that the statement was not defamatory."
FAIR COMMENT--
"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."
QUALIFIED PRIVILEGE--
"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate.
THE PATIENT FACTOR
http://thepatientfactor.com/canadian-health-care-stories/the-unholy-alliance-between-organized-medicine-and-government-a-fathers-quest-for-truth-and-justice-in-public-health-care/
http://www.torontosun.com/2013/10/11/why-did-woman-die-after-routine-surgeryhttp://www.torontosun.com/2013/10/18/secret-medical-cautions
Terra Dawn Kilby "An Angel In Our Lives"
April 22/78 to July 21/06 http://anangelinourlives-awk.blogspot.ca/
Video https://www.youtube.com/watch?v=lMof3T--zUY
Poems www.facebook.com/terradawnkilby
NOTHING HAS CHANGED SINCE TERRA'S DEATH IN 2006
THE ULTIMATE RESPONSIBILITY AND ACCOUNTABILITY FALLS TO THOSE WHO ARE IN CHARGE! THE FOLLOWING COMMENTS REFLECT THE CONTINUING LACK OF CONCERN BY THE VERY SAME PEOPLE WHO WERE IN CHARGE OF MY DAUGHTER'S HOSPITAL ON FINCH STREET.Beautiful new hospital BUT same old story!
My guess is the Patient Ombudsman's Office may be getting several complaints. Comments reflect the overall lack of leadership. One would think the CEO and COO would address the very common complaints made by so many people over so many years?????
SYSTEMIC ISSUES IGNORED FOR YEARS
this hospital is the worse hospital in Canada, facility and doctors do not have care about patient.
i visit last night and i have a swear pain in stomach , i was there from last two hours but no doctor was came to diagnose me. i was servings from pain. doctor was very very rude his name was vaidyanathan sammy . when i came nurse put drip at wrong part ,i was telling her its paining but she said no its write .then i told other nurse who was in reception she said i can not do anything i can not do any thing "very rudely" .then after, near about 2 am when doctor came and ask to give medicine by drip then other nurse realise that drip needle was at wrong position and the needle was in my body from three hours and paining a lot. then she take it out and insert new one. hospital was so dirty. i swear to god i will not go there again. that 6 hours was very bad hours of my life when i was in hospital Submitted Jan. 18, 2017
***********
The majority of the staff does not care about the well being of their patients, particularly in emergency. Waiting patients went unassisted for 30 whole minutes, due to the fact that there was not ONE nurse checking people in to even register as a patient. Truly horrible. Don't come here if you're in an actual emergency. Submitted Jan. 10, 2017
*************
Terrible service. Took about 2hrs once just for a doctor in the ER. Some nurses do not do there jobs but have patients family members do the job for them. With all that that technology, you'd think they would provid top rated service. Submitted Jan. 7, 2017
**************
Horrible experience. I went to the ER after passing out cold, having a bad headache and bloody nose. The Dr came in, asked me if I had a flu shot and I said no and I dont want one. She asked me if I had a fever and I said that I didnt know if I did or not. Then without checking my temp, blood pressure, etc... she said I had the flu...
I had no symptoms of the flu and went in because of passing out, severe headache and bloody nose. Ended up passing out on the way home from this hospital and in a different ER which then diagnosed me properly.
Literally the worst ER experience that I have ever had Submitted Jan. 6, 2017
************
Understaffed er,very slow and poor care. 9 hours waiting I guess it is the norm this days. Submitted Jan. 6, 2017
*************
Given antibiotics for a virus. Containers in both room and bathroom filled and overflowing with fecal waste over the Labour Day weekend. Incompetency and rudeness of nurses. Total unprofessional on the whole Submitted Dec. 29, 2016
************
HRH, the nurses need much training in the service dept. I went for surgery and every work station I passed by, there was nothing but arguing and bickering amongst them. It was embarrassing to hear, from professionals. It also clouds the judgement when taking care of patients. Grow up. Submitted Dec. 19, 2016
***************
Hosptial kills there patients and than try covering it up I lost my uncle today because of them Submitted Dec. 17, 2016
*************
Do yourself a BIG favour when in need and go to the more established and specialized hospitals in downtown Toronto....enough said. All the best. Submitted Dec. 11, 2016
**************
I think people who works at the emergency here don't know the meaning of emergency and do not treat patients with care or any concern. Emergency room is full of people with non-emergency situations while people who need urgent care has to wait bleeding and in pain. Ontario provides free health care which is nonsense thinking that these hospital staff and doctors are being paid with our taxes. Although I am complain about this hospital and its service right now there is no government related offices that I can complain to make a difference... That tells me what a b_llsh_t system we are living in. Submitted Oct. 6, 2016
**************
Humber hospital has GTA's highest death rate- It's covered up by the College of Surgeons and Physicians. 100% transparency is needed. Cameras needed in the surgery rooms to hold all medical staff accountable and to eliminate/reduce mistakes and negligence. Patients have the right to see what has been done to their bodies during surgeries, especially when under anesthesia. Patients require a digital copy of their surgery. Submitted Oct. 5, 2016
***********
Last month Sept. i had a right breast infection surgery at HRH . Doc and operation nurses were taking care me for about 1/2 an hour. Guess what? at the end of breast infection surgery was over they forgot many meshes like a small sponges in my deeply right breast infection. After 3 days surgery i got that out from the CCAC clinic. All of them turned to black colour and stinky smell. I still have the picture record when they were changing wounded. Then i talked to the Doc about it, he said did not do it, maybe nurses... Then he did a right breast surgery again because it was causing my health in dangerous and my both legs was swollen and fever and painfull... For me, i hope everyone who is chosing to go HRH more carefully and keep eyes on your surgery... Finally, i hope they are working with their heart and care to patients because we are same person... I forgive them all because Jesus love them too and God bless all of you guys and all patients... Submitted Oct. 3, 2016
**************
15 Mar, 2016
"Registered Nurse" Current Employee - Registered Nurse in Midtown Toronto, ON
Doesn't Recommend
Disapproves of CEO
I have been working at Humber River Regional Hospital full-time
Pros
Unfortunately very few positive comments to make about this hospital and the environment. It's a job that pays your bills! You do meet a lot of great people and build close relationships with other employees/ coworkers.
Cons
Let's start with the upper management. Very poor culture that does not value their employees. Upper management has displayed unprofessional behaviour on several occasions, where upper management was yelling at the unit manager in front of employees. That tells you a lot about the professionalism of the higher management.
Moreover, managers will never give you positive feedback, the only thing you ever hear from them is negativity. Patient assignments are extremely unsafe and when you bring it up to the management they turn it around and make it seem like it's your fault that you don't know how to time manage or lack skills! Unfortunately it's a very unsupportive environment. Management only cares about their budget, not the patients or the employees.
Vacation time, managers give you really hard time when requesting vacation time even when you have accumulated enough vacation time and is entitled to vacation. Not sure why they are doing it but I have witnessed it on several units with several managers.
Team leaders, make unfair assignments that favor their friends. Once again when you bring it up to the management nothing is being done.
Humber river hospital cannot keep their employees, there is a very high turnover and nurses leave with the first opportunity they get. No surprise there are always jobs available and they are always hiring.
The ONLY pro is that it's a new hospital with new technology; it's all nice and clean with really cool bedside gadgets.Show Less
Advice to Management
It's time for you to quite and make room for new managers who care about their employees and patients. Your vision is outdated. We are all humans and deserve respect as we all work very hard so please show your employees respect and appreciation to the hard work we do.
***********************
What a frightening experience. Dad went in for pneumonia, out a week later, then back in a few days later with another but worse. Apparently the first was not serious I learned, thou at the time they said it was the most dangerous. It was a nightmare from emerge to the room. It was like no information was passed to anyone. They tried giving him water, and ice cubes which can kill him cause of aspiration. Luckily family was present on every occasion. If you know anyone there, DO NOT leave them there alone please! Someone stayed with around the clock. A few great nurses both male and female. Roland an Anna (awesome). Many nurses clueless and don't give a ....have to always chase them down to do there job properly. Doc arrives 30 hrs after said Fad had 23/48 hrs. Dad's a Champ! Made it out, a week later and still recovering. Never again. St. Michaels or Mount Sinai is what I will demand in the future. So many horrific memories with the care received.God bless to patients and family members that have to walk through those doors. Submitted Sept. 15, 2016 |
***********************
Shittiest hospital ever. They don't give a crap about people
Submitted Sept. 1, 2016 |
***********************
Please stay far away from this hospital. They mistreat you, misdiagnose you, and lie to you. If you value your life, please do not go to Humber. Submitted Aug. 19, 2016 |
***********************
the new hospital is incredible,but as all these previous comments have said, the staff and waiting times are atrocious for people who are ill and need immediate attention. i was in emerg with critically low hemoglobin and platelets for over 12 hours before I was given life saving blood transfusions. then, i had to wait 6 hours to be taken to a room. Why? because the hospital only employs 15 porters for the entire facility who are overworked and completely stressed. They told me that other hospitals have over 40 porters! What is Humber thinking? Is this how they make their hospital more efficient, by stressing staff and patients needlessly? And forget those call buttons for the nurse. They never come. I've been in other hospitals when they respond in under 5 minutes. Here, it can be up to half an hour before they come in, yet you can hear them chatting at the front desk. What if you were having chest pains, or a heart attack? You'd be gone by the time they came in. I was sick and threw up in bed, and I had to wait, dirty and nauseous for half an hour before anyone came. And you can go hours and hours without seeing your nurse. They don't do vitals like they should. You feel abandoned and forgotten and a burden to them. My mother almost died here needlessly. And if it wasn't out of necessity I would have never gone here. Even the cab driver who took me here warned me against coming here. Without a doubt this is the worst hospital in Toronto. And i agree with all the comments here. If you or your loved ones want to die, come here. The hospital itself is beautiful now, but that is only a facade. Everything else is still the same. Insanely long waiting times, poor nurses with bad attitudes (and in some cases prejudice towards the patients), miscommunication, lack of information, and a lack of confidence. Does the director of this hospital ever read these comments? Another reason to stay away. No one cares. Someone in customer care should be monitoring this site and taking these comments seriously before major disaster strikes and a scandal ensues in the press and in public. Submitted Aug. 13, 2016
***********************
Fazilet E 2016-08-16
The worst hospital ever. In 2002 my daughter almost died due to a misdiagnosis. In 2014 my mother had 2 heart attacks in the Triage. She died after the 3rd one In 2016 - we arrive in an ambulance with my brother as a heart patient and 5 others arrive after yet they were given preference. It is only when I complained after 3 hours that we are going home as obviously ours was not critical enough and he stopped breathing in front of the nurse they took us inside. In 2016 - we got a discharge and referral for a consultant. When I called her she told me she has no idea and I should contact the hospital These are our hard earned tax dollars at work.
***************************************
Regina Bianca Delos Santos 2016-08-04
Slow service. Doctors are not informative. Understaffed. Incredibly rude nurses and doctors.Nurse team leader said "Whatever" when I told him that Im concerned for my father's health even more because the patient beside him had contact precautions. I asked to get my dad transferred to a private room. Team leader kept yelling at my family and I, saying he cannot do it. We told him we'll pay for the private room anyway and there were a lot of vacancies on the floor. He also said that the contact precaution was wrong documentation. Good thing a kind nurse helped us solve the problem. We did end up transferring thanks to the kind nurse's help. And the patient beside has contact precautions. Also, Dr. Singh on the 9th floor makes me wonder why he even became a doctor. The man did not explain findings to us, he was just like, "I printed the MRI results for you to read" and then left.
***********************************
| apppleshampoo 2016-07-27
Have been here twice, first time my nurse went on break and I was forgotten about, didn't even get an IV before going into surgery. New technology is a great idea but it's probably better to make sure staff understand it and it actually works before implementing it. Wouldn't come back here if I had a choice.
****************************
Jason Pickavance 2016-07-10
I can't even begin to explain how absolutely incompetent this place is. Don't ever come here. No body knows anything. It's everyone's first day here. No body explains anything. After seeing so many people's drug over dose my mother countless times and they thought it was no big deal. They are asking my mother's questions and listening to her when she has no idea what she is saying, when they should be asking me. When I'm out of here with my mother this place will be sorry. Absolutely the worst hospital ever
****************
jabar mushtaq 2016-07-05
Staff are rude and disrespectful. members including nurses or technicians. This was my first time at the facility with my mother. I am extremely disappointed. No sense of patient centered care or making the patient feel comfortable in a new environment. I would rate them a 0 and recommend to all people don't waste your time there stuff even don't know doctor iv available or not
*********************************
I can't believe a new modern facility is run in such a horrid way. I hope these reviews are noted and changes made. Go elsewhere! Submitted Aug. 2, 2016 |
***********************
Go elsewhere if you want to walk out a whole person. Submitted July 21, 2016 |
***********************
doctors have egos a little to big, wait time very bad Submitted July 13, 2016 |
***********************
Was here when my mother in law fell sick and died. She broke her hip in the hospital and died one week later. While alive she was given loads of family approved MORPHINE which put her into a coma since she had Liver Disease; the nurses tried to vehemently cover this fact up. 99% of the nurses were atrocious, one from church location who was working there was good. Overall the experience here was horrendous, the reason being the lazy, uncaring, I knowledgeable nurses and invisible doctors. No amount of billion dollar equipment or fundraising will ever make the difference.
This is obvious in the more recent reviews. You go here to DIE. You go here so they can bill OHIP for medications, 'health care', xrays, testing etc.... This morbidly large 'state of the art' hospital is only an illusion of healthcare. Everyone knows the difference is in the PEOPLE the DESIRE of those people and this hospital is a Zero. Another Cash Grab. Another Big Pharma monster and another way to heard the sheep to their deaths. People it's time for a revolution. A Wake Up Call. These people do not care. This hospital is truly an illusion of good healthcare. Submitted July 10, 2016 |
***********************
Samia B 2016-06-27
Staff are rude and disrespectful. No introduction from hospital staff members including nurses or technicians. No explanation about the procedure. Not even a hello. This was my first time at the facility with my mother. I am extremely disappointed. The facility is huge and beautiful but the staff are horrible. No sense of patient centred care or making the patient feel comfortable in a new environment. I would rate them a 0 and recommend the hospital to seriously improve their patient centred care standards.
*****************************************
Do you have a death wish? Then this hospital is for you! Please for the love of anything or anyone, do not get treated here. Do not place your loved ones here. If they are there now, GET THEM OUT! This hospital is where you do to DIE, not get better. They will do procedures that only enable a slow and painful death. Who the heck has ever died from a bladder infection that was the due negligence of nurse and pointless, empty IVs. Majority of nurses should be ashamed of themselves and how the treat people and their hygiene themselves. Flirting with doctors and staff hours on end but god forbid you do the work around your patients. May god have mercy on the patient's souls who have died here and are currently still here.
Submitted June 25, 2016 |
***********************
Kijiji Follower 2016-06-07
Putting lipstick on a pig doesn't turn a pig's ear into a silk purse... transferring poor, unfriendly staff from old locations into bright new building does nothing to change the care. "patient centred care" is supposed to be the model for HRH, rather it is more like "patient centred care is avoided here". For a supposedly 'digital' hospital, it doesn't even offer wifi to visitors... wifi is expected to be available, but there will be a high cost for it. Why do other hospitals and facilities offer free wifi and HRH avoids this plus plans to make a profit too!
**********************
Misha Scarlett 2016-06-22
Where do I begin. New facility same old ways. In April 2016 I was experiencing chest pain, sore throat and the inability to keep my head up. I knew this wasn't the typical sore throat because I could keep anything down. Anyways I was losing weight fast and off to hospital I went. First off, the wait time is crazy. I know you have to wait but to wait all day to see someone is stupid. Secondly, the nurse couldn't find my vein to take my blood and told me to stop complaining. She poked me multiple times. I'm confused as to how med labs can take my blood in one shot and a everyday nurse has to poke me a bajillion times and not even be gentle about it. Then after they tell me I'm young and not to worry, I'm given a referral to a doctor who they supposedly faxed as urgent. It is now June and I am still waiting for that referral.I called the doc for them to only say humber didn't fax it. I called back humber and they said they would get back to me. They didn't . I don't get it, when I was in emerge, the nurses were laughing with the doctors and having a good time. I've never been to a hospital where everyone has so much free time and is surrounded by chaos. I hope I never have to come back. And by the way after going to western hospital and given a referral it turns out it wasn't strep. But thanks humber!!
******************************
This is the worst hospital!!! The triage nurse was very rude. I told him I've had pain spreading through out my body and he said I've been standing in line so basically saying that I was lying and then asked me what he should write in the computer... I wanted to tell him that is his job not mine. Then they sent me to the Ozone where the doctor came in and told me I needed blood work. I also have a needle phobia so I get pretty anxious when they take my blood so when the nurse came in I told her that and I asked her to use a butterfly needle which is smaller so she agreed. As she was looking around and feeling my arms for a vein she could see I was getting anxious so she said I was making her nervous so she went to call someone else. I don't think any nurse should say that. So another nurse came in and I told her the same thing and she asked me what my phobia was and my husband told her and she said ok well I don't like needles either but why the phobia so anyways I asked her to use the butterfly needle and she said she's gonna use the biggest needle because butterfly needles are to short. I think that's very unprofessional and inappropriate to say to a patient who has a phobia of needles..so anyways we wanted 4 hours for blood test results and the doctor didn't know what was wrong. So big waste of time!!! I will never go back!!!!
Submitted June 21, 2016 |
***********************
Worst hospital ever! Was in the waiting room for an hour someone threw up and it wasn't not cleaned! Waited 6 hours and went to 4 different waiting rooms... Came a second time and was told there was only 1 doctor for two different wards. Go to a different hospital and save your self some time
Submitted June 12, 2016 |
***********************
Savena Ramnarain 2016-04-20
my sister's got into a realty bad car accident and they didn't even think to give them any xrays or assess them properly. a day later and turns out my sister has a severe concussion and the other one has a cracked chest bone. This hospital literally did not check for any of these things, it was a terrible experience. Hospitals shouldn't have bad service in a country like this, it was disgusting
*******************************
priscilla pris 2016-05-14
New hospital....same staff same crappy service. If you want to die go there. Staff and Dr are very very unprofessional. A doctor was called in and apparently another one come in. He was arguing with the nurses and charge nurse!!! That he is not leaving its was so bad...and sad they have no love for the job only for the money. #rated the worst hospital in #Canada. For a new hospital. I would never go back
***************************************
A death trap Period. The Guantanamo of hospitals Submitted May 9, 2016 |
***********************
They may have a new facility, but the same nasty prejudice d nurses are still there. The pre/post surgical nurses. Are miserable, especially charge nurse ulene (spelling unknown,,). She belongs in a prison Ward. She is a purely evil woman
Who enjoys the suffering of her patients. As long as there are truly evil nurses like ulene there, you will never recover. It takes forever to get anything done, and some doctors, like dr. Pychur, are truly incompetent egomaniacs. What kind of decent doctor reads your results for the first time when you come back weeks later for a follow up! Keep away from this hospital, the worst one in the city
Submitted April 25, 2016 |
***********************
Jeyhun Ashrafov 2016-04-25
I wish I could mark minus zeros for this place. It is anything, but hospital. Especially employees are so rude and lack minimum compassion that any average hospital worker should have. I was very disappointed by african american lady operating as cashier. Terrible, terrible, terrible...
********************************
Worst hospital ever! Took an hour just to see the triage nurse! Nurses were completely rude, avoid this hospital like the plague! Submitted April 15, 2016 |
***********************
Was there last night for 6 hours and did not get seen by a nurse to check up on my condition or a DOCTOR! Worst service ever! Will never go back to this hospital again. Submitted April 10, 2016 |
***********************
Worker (Former Employee)
Bad reputation
Worker (Former Employee) – Toronto, ON – April 10, 2016
This hospital has a reputation for uncaring staff , and it is true. It is not considered a professional hospital. Managers threaten nurses and insult nurses.
Pros benefits
Cons managers are narcissists
********************************************
For a hospital that has high end technology and that just opened up, not very impressed and these reviews are horrible. This needs to change asap!!!
Submitted April 4, 2016 |
***********************
12 hours at the emergency, from 4 pm to 4 am next day! Three tests done, it took 5 hours to evaluate them and talk to the patient. Discharged and told to go home at 4am, week and exhausted after of waiting. Very unprofessional and rude staff, treating patients without any compassion! Submitted March 31, 2016 |
***********************
Serhiy Zavhorodniy
terrible service. rude staff.
last Friday our family had very bad experience. My 15 month daughter cut here finger. Pretty deep. We called 911. Guys came very fast in 10 minutes. They were very professional and thoughtful for my baby. No complaints. Respect and thank you guys.
But hospital experience was opposite. We waited over 2 hours we were lucky the baby slap. But if didn't? My wife asked one of nurses when a doctor will help us and gave rudely answer.
Finally a doctor showed up and instead of taking care about the baby he started to talk to his colleague and there conversation wasn't about how to help my daughter. I herd. He was very relaxed. It looked like he deals with machines but not with people. We asked him to move faster but got surprised look and he started to argue with us. At this time my daughter woke up and cried. Came his nurse and story started from the beginning (no attention). Finally they did there job, stitched the finger.
It was terrible and unacceptable service. Submitted March 29, 2016 |
***********************
20 Mar, 2016
"Registered nurse"
Former Employee - Anonymous EmployeeDoesn't Recommend
Negative Outlook
Disapproves of CEO
Pros Pays your bills, I guess
Cons Horrible, bully managers. Favoritism. Managers have poor people skills and abuse their perceived powers. You have to shut up or you are targeted and fired. Would NEVER refer anyone there.
NOT a hospital of choice.
Advice to Management
Advice to Management
You were all promoted to your management positions because you are way cheaper than competent managers with managerial skills. You let your positions get to your heads. You favour your nurse friends that you worked at the bedside prior to your promotion. You were horrible nurses even at the bedside. You were promoted because the admin is just as uneducated as you managers are and cannot appreciate how amazing Humber's reputation could be if they actually put patients first.
***********************
You are bullies. Step down before karma kicks in and let the few competent nurses that you have provide the care that patients deserve for a change, without you on their backs..
Winni Chan 2016-03-15
If you want a job there be careful. A certain religion is not suppose to have a superior who is not of their religion, once she/he is a manager/superior, he/she will remove those who are not her religion and hire those who are their religion. One manager there comes from Tansania. She had very little experience in Canada. Her relative by marriage had her hired as a head nurse at the former Salvation Army Hospital. She removed nurses working under her, t replacing nurses with her religion. Her relative/boss arranged to have her manage a floor with light duties, excessively accommodating her well over a year while she made mistake after mistake and collected over $100,000.00 yearly. When she had to take on more duties, her incompetence could no longer be hidden by her boss/relative, and she was walked out of the building. She likely used him (her relative) as her reference, and did not tell Humber the truth about her previous dismissal. Now she works at Humber. For her to be in that position, there is likely someone from Humber's H.R. who was influential in getting her that position--someone also related or attends the same religious setting she attends.
***************
it is the worst hospital ever !!!!
please people, if there is an emergency never ever go to this horrible hospital !!!! its much better to wait longer in another hospital than be seen by their horrible and inexperienced doctors !!! they are the worst !!!!!!
the O-zone waiting area is horrible, the nurses just waste their time without doing anything positive, they don't even have blanket !!!! the doctor was super stupid !! the nurses were terrible. seriously what a waste of money to build this shit hole !!!!!
Submitted March 16, 2016 |
***********************
15 Mar, 2016
"Registered Nurse"
Current Employee - Registered Nurse in Midtown Toronto, ON
Doesn't Recommend
Disapproves of CEO
I have been working at Humber River Regional Hospital full-time
Pros
Unfortunately very few positive comments to make about this hospital and the environment. It's a job that pays your bills! You do meet a lot of great people and build close relationships with other employees/ coworkers.
Cons
Let's start with the upper management. Very poor culture that does not value their employees. Upper management has displayed unprofessional behaviour on several occasions, where upper management was yelling at the unit manager in front of employees. That tells you a lot about the professionalism of the higher management.
Moreover, managers will never give you positive feedback, the only thing you ever hear from them is negativity. Patient assignments are extremely unsafe and when you bring it up to the management they turn it around and make it seem like it's your fault that you don't know how to time manage or lack skills! Unfortunately it's a very unsupportive environment. Management only cares about their budget, not the patients or the employees.
Vacation time, managers give you really hard time when requesting vacation time even when you have accumulated enough vacation time and is entitled to vacation. Not sure why they are doing it but I have witnessed it on several units with several managers.
Team leaders, make unfair assignments that favor their friends. Once again when you bring it up to the management nothing is being done.
Humber river hospital cannot keep their employees, there is a very high turnover and nurses leave with the first opportunity they get. No surprise there are always jobs available and they are always hiring.
The ONLY pro is that it's a new hospital with new technology; it's all nice and clean with really cool bedside gadgets.Show Less
Advice to Management
It's time for you to quite and make room for new managers who care about their employees and patients. Your vision is outdated. We are all humans and deserve respect as we all work very hard so please show your employees respect and appreciation to the hard work we do.
****************************************
I went to the emergency department with concerns about a pregnancy. I was only 6 weeks pregnant... Had pain on my left side and started spotting earlier that morning. This was my third pregnancy so i knew something was wrong- especially concerned about a miscarriage or ectopic pregnancy.
I arrived at 7pm and didn't get discharged until 330am.
Waited in the main waiting room, then in the o-zone waiting room, waited in the room to be talked to for only a few minutes and be transferred to another waiting room. I told the dr's my concern and his response was "i think we both know whats happening here", however if i knew i wouldn't have been there. He then rudely told me without any tests to back him up "you are having a miscarriage."
The transferred to the next waiting room to have blood taken and drink water for an ultrasound that i had to request. They gave me 2 cups the size of almost shot glasses and told me to drink up and got annoyed when i kept asking them to refill it (from the bathroom sink- nasty.)
The ultrasound tech called me in and told me there was not enough water in me (surprise surprise) and sent me back to drink 2 big glasses and she would call me as soon as i was done. After she called 3 other patients ahead of me, and i was in pain about to burst- she called the next patient. I threw a fit asking why everyone else who came AFTER me were being seen before me and her response was "i don't have time to waste on someone who wasn't ready in the first place, so you are at the back
Of my line". I threatened to leave and that's the only reason she saw me right away.
After that the dr came into the waiting room where i was ... With about 20 other people and told me i had a miscarriage and that i was overweight.... Not in private but in front of EVERYONE else. So rude and unprofessional.
Will never go back here. Submitted Feb. 22, 2016 |
***********************
My mother had a total knee replacement on Dec, 2015. The new hospital facilities are incredible. However, the staff were horrible from the janitor to nurses. The nurse were not helpful. When paged the nurse they would come after 15- 60 mins or not show up at all. There was only 1 day nurse that was exceptional.
Unfortunately all the technology can not conceal for horrible staff. Get your staff re-trained or get staff that like what they do. Submitted Feb. 6, 2016 |
***********************
Jahaan Aara 2016-02-06
Emergency service is a trip to hell. After 5 hours that involved an Xray the doctor didn't even see my shoulder properly he just stood away from the bed and asked me to touch my shoulder to show him where the pain is I touched my entire shoulder then he said ok u need Xrays and walked away. After hours and an Xray the doctor pops in and says nothing is broken the nurse will give u a needle , a prescription , put ur arm in a sling and give u directions for a cold compress n walks away. After waiting in the lounge the nurse gives me a needle in the waiting room, puts me in a temporary sling, hands me the papers gives me no instructions about a cold compressions as per the MD n walks away. No staff here exudes any CS
************************************
I went in because I was scheduled to be induced. I was told that I needed to stay in the hospital instead of leaving like most women are told to. I was not close to even being one centimeter dilated twenty hours in. I felt something was wrong so I asked if a c-section is an option if all fails. The doctor and the nurse said it's the last resort. Now here is when I realized this hospital is run by unprofessional people. My sister went to the nursing station at the mat section a couple minutes later. She over heard the nurse that had just been in my room talking to another nurse loudly how I was trying to take the easy way out and people these days and blah blah blah. Now at the 24th hour I was one centimeter dilated they transferred me to the birthing unit. When they brought me there there was miscommunication amongst the staff that I was being transferred there. They started to criticize the doctor in charge in front of me and my family that he's clueless and disorganized. Hmm that made me feel secure. Moving on, so they connected me to an IV of pitocin. The nurse that was monitoring me was a sweet young lady who looked like she was 15 years old. About four hours in I'm in pain but mine and my unborn child heart rate is slowing down. I asked the nurse what was going on and he assured me everything was ok. The nurse looked nervous when she was alone and checking the heart rate. She told us that it wasn't normal. Then another dr comes in and I ask if this can affect my child the fact that his oxygen is low. She said "I don't have a crystal ball". WTH does that mean? If she doesn't know then why was she there? To cut this story down they took me off the pitocin and then put me back on to check if that was what was making the oxygen level go low. It was and they still put me on it again. Then there was the stand off between my family and two Drs and three nurses. I was not dilating any more and mine and my child's oxygen level was dipping real low. We started to push for a c-section since no one can guarantee me there would be no repercussion. They spoke to us like were stupid. One of the Dr had an attitude problem to the point she left the room fuming. They assured me every time was ok. The shifts changed and I got another nurse. Within an hour this nurse read the heart monitor paper and called the doctor and in front of us told him that it was not normal. He left and came back a couple minutes later to say that I'd be having an emergency c-section with a "you win" attitude. If anyone has every had a c-section they'd know it's no "easy way out". In surgery my mother was with me. She was nervous and on edge because of the drs behavior. During my surgery two of the medical students that were there passed out right in their spots. Now i understand it happens BUT for regular folks who its their first time in a c-section surgery it's the last thing you want to see. Afterwards the surgery I was transferred to the recovery room. I had one nurse take care of me while the other three were too busy asking my family where the father of the child was. Now I've gone with my friends when they've given birth at other hospitals and I never heard anyone ask about the father of the child. It's nobody's business. My mouth was so dry I was having a really hard time breathing. I kept asking for water. One nurse told my sister I can get one ice chip at a time. My sister was tending to me instead of the nurse. And I was the only person in the recovery room. There's no excuse. There was at least eight nurses there doing nothing. When I was taken back to my room and for the next couple of days I was told to give my child only 20oz of formula every 3-4 hours and not anymore. When I took my child to see his pediatrician five days after birth he had lost one pound because I was starving him. He told me it's 20oz every two hours or feed him as often as he wants.
Moral of my whole story is do not go to this hospital to give birth. Go to the downtown hospitals. They are rude, do not know what they are talking about, unprofessional with the patients and each other. It's unfortunate that it's the only hospital in the immediate area. Submitted Jan. 29, 2016 |
***********************
Technology alone cannot heal the culture of uncaring at this hospital. Although there are a few shining stars there is mostly a dark void. If you are old and want to live longer go to NYG or Sunnybrook the first time. Submitted Jan. 25, 2016 |
***********************
Just spent the last 16 hours and 8 minutes in emerg w a family member and it was a complete waste of time. A waiting game with 3 tests done all showing abnormalities however 2 docs could not effectively interpret. Waited from 7pm to 5pm to see the surgeon and even she could not conclude what the cause if pain was as she apparently does not specialize in dealing with that pain. Some nurses were nice and a couple were nurturing however the overall feel is that staff are overworked, not fully educated or compassionate and not professionally. New hospital looks great but don't judge a book by it's cover...many issues and not being utilized to it's highest potential. Would definitely not recommend this hospital!!! Submitted Jan. 16, 2016 |
***********************
Been sitting in ER with sever pain for the past 3 hours only to be called to the o-zone to sit in another waiting room to wait for a doctor. No tests run in the meantime. I tell the nurse my pain is worse than when I came in and she says I can't do anything for you. We're doing the best we can! This place is terrible! These people have no idea how to run an efficient ER. Pathetic!! Submitted Jan. 5, 2016 |
***********************
I've worked at Humber for over 10 years. I thought that moving to the new hospital would change things, but oh boy was I ever wrong. I remember a time when I enjoyed coming to work, but that was a very long time ago. What's different is the fact that when I first joined this team, management was all in house. As time went on the hospital chose to outsource it's management to a private company called Compass. This is when everything began to go downhill. Compass is by far the WORST company in the world. They underbid for contracts, receive the contract and then have to cut corners to make up for the shortfalls. For example, I work in the Environmental Services department. Our managers and supervisors don't even supply us with enough supplies such as garbage bags, mops, paper towels etc. How are we supposed to clean without supplies!!! Furthermore most floors have 1 individual cleaning 64 rooms on the evening shift! How On Earth is one person supposed to clean 64 rooms in 8 hrs. Humber CEO and Vice President need to wake up and smell the roses. If you want your hospital to be the best then get rid of Compass and hire in house management!!!
Submitted Jan. 5, 2016 |
***********************
Went there yesterday with injured knee. Waited almost 4 hrs even if it was almost empty with 4 doctors on site. The young female doctor did not seem to really care. Sent me for xray and then stated there was nothing broken and that: "i don't think you need sonography. I think you just bruised the meniscus." I kept repeating her my knee medical history to persuade her to send me for sono, she just did not care. Well, every child knows xrays don reveal soft tissue damage. She suggested going to my GP if it persists. Overall, its new hospital and xray machine was not working properly, i asked for a discharge paper and doctor ignored me, did not get one. She even failed to write her name on a prescription which i found out at a pharmacy. Summary : i wasted almost 4 hrs, going today to a doctor as i need a note for my employer, a prescription for crutches and referral to orthopedist. Submitted Dec. 23, 2015 |
***********************
Dec 18 2015 2PM to 5:45 PM my father-in-law 94 years old has been a patient since the site has opened...he was transferred from the Finch site. I while I was there visiting he was brought down to radiology, and I went down with him. We waited and waited to be brought back to his room. many calls were made to get an orderly to bring him back to his room....after waiting 3 1/2 hours finally two workers from the radiology dept brought us back to his room ...Nurses on his floor were searching for him since he has dementia. I wrote email to admin dept...no reply.....building looks great...but patient care is lacking...shame, shame, shame. Submitted Dec. 23, 2015 |
***********************
I would like to know if any females who have ever been admitted to the Mental Health Unit at this hospital, have ever suffered any sexual assault by other patients This is a serious matter and should not be ignored. Submitted Dec. 19, 2015 |
***********************
I've been waiting over 4 hours to see a doctor in the emergency ward. The worst ever and this is a head injury. Waste of my tax paying dollar. The staff needs more training and this location requires more staff. Not impressed. Submitted Dec. 11, 2015 |
***********************
Terrible place doctors don't know how to speed up emergencies, slow,waiting lines should not be that long considering the magnitude of the hospital really bad experience
Submitted Dec. 4, 2015 |
***********************
No comment, very bad service, not recommended, find another way to solved your health problem.Nurses not professional. Submitted Dec. 2, 2015 |
***********************
Wasted tax payers money on building materials and state of the art equipment.
Staff are not a 21st century level to utilize the equipment and tools.
Narrow minded and third world doctor who could not grasp the patients history to do the necessary testing.
CONTACT THE COLLEGE OF PHYSICIANS AND SURGEONS TO REPORT LESS THAN HELPFUL DOCTORS - THEY WILL BE PUT ON REVIEW.
STAY AWAY GO DOWNTOWN TO TEACHING HOSPITAL.
Submitted Nov. 21, 2015 |
***********************
I feel sorry for this nice , high tech hospital with such bad , mean, untrained employees
Submitted Nov. 19, 2015 |
***********************
The worst, especially the nurses in Pre-surgical Department. Inefficient lazy employees, nurses are very rude in person and on phone. Obviously they don't like doing their job. They need to hire new and happy nurses for the new Humber Hospital. These horrible employees don't deserve the high tech facilities. Submitted Nov. 14, 2015 |
***********************
Stay away from this place! People are rude and very disrespectful. Nurses seem to be overworked. Running a round like little ants. Equipment doesn't seem to function properly (even at the new hospital with all that fancy equipment).
Submitted Oct. 23, 2015 |
***********************
Worst hospital ever. they should be sued for the utter contempt and prejudice they show people. Watch out for charge nurse Euleen, a miserable spiteful woman who I pray loses her job. No one checks on you or gives meds on time. Bot there is lots of time to gossip and laugh. What a disgrace Submitted Sept. 27, 2015 |
***********************
Humber River Regional Hospital Comments
I cannot believe this hospital still operates! The level of expertise is deplorable at best.This hospital needs major funding. Also, needs to be overlooked by a teaching hospital.
I cannot believe that the government allows this to happen to the most vulnerable people in that area that it services. Just horrible. Submitted Aug. 24, 2015 |
***********************
I have to wait forever in the emergency room with pain before getting calling in (few hours) then I have to wait again for a doctor, more than 3 hours just sitting in a chair. Hate this hospital Submitted June 10, 2015 |
***********************
I agree. Bad service, bad nurses AND doctors. Doctor did not come visit after surgery, nor did any other doctor. One nurse may have given me a placebo instead of pain medication, I will probably never know. Submitted June 7, 2015 |
***********************
I will never go back to this hospital. One particular Asian ER doctor was so rude and disrespectful. Frankly I wouldn't even want my worst enemy being cared for by this arrogant person. Submitted May 11, 2015 |
***********************
HRRH is infested with the 'little man' syndrome: people who abuse their small bit of power by treating patients with contempt, disrespect and negligence.
***********************
I had a pre-op workup which entailed having several tests and consultations over 4+ hours. The physiotherapist came out to the waiting room and called for me while I was meeting with one of the doctors. So he left. I mean, left the office altogether. I came out to wait for him, and continued to wait 45 minutes until I finally asked the secretary if I'd been forgotten. She got on the phone and called him back.
When he returned, I smiled and said, "What happened?" He replied, "You weren't here when I called you."
I said, "But I was in another room with another doctor." He retorted, in the cockiest of tones, "Well, that's what happened."
The arrogance was astounding. He blamed me for something that, as a patient, I had no control over; he spoke to me with contempt; and to top it off, he was negligent and irresponsible for leaving without treating me.
The consulting nurse seemed proficient enough, but snippy and impatient. The anesthetist was helpful and respectful, and the x-ray technician was very professional and personable. I guess you have to focus on the good ones and hope the rotten apples don't make any fatal mistakes. Submitted May 7, 2015 |
**********************
Worst hospital when it comes to patient care. I went to the ER today (church site) today regarding some chest pains I been experiencing and to be honest it was a waste of time. The nurse that registered me was not friendly at all, her presentation was not welcoming at all. Nevertheless, she asked me all health related questions and told me to wait when I called. Sat down for literally 1 minute and I was called by one of the clerks and asked me almost the same questions the nurse asked me moments ago. (The clerk was very nice and understanding tho, way better then the nurse) when in and followed the orange line on floor and waited patiently for another nurse to see me. Went to the room waited, a different nurse came in and asked "what can I do for u today, what brought u here?" I explained my complaints to her and she told me the doctor will be in shortly. After 1hr and 30 mins the doctor came in and asked me "what seems to be the problem" explained my issue for the 3rd time! He tested me heart beat/rate with the stethoscope, tested my pulse, and tested my chest by pushing pressure using his two fingers. And at the end of it all he had to say is that its nothing serious, all u need to do is have some rest, its not a blood clot or anything. So I asked him u guys won't be doing any further test on me? No x-ray, breathing tests? He replied and said no, no need for that. I was so upset because this doctor was basically assuming and didn't use and equipment or test to at least try to find out what it may be. SMH. I had this chest pain problem 4 yrs ago, went to the same hospital and at that time the nurses and doctors did everything they could to find out what was going on with me and when the results came back it was a small blood clot.
I would never recommend any one to this hospital. majority of the nurses don't care about the patients, most of them are just in it for the money, socialize and talk gossip. I find the clerks are 100% better caring staffs than the nurses and doctors end of story ! Submitted April 7, 2015 |
***********************
March 13 my husband belongings got lost, keep calling but no updates, I just going to give up, but this is wrong at all levels. worse hospital ever it is a shame we have this kind of hospital in a first work country. No rate for this hospital, if we can we won't ever come back here Submitted March 18, 2015 |
***********************
I had a surgery in this hospital 2 wks ago and it was the worst experience of my life. I've been in the hospital for four days and I would say the nursing care was very poor. I will never go back in this hospital again. Submitted March 5, 2015 |
***********************
Please avoid this hospital! I've never dealt with such rude, inconsiderate, unprofessional people in my life! Stay away! Submitted March 2, 2015 |
***********************
My mom has been in this horrible hospital for 12 days very stressful days for her and the family. Nurses not attending to patients leaving them sitting in their urine or bowel movements for hours, not answering the nurse call button and not being available when needed and always unpleasant and rude. Yes they may be overworked but if they want to be nurses they need to be caring otherwise go find another job. Patients are human not like pushing paper work. Emergency department was awful you have to fend for yourself no one willing to help or tell you what's going on can't get answers patients and families are so desperately looking for. My mom was left in her room with a dead body in the next bed for over 2 hours they should have removed my mom when I arrived she was traumatized. They then put her in the hallway for over 7 hours with no water, food or diaper change where is the dignity in that. There is a lot more I can say but I will do everything in my power never to have my parents go there again it is the worst hospital ever. One doctor from Mississauga said you go to Humber to die and stressed never to go there they are so right. Another doctor said all they are going to do is move all the horrible nurses and doctors to the new location what a shame. I truly hope the CEO does what needs to be done to make it a better place starting with the firing of many of the useless staff. Submitted Feb. 7, 2015 |
***********************
Dirty place, incompetent , and arrogant doctors, rude nurses with long dirty fake nails. Submitted Jan. 26, 2015 |
***********************
Horrible hospital. I went in one day with bad chest pain. It took 4 hours for me to get a bed and another 3 hours for the doctor to see me. When I was discharged, they basically sent me home with pain killers and no diagnosis. I was rushed via ambulance the night after with the same chest pain and upper stomach pain. Again the wait time was ridiculous. The ems guy apologized to me for the wait. The nurse did and exg on me on the stretcher in the waiting room so my chest was revealed to everyone. After my long wait, I was told to come back in the morning because their ultrasound is closed...what?!?!? So I got sent home again with pain killers. I go the next day for the ultrasound at 9 a.m.. I get to speak to the doctor at 2 p.m. at which point he said "your ultrasound is clear. Go to your family doctor." I said, "I still have bad pain. What do I do?" He said, "go to your family doctor." I said, " OK so what if I have severe pain like I did last night?" He then said, "you can come back"........ I was sent home with no results. I'm still in severe pain. Submitted Jan. 15, 2015 |
***********************
I would never ever recommend this hospital to anybody. I tried for a week to find out information about my father who was a patient at this hospital. After 1 week they still could not answer my questions about what medications the hospital was giving him. The patient care is terrible. The nurses stand in the hallways talking in the critical care unit. The bedside button was not working to call them probably because they mute it at the nursing station so that when a patient calls them, the call can be ignored. Worst hospital ever! Do not go there! Submitted Jan. 13, 2015 |
***********************
We be here for over 5 hours waiting to see a doctor. The main waiting area is dirty
Submitted Jan. 8, 2015 |
***********************
Institutional Betrayal Number Two
POSSIBLE BREACH OF TRUST??? --CHIEF CORONER'S OFFICE OF ONTARIO--Drs. Bert Lauwers, Andrew McCallum, Dirk Huyer--appointed by a Liberal majority gov't
CPSO's Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. (Laz) Klein in this case.” The CPSO issued a secret written caution to Dr. Klein and stated that PERHAPS he MIGHT want to CONSIDER administering the mandatory antibiotic prophylaxis in THE FUTURE when converting from minimal evasive to open surgery!
IT APPEARS WHEN YOU SCREW UP, YOU GET PROMOTED
TO ANOTHER GOVERNMENT JOB PAID BY ONTARIO TAX PAYERS!
Andrew McCallum, past Chief Coroner of Ontario, presently Head of Ornge
Bert Lauwers, past Deputy Chief Coroner of Death Investigation, presently President and CEO of Ross Memorial Hospital in Lindsay, Ontario.
ONTARIO, CA. CITIZENS BEWARE. Should an adverse medical event take place the hospital, surgeon, doctors, Coroners, CPSO, HPARB, DIOC, Ombudsmans Office, the Provincial Health Minister, the Premier and her cabinet etc etc. will lie and/or do nothing. It is a shame that the majority of Ontario citizens are oblivious to this, until it happens then it is too late, as I unfortunately found out. The truth is out there but not in Ontario.The Chief Coroner's Office should be held to account for its biased, extremely flawed death investigation ignoring the evidence and they should also be asked to support their opinion with documented fact from medical texts etc. They should be asked to redo the death investigation and not have so many omissions, and they should be asked to hold a public inquest! The Minister of Corrections should get more involved and demand an open public inquest. The Minister of Corrections can step in and demand this.
One must ask if Ontario is really being served by those who are suppose to ensure our safety in terms of Health Care?
How on earth could the, HPARB, the Ontario Ombudsman, and the DIOC be completely duped by the faulty death investigation by the Chief Coroner's Office and the decisions from the CPSO?
All above exhibited the following:
Confirmation bias = seeking or interpreting information that (one thinks) will support one's favored hypothesis or diagnosis.
Ego bias = biasing probability estimates in a self-serving way.
Is it possible that in Ontario we don't truly have transparency and accountability? It appears so.
When the CPSO investigates its own members, and when the Chief Coroner of Ontario, (who is a member of the CPSO) will not consider the expert opinions given from qualified surgeons from around the world, the citizens of Ontario are in deep trouble. This has been so for at least two decades. It is understandable the CPSO will put their members first, but this is wrong. It is understandable that the Chief Coroner can't possible go against the College to which he belongs, so his death investigation involving the medical care or lack thereof is completely flawed and bias when it comes to death investigations involving a hospital/surgeons/doctors.
A. Dear Mr Kilby:
I have read the sad account of your daughter's illness and the medical society's review and find the review flawed and inadequate.
I cannot be an expert witness since I am no longer a practicing surgeon. However, I formerly served on our San Francisco Medical Society's Review Panel. Your daughter's surgeon was wrong and failed to observe your daughter's presenting laboratory and physical findings of intra-abdominal sepsis and wound infection. The surgeon's "slap on the wrist" and review submitted by the Society must have been upsetting to him as a caring surgeon. This may be the only consolation you can ever see for your daughter's death. Hopefully he will have learned from this experience and it will help him provide better care for future patients.
James P. Geiger, MD, FACS COL. MC US ARMY, Retired
*********************************************************************
B. Mr. Kilby,
I have reviewed the document and stand by the comments and concerns that I have sent to you through various emails. In addition to those, my only other comments are:
1. It is very concerning that the nurses repeatedly documented in the chart that her abdomen was large and there was foul odor coming from the wound. Since there was no documentation from the surgeon re: an exam on multiple days, then one can only infer that no surgeon examined her on those days.
2. Gram-negative bacteria on the cultures from a wound with foul drainage suggest an intestinal injury or anastomotic leak.
3. Preoperative antibiotic prophylaxis is the standard of care in the US and, I would imagine, the same in Canada.
4. I can't believe that any physician or surgeon would release a patient from the hospital without seeing the patient or, at least, speaking with the nurses caring for the patient by phone.
Hope these comments, as well as those that I have made in the past, help your cause.
All the best, David
David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015
While complications can happen with any operation, I think the key thing with your daughter's care is that it appears to me that there was evidence that there was a problem before she left the hospital that was not picked up by the doctors, either because they ignored the evidence or didn't see / examine her. How long was she at home after her discharge from the hospital before she returned to hospital / ED
D. Lanning MD
“It is also concerning that she had not passed stool and was quite distended.”
D. Lanning
**********************************************************************
C. I have reviewed the data you supplied and the data from the colorectal surgeon (acting as an independent peer review). I am at a loss to understand the opinion he offered given the abdominal incision was leaking foul discharge which would mandate re-exploration, or at the very least, a CT scan of the abdomen which would likely have shown significant intra-abdominal fluid, suspicious for anastamotic issues. I have four children and my only prayer is to be in the ground before any of them……Short of not agreeing with the expert opinion offered by the independent physician I don’t know how I can help. Your daughter’s loss was tragic and it would appear to me preventable.
Good luck with your appeal if that is the direction you chose……………….Moe Lyons MD FACS
**********************************************************************
D. Dear Mr. Kilby,
I just read through the attachment, and I recall reading your prior email.
My personal opinion is that your daughter died of septic shock related to dehiscence of her bowel anastomosis complicated by acute hemorrhage.
Apparent lapses in care are:
1) Lack of peri-operative antibiotics (I am not a general surgeon and do not know if this fails to meet standard care for right colon surgery).
2) Discharging your daughter with ongoing diarrhea of unexplained etiology,
3) Prolonged period of inadequate nutrition,
4) Nursing records that appear to be at odds with the physician record of the abdominal exam,
5) Failure to distinguish the intra-abdominal catastrophe from the wound infection.
It is self-evident that she was discharged prematurely or she would not have died outside the hospital of a devastating post-operative complication.
The big questions are: would a reasonable general surgeon have acted differently, and did her surgeon practice according to the standard of care – I seriously doubt that he did and I think a good surgeon would have done a more thorough investigation prior to discharge.
Things to consider:
1. The low hematocrit prior to discharge is not evidence of malpractice as this is common with acute illness such as what your daughter exhibited.
2. It would be interesting to see if there was a platelet count prior to discharge.
3. The temperature curves and the reported abdominal fullness are concerns that seem discounted by the College assessment.
As I told you previously, I am a father of an almost 3 year old girl and I now have a 6 month old son and a 4 year old son. I cannot imagine losing any of them particularly in such circumstances. Only you can decide if your quest for justice is worth further fight. I do not understand the Canadian system, so I cannot judge. Your case would be helped if you could find a Colorectal surgeon to review it. Unfortunately, most surgeons would not take interest and I do not personally know anyone who can help you.
I do wish you the best and I hope that at some phase you can find peace.
Max Mitchell MD FACS
***************************************************************
E. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. “It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.”
I'm sorry to hear about the death of your daughter. A parent should never lose a child.
Allan Stewart MD
***********************************************************
F. Dear Mr. Kirby: From what I remember and my review of the information you sent me my opinion is that your daughter received suboptimal care approaching malpractice-at least by US standards. I would have to assume that Canadian standards are equivalent to US standards but from the response I read perhaps they are not.
Best wishes, Steven J. Phillips, MD FACS
*******************************************************************
H. GET A BETTER LAWYER. RRG SWCVTS
******************************************************************
I. Hello Mr. Kilby, It is very difficult to comment sufficiently on your question. There are just so many issues that I may not be aware of and questions that would need to be answered to give you an adequate answer to your question. I can say that for many years I have encouraged patients to build themselves up prior to surgery and to begin using amino acids as soon as possible after surgery. And I have given amino acids to patients so they can begin using them as soon as possible since I do not agree with the often followed practice of near fasting for patients after surgery - the body needs the amino acids to begin the healing process.
I am really sorry to hear of your daughter's case and I am so sorry for your loss. I do hope that someday physicians will be more proactive about improving their patient's nutritional status before and after surgery. I am not optimistic given the general disregard for nutrition that exists anyway.
God bless you, Roger Roger Trubey Dr PH, MPH, ND
You are welcome, Arnold. All I can say is that here in the States you would have a solid case for litigation. I don't encourage frivolous lawsuits or ambulance chasing but some cases can be so egregious that the only way hospitals and physicians will learn is to pay for their mistakes with the hope that the pain is such that it will save others from your daughter's fate.
God bless you, Roger
*********************************************************************
J. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered.
Matthew M. Cooper, MD FACs
*********************************************************
K. “The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge.”
Paul Kirshbom, MD Emory University School of Medicine
**********************************************************************
L. “If there is a documented infection it is mandatory to treat it with antibiotics”
Wendel Smith, M.D
*********************************************************
M. “Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case”
Ron Hill, MD, FACS
To save time and not bore you as many of the comments are similar to those above. THEY ARE ALL QUALIFIED SURGEONS, NOT GENERAL PRACTITIONERS.
1. Sincerely; Niazy M. Selim, MD, PhD, FACS Associate Professor of Gastrointestinal/Laparoscopic, Endoscopic and Robotic Surgery Medical Director of Bariatric Program. Department of Surgery
2. MPC Michael P. Collins, MD, FACS Chief, Division of General Thoracic Surgery Intermountain Medical Center and LDS Hospital Clinical Professor of Surgery Division of Cardiothoracic Surgery University of Utah School of Medicine
3. Matt Slater, MD Associate Professor Clinical Director, Adult Cardiac Surgery OHSU
4. Peter M. Scholz, MD & James W. Mackenzie Professor of Surgery
Associate Dean for Clinical and Translational Research Department of Surgery
UMDNJ-Robert Wood Johnson Medical School
5. C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons
6. Kumar (B. Sivakumar MD)
Call me if you need any help. Best Dr Schraibman MD
7. Paul E. Wise, M.D., FACS Assistant Professor of Surgery Director, Vanderbilt Hereditary Colorectal Cancer Registry Vanderbilt University Medical Center
8. lex Ky MD,FACS,FASCRS Division of Colon and Rectal Surgery 212-241-3547
9. Regards, Douglas Boyd Professor of Surgery University of California Davis
10. Ismael N. Nuno, MD, FACS, FACC, FAHA. Chief, Cardiac Surgery Service LAC+USC Medical Center TEL: (323) 409-8666
11. John Calhoon MD Professor and Head CT Surg UTHSCSA
12. Karen Nugent Honorary Secretary Association of Coloproctology of Great Britain & Ireland
13. Lishan Aklog, MD Chair, The Cardiovascular Center
Chief of Cardiovascular Surgery St. Joseph’s Hospital and Medical Center
14. John V. Conte, M.D. Professor of Surgery Johns Hopkins University School of Medicine
15. Sorry about your loss. Regards, Luca Vricella Luca A. Vricella, MD, FACS
Associate Professor of Surgery and Pediatrics Johns Hopkins University
16. Regards Wan-Jin Shao Chief Consultant Colorectal Surgeon,
Clinical Professor American Society of Colorectal Surgeons(ASCRS )member
Department of Colorectal Surgery Nanjing University of Chinese Medicine Hospital
17. Lynn H. Harrison, Jr., MD Clinical Director
18. Bruce Keogh Bruce.Keogh@dh.gsi.gov.uk Sir Bruce Keogh NHS Medical Director
19. Tonia M. Young-Fadok, MD, MS, FACS, FASCRS Professor of Surgery, Mayo Clinic College of Medicine Chair, Division of Colon and Rectal Surgery Mayo Clinic, AZ 5777 E Mayo Blvd Phoenix, AZ 85054 Phone: 480-342-2697 Fax: 480-342-2866
20. Matthew M. Cooper, MD FACS
21. Douglas Iddings MD
22. Dale D Burleson, MD
23. Sincerely, Daniel H. Hunt MD
24. W Mourad MD
25. I hope you will find peace in your future Amelia Grover, MD
26. Willie Melvin MD
27. Your Welcome, Dr. DeNoto MD
28. Victor Tomulescu MD
29 Helen Chan MD
30. Michael LI K.W. MD
31. Michael H. Wood, MD, FACS
32. Gregory Gallina MD
33. Harold Kennedy MD
34. Elliot Newman MD
35. Best Regards Dr.Tvaruzek MD
36. Charles Anderson MD
37. Dr. Keith Kim
38. Dr. Eduardo Parra-Davila
39. Dr Hugo Gomez-Engler
40. Wendel Smith, M.D.
41. Adrian Greenstein, MD
42. Sanjeev Sharma MD FACS
43. Cohen, Robbin MD
44. Todd Grehl MD
45. Anthony P Furnary MD
46. J.S. Smetana Josef MD
47. David Jayne MD Senior Lecturer in Surgery Leeds
48. Demeester, Steven MD
49. Fernando Fleischman M D
50 Luis Castro. MD
51. HOMAYOON Ganji MD
52. Long, William :LPH Dir. Tra
53. Cord Cordell H. Bahn MD
54. Tara Karamlou MD
55. Michael Wood MD
56. Mike Perelman MD
57. Diethrich, Edward MD
58. Tragic outcome. Good luck in your struggle to obtain justice for your daughter.
Stanley Carson, MD
59. Benson Roe MD
60. Sincerely, A. Michael Booth MD PhD FACS
61. Said Yassin MD
62. Grantham, Nathan MD
63. Bill Murphy MD
64. Blackmon, Shanda, M.D.
65. Brinkman, William T MD
66. Derek von Haag MD
67. Baron Hamman MD
68. Trachte, Aaron Dr.
69. Dr. MacMillan MD
70. Denton A. Cooley, MD
71. Scott B. Johnson, MD Associate Professor
72. John Reza Mehran, MD
73. TW Christiansen MD
74. Kypson, Alan MD
75. Steven J. Phillips, MD
76. Mark S. Allen MD
77. Sorry for your sorrow. Robert L Replogle. MD
78. Zwischenberger, Jay MD
79. Hendrick Barner MD
80. Walter G Wolfe MD
81. SOC Miller, Daniel MD
82. Marcelo Cardarelli, MD
83. Joshua Sonett MD
84. R. Neirotti Rodolfo A. Neirotti, M.D., Ph.D., FETCS
85. God Bless. Cristy Smith MD
86. Paolo Macchiarini MD
87. Sertac Cicek, MD
88. Neil Hyman MD
89. RL Whelan MD
90. Regards feza Feza H. Remzi, M.D. | Chairman | Department of Colorectal Surgery
91. Sincerely yours, Mark Helbraun, MD, FASCRS
92. Thanks Ron Hill, MD, FACS
The CCO's one CPSO expert who was unnamed and the CPSO's one Independent Opinion Provider VS All Qualified Surgeons from around the World who do not belong to the CPSO.
2 CPSO member experts vs 100 experts and I lose??
Statistically impossible but not in Ontario!
********TERRA, I AM SO SAD
Sitting here all alone and I cry.Sadness, depression always present but I try;
To suppress these each and every day.
When Mom and Brandy are far away.
Tears coursing from my lifeless eyes,
Hollow feeling in our lives.
Listening to music—torment in my heart.
Since the day we did part.
Mom and I survived the accident,
Preventing me from my heavenly ascent.
Your presence protected us from any harm.
Caressing your blue rose and name on my arm.
Anguished existence, not alive, my dear,
For some crucial purpose I linger here?
My efforts failed so I question Why?
What am I to do before I Die?
Suicidal thoughts from time to time,
But out of these depths I do climb.
I must be present for Paulette and Brandy. This I recognize for a certainty.
WHAT AM I TO DO?
*************
READERS of this post: After reading this posting, do you feel an investigation of "Breach of Trust by a Public Official" should be initiated?
The past Deputy Chief Coroner has threatened through his lawyer, a defamation suit against me.
jliswood@millerthomson.com -- the law firm blauwers@rmh.orgWhat I e-mailed back. Mr. Liswood,
All posts I have looked at and made minor changes on very few. Really sooner or later I might find something that you appear to be referring to as defamatory??? NOPE, I DIDN'T. But thus far, someone is really stretching things. As well, my "linked posts" have been written carefully and I have gone through all of them. I don't believe you have any authority to stop me from inviting linked"connections" from within the medical field in Ontario or any other parties in Ontario.
What does the reader think?
A PRIMER ON THE LAW OF DEFAMATION IN ONTARIO "Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words) Proving a Claim in Libel and/or Slander "the statement must be false!"
Defences to Actions in Libel and Slander
TRUTH-- "The first defence is the defence of truth. The defence can be made that the statement was truthful and therefor there was nothing false about the statement, meaning therefore, that the statement was not defamatory."
FAIR COMMENT-- "The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."
QUALIFIED PRIVILEGE-- "The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate. especially considering the numerous deaths which occurred after my daughter's death and the one in Dec of 2012.
THOSE WHO VIEW THIS POSTING, PLEASE SHARE WITH YOUR CONNECTIONS.
Sadly, a deceased woman is less valued than one who remains alive in a vegetative state-- one reason why a malpractice suit is rejected by law firms. But in this case, besides the Surgeon, Dr. Klein, I believe a suit could be filed against all who supposedly looked into this death--- Humber River Regional Hospital, Chief Coroners Office of Ontario, the Death Investigation Oversight Council, the Ontario Ombudsman's Office, the Ministry of Health, the Ministry of Community Safety and Corrections, the Health Professions Appeal and Review Board. A knowledgeable Law Firm would know the exact reasoning for a suit against the above publicly funded institutions But "Breach Of Trust" would not in the least bit be difficult to prove.Message from beyond:
"I want you all to know how much I love you and miss you. But I am content and watching over all of you. Until we meet again, please remember all of the good experiences we shared and the fun times we had together as a family."
“ Continue the fight, Dad, so changes are made to protect others”
**********************************************************
THE OFFICE THAT CONDUCTED MY DAUGHTER'S DEATH REFUSES TO ANSWER THE QUESTIONS POSED TO THEM IN A WRITTEN RESPONSE.
Hey there,Remember Eeyore from Winnie the Pooh?
That unbelievably loving donkey whose tail kept falling off, and who was really quite depressed? In my case it is my heart that keeps falling apart.
Eeyore lived in the beautiful Hundred Acre Woods, had friends who loved him, and really he had every reason to be happy... But he wasn't.
He was actually quite depressed. I can related with Eeyore, because I live there too.
My life on paper looks great, I SHOULD be happy, but I am not.
*********************************
Update: Feb. 24, 2016
Subject: Re: Formal Requests to the Chief Coroner
DIOC----COME ON NOW, DO THE JOB YOU HAVE BEEN APPOINTED TO DO. DEMAND WRITTEN RESPONSES FROM DR. HUYER. DON'T ACCEPT GENERAL OPINION BASED ON ACTUALLY NO FACTUAL DETAILS.
MINISTER OF COMMUNTITY SAFETY AND CORRECTIONS, YASIR NAQVI -- YOU AND YOUR MINISTRY HAVE DIFFICULTY RESPONDING TO E-MAILS MUCH THE SAME AS DR. HUYER WHO IS UNDER YOUR RESPONSIBILITY --WHEN WILL YOU AND YOUR MINISTRY LOOK INTO THIS AND THE MANY CONCERNS I HAVE SENT TO YOU IN THE PAST WITH NO RESPONSE
PREMIER WYNNE--YOU AND YOUR OFFICE SEEM TO BE INFLICTED BY THE SAME DISEASE AS MINISTER YAQVI AND DR HUYER WHEN IT COMES TO THE COMPUTER AGE. WHEN WILL YOU LOOK INTO THIS THE HUNDREDS OF OTHER E-MAILS SENT TO YOU AND YOUR OFFICE?
MS NOONAN, YOU MUST HAVE LEARNED A LOT ABOUT THE INNER WORKINGS OF THE CHIEF CORONER'S OFFICE. IT AS REALLY OPENED YOUR EYES. I KNOW YOU ARE FROM EASTERN ONTARIO WHERE WE DO VALUE TRUTH AND HONESTY AND INTEGRITY AND ETHICS. I THINK YOU WOULD AGREE WE NEED A LITTLE MORE "COUNTRY' WITHIN THIS OFFICE.
HOW IS HE ALLOWED TO CONTINUE TO CONDUCT HIMSELF AND THIS OFFICE IN THIS MANNER? The public has lost all confidence and trust in this Office.
WHAT A WASTE OF TAXPAYER'S DOLLARS.
OH, THAT'S RIGHT, WE JUST ADD THAT TO THE BILLIONS OF DOLLARS THE LIBERAL GOVERNMENT HAS THROWN DOWN THE TOILET. I KNOW WHAT NEEDS TO BE FLUSHED.
I don't see the difference, do you see the difference?
**********************************************************
DR. HUYER
Congratulations on this being your very first e-mail sent to me from the many, many e-mails sent to you from me. Your wife and co-workers must be extremely please with your progress and joining the computer age. A bit of a slow learner, though.
It should be noted you will not comment with a detailed written statement with regard to my other requests.
You have cleverly used the meeting which was oral and no records kept for others to review:
TO CONTINUE TO CONCEAL NEGLIGENCE CONTRIBUTING TO MY DAUGHTER'S DEATH TO PROTECT THE SURGEON.
YOU CONTINUE TO CONCEAL THE DEATHS OF OTHER CITIZENS BY THIS SAME SURGEON.
YOU WOULD NOT COMMENT ON THE TEMPORARY CLOSURE OF HIS DEPARTMENT IN 2010 DUE TO MORE DEATHS.
YOU FAILED AT THAT MEETING TO DISCUSS THE ISSUES SURROUNDING THE PAST DEPUTY CHIEF CORONER AND PAST CHIEF CORONER AS YOUR ORAL STATEMENT WAS "THEY DON'T WORK HERE ANYMORE".
ARE YOU PREPARING FOR YOU OWN DEPARTURE FROM THIS OFFICE TO ESCAPE ACCOUNTABILITY AND TRANSPARENCY?
E-MAIL RECEIVED TODAY, FEB 24, 2016
"At the meeting I told you that I would not be responding to future dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest as our investigation is complete.
You acknowledged my position at the June 26th meeting and in a subsequent e-mail on July 3, 2014." **************************
IF YOU TRULY BELIEVE WHAT YOU SAID DURING THE MEETING, WHY NOT PUT IT ON PAPER??????
Do I have a written statement from you with regard to what you state above??? No, and not once did you respond to the e-mails your refer to above. Why? --Again, to avoid a paper trail. And does my e-mails to you agree with what was discussed at our meeting? Of course not.
I would like a written response response to my other requests.
Could you provide my MPP with written reasons as to why you will not respond in print to me.
DO YOU HAVE THE "BALLS" TO RESPOND AND ADDRESS MY CONCERNS SPECIFICALLY OR CONTINUE TO COMMENT WTHOUT SAYING ANYTHING AS YOU HAVE DONE TO OTHERS YOU HAVE MET WITH ie-- Charlotte in Northern Ontario, Michael west of Hamilton --do you require the names of others?
I forgot castration was mandatory in accepting the job of Chief Coroner. Perhaps, this explains your wife's excitement when you informed her of accepting the position.
WHEN WILL OUR SYSTEM APPOINT REAL MEN TO HOLD THESE IMPORTANT POSITIONS? What we need is a responsible female to take over.--oh God, not K Wynne nor D Matthews-- I said "responsible"
And, when will the people who have the authority to act, ACT?
From: Huyer, Dirk (MCSCS) Dirk.Huyer@ontario.ca>Sent: February 24, 2016 11:21 AM
To: Arnold Kilby Cc: Noonan, Julia (MCSCS) Subject: RE: Formal Requests
Dear Mr. Kilby,
I am writing as a reminder of how we concluded the meeting between you, your family members, Ms. Noonan and I on June 26, 2014.
You requested the meeting so that you could present your questions to me and I provided responses based on my review of the information.
At the meeting I told you that I would not be responding to future dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest as our investigation is complete.
You acknowledged my position at the June 26th meeting and in a subsequent e-mail on July 3, 2014.
Respectfully, Dirk
Dirk Huyer, MD Chief Coroner for Ontario 25 Morton Shulman Avenue Toronto, Ontario M3M 0B1 647-329-1814
Give him a call, he won't personally respond.
****************************
You can support this by contacting the OPP and request a Breach of Trust investigation into the Chief Coroners Office:
ATT: Commissioner J.V.N. (Vince) Hawkes
General HeadquartersLincoln M. Alexander Building777 Memorial AvenueOrillia, ON L3V 7V3 (705) 329-6111 1-888-310-1122
How Chief Coroner Dirk Huyer reacts to the family of a loved one who died due to medical negligence besides just concealing the truth and covering it up.College’s Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. Klein in this case.”
The College recommended to the surgeon that perhaps "he might consider the use of antibiotic prophylaxis in the future when converting to open surgery" HE MIGHT CONSIDER???????
The Chief Coroner's Office, the College of Physicians and Surgeons of Ontario, the Health Professions Appeal and Review Board, the Death Investigative Oversight Council, the Liberal government and Liberal Health Ministers and Premier Wynne apparently agree that it is perfectly within the accepted Standard of Care to:
--have open abdominal surgery without the mandatory antibiotic prophylaxis
--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed
--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics
A VERY DANGEROUS PRECEDENCE HAS BEEN SET BY ALL OF THE ABOVE AS THIS DECISION CAN NOW BE USED TO JUSTIFY SIMILAR COMPLAINTS. EVEN THOUGH, IT WAS AN OBVIOUSLY WRONG DECISION.
******************************************************
I did get a response from the Ministry saying they don't have the authority and I should contact the Minister Of Corrections and the Chief Coroner's Office???
So I sent the same letter to Minister Naqvi. He has never responded to me before so I doubt I will receive anything now.
ATT: Attorney General of Ontario-- Madeleine Meilleur attorneygeneral@ontario.ca mmeilleur.mpp.co@liberal.ola.org
Please send a request to the current Minister of Corrections who supposedly oversees the Chief Coroner's office.
Yasir Naqvi
MCSCS.Feedback@ontario.caynaqvi.mpp@liberal.ola.org;
ynaqvi.mpp.co@liberal.ola.org
I ALSO SENT A REQUEST TO THE OPP FOR AN INVESTIGATION INTO THE CHIEF CORONER'S OFFICE.
***************************************
I should note that that a few years ago, I inquired her assistance with regard to the DIOC. I asked a question as to why the DIOC could not look into the medical aspect of my complaint to them against the Chief Coroner and what she could do. She was Minister of Corrections then.
The answer came back from her constituency office with merely the following letters. "FYO"
After thinking what the three letters meant, I got it. I think you can figure it out. "f--k you over" Surprisingly, I received a further e-mail from her office asking me to disregard the previous e-mail as it was sent by mistake.No, someone in her office was actually stating the truth.
**********************************************
re: DEATH INVESTIGATION OF TERRA DAWN KILBY--totally inept death investigation whereby their own independent opinion provider investigating Terra's overall care contained numerous omissions that were very relevant to her death.
PLEASE READ THE INEPT REPORT SUBMITTED BY DR. LAUWERS INDEPENDENT OPINION PROVIDER AND SUPPORTED BY BOTH DR. McCALLUM AND DR HUYER. THEN LOOK AT THE OMISSIONS FROM THIS REPORT. KEEP IN MIND, ALL THREE LOVE TO QUOTE FROM THIS REPORT.
Where the Chief Coroner evaluates death investigations and forms his responses to citizens' requests.
"WE SPEAK FOR THE DEAD TO PROTECT THE LIVING"
November 17,2008
Dr. A.E. Lauwers,CCFP, FCFP
Associate Deputy Chief Coroner
Office of the Chief Coroner 26 Grenville Street Toronto, Ontario M7A 2G9
Dear Dr. Lauwers: RE: Terra Kilby Deceased: July 20,2006
OCCFileNo.: 2006-11425
As you requested, I have reviewed the file on the above person and provide my report. In reaching my opinion, I have reviewed the following materials:
1. The hospital record from Humber River Regional Hospital related to admissions from March 3 to March 4, 2006 and July 11 to July 20, 2006.
2. The Coroner's investigation statement (statement number 2006-054-8).
3. The report of postmortem examination by Dr. Caroline G. Rowlands dated March 22, 2007.
4. A compact disk containing images taken at autopsy and provided to me by Dr. Rowlands.
In summary, the deceased presented to Humber River Regional Hospital on March 3rd with abdominal pain. She was found to have a large mesenteric cyst. There were no acute issues, and she was therefore discharged for further investigation as an out-patient. She was assessed by Dr. Klein and underwent further investigation. A decision was reached to resect the mesenteric cyst. On July 11th she underwent attempted laparoscopic resection of the cyst, but because of intraoperative concerns the procedure was converted to laparotomy. Removal required right hemicolectomy with resection of the associated mesentery that contained the cyst. On the second postoperative day, the patient did have a low-grade fever but this resolved by the following day.
However on the fourth postoperative day it was noted that she had a wound infection. The skin was opened and the infection appeared to be confined to the subcutaneous space and not extend below the fascia. She then had some diarrhea and cultures for Clostridium difficile were negative. This seemed to settle and she was discharged home on the ninth postoperative day. Arrangements were made for Home Care visiting nurses to manage the abdominal wound with the intent that it would heal by secondary intention. The records indicate that on the evening of discharge she collapsed at her parent's home and was returned to hospital by ambulance but died in the emergency room despite resuscitation efforts. A Coroner's investigation was undertaken and a forensic autopsy carried out. The pathologist concluded that the patient died from hemorrhagic shock secondary to acute intraperitoneal bleeding. It was noted that on arrival in the emergency room on the evening of death, the patient had a marked coagulopathy.
The pathologist concluded that a clear source for the bleeding was not identified and that the underlying coagulopathy could have been a contributing factor. You have requested that I review the quality of care that this patient received and I have done so. In preparing this report, I have given consideration to the concerns that the patient's family expressed specific to the quality of medical care provided.
I believe that the initial assessment and care plan on March 3rd and 4th was entirely appropriate. Dr. Klein subsequently carried out an appropriate investigation and reached a management plan that reflects a good standard of care. The operative procedure was carried out according to the appropriate standard and good decision making is evident.
The postoperative care was appropriate. Specifically, treatment of a superficial wound infection is opening of the wound and allowing drainage. Subsequently allowing the wound to heal by secondary intention is the correct management. The use of antibiotics in the absence of systemic sepsis is not necessary, and does not improve the outcome. Unnecessary use of antibiotics does have risks including increasing the probability of development of antibiotic resistant infections including Clostridium difficile. There were no clinical indications for a CT scan or other investigation. It is not unusual for patients to be discharged without having had a solid bowel movement and there certainly are care paths for bowel resection that do not even require passage of flatus. There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no indication for supplements of things like vitamin K and calcium.
Postoperatively, the hemoglobin, white cell count and platelet count remained within expected ranges. Culture from the infected wound grew the expected bowel related organisms. Samples of the loose stool for Clostridium difficile were negative. The last hemoglobin measurement that I can identify was on July 18 \ There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigations. Discharge on July 20,2006 was therefore clinically appropriate.I concur with the pathologist that the cause of death was hemorrhagic shock. It is my opinion that the coagulopamy was a dilutionalcoagulopathy as a result of the hemorrhage, rather than a causeof the hemorrhage. I believe that the bleeding came from one of the staple lines on the anastomosis. Following removal of the right colon, the bowel was reconstructed using mechanical staplers and a technique known as a functional postoperatively, or be delayed. When it is delayed it is not uncommon for this to happen 6 to 10 days postoperatively. This complication end-to-end anastomosis. This is the predominant technique in use today for joining two ends of bowel together. This was properly done by Dr. Klein. One of the risks of any anastomosis is bleeding or leak from the anastomosis. This can occur very early happens in spite of proper surgical technique. Its incidence varies based on numerous factors, but is generally quoted to be in the order of 1 -5% of all bowel resections. I believe that the defect occurred because of ischemic necrosis at the intersecting staple lines created by the functional end to end anastomosis. This led to an open edge of bowel that subsequently bled. This led to hemorrhagic shock, subsequent dilutional coagulopathy and the patient ultimately expired from these events.I find no area of concern with respect to the standard of care that she received.
If you have any further questions, I would be happy to discuss this at any time
UNSIGNED
********
Now check out the responses from the Chief Coroner's Office and notice how they fully agree with the above expert and also what they state about there being "NO OMISSIONS OR COMMISSIONS" In their own words I believe they confirm their own breach of trust.
Letter dated Oct 27, 2008 from Dr A. McCallum
“As I write this, I am very mindful of the tragedy that you and your family have experienced. Please be assured that all of our staff, including Dr. Lauwers, will do their utmost to provide helpful information to you.”Letter dated November 17, 2008 from Dr A. Lauwers
“You have requested that I review the quality of care that this patient received and I have done so.”“The operative procedure was carried out according to the appropriate standard of care and good decision making is evident.” (Dr Lauwers repeating from consultant’s report.) No anti-biotic prophylaxis?
“There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no need for supplements of things like Vitamin K and Calcium.” (This was Dr Lauwer’s repeating verbatim from the expert’s report)
“While the patient suffered the most devastating complications of an operation, and specifically one of the common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care she received.”
JUST ONE YEAR LATER, HOW THIS CHANGE FROM THE DR. McCALLUM'S LETTER TO THIS ONE. THIS IS WHAT HAPPENS WHEN YOU ASK QUESTIONS THAT PUT THEM ON THE SPOT AND THEY DON'T WANT TO ANWSER!
The College of Physicians and Surgeons of Ontario's puppet within the Chief Coroner's Office--Dr. Bert Lauwers -- now VP at Ross Memorial Hospital in Lindsey, Ontario
Letter dated November 5, 2009 from Dr. A Lauwers
Nov 5, 2009Dear Mr. Kilby:
I am writing to acknowledge our telephone conversation of October 30, 2009.
As previously stated by Dr. McCallum in his letter of July 8, 2009, all the information that our office can provide has been conveyed to you in previous correspondence. The investigative mandate of the Office of the Office of the Chief Coroner is concluded.
To that end, our office will not be in a position to return phone messages to you in the future.
Sincerely,
A.E. Lauwers, MD, CCFP, FCFP
Deputy Chief Coroner-Investigations
It should be noted the telephone call referred to became somewhat heated as he refused to answer very pertinent questions posed to him and merely state his expert found nothing to be concerned about. They also would not respond to my e-mails or letters.
Letter dated March 4, 2009 from Dr. A Lauwers
“The last issue that the coroner must consider when making a determination about whether or not an inquest is necessary, is the likelihood that the jury on an inquest might make useful recommendations directed to the avoidance of death in similar circumstances.”…. How could HRRH have known that Terra would bleed to death hours following discharge from a site along the line of anastomosis?”Letter dated March 13, 2009 from Dr A McCallum
“As you are aware, I have some background knowledge regarding your daughter’s untimely and tragic death because I met with you and your wife after your daughter’s death in my capacity as Regional Supervising Coroner for Eastern Ontario, prior to my appointment as Chief Coroner.”“There has been a great deal of scrutiny or your daughter’s case. As part of that scrutiny, an expert review was obtained from an independent surgical consultant. Based on my review of the independent expert, review’s opinion, I conclude that there are no omissions or commissions during your daughter’s treatment that contributed to or caused your daughter’s death.”
“Given that the care was appropriate, it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance.”
“Based on the foregoing, I conclude that the mandatory questions can be answered, and have been answered in the attached Coroner's Investigation Statement. Your daughter died due to natural causes as a complication of treatment and the cause of her death was intra-abdominal hemorrhage consequent to dehiscence or disruption of the joining line in her bowel that had been closed with staples. As the expert reviewer stated, such a disruption can and does happen despite proper surgical technique. Though it is uncommon, it does occur in 1 to 5% of all bowel resections.”
Letter dated April 1, 2009 from Dr A. McCallum
“While I realize that you have many remaining questions, I am not in position to respond. You may wish to speak with your daughter’s caregivers regarding these questions.”“However, I can state that our investigation did not reveal an issue in care that led to your daughter’s tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.”
Letter dated June 25, 2009 from Dr A. McCallum
“The expert consultant who reviewed your daughter’s case had no affiliation with the University of Toronto Faculty of Medicine and thus had no conflict of interest. I can assure you that the review was both thorough and independent.“As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter’s death. The Patient Safety Review Committee’s mandate is to look at systems issues contributing to a death. As there are no systems issues contributing to your daughter’s death identified by our investigation, it would not be appropriate to refer her case to that committee.”
LET US LOOK AT THE OMISSIONS AND COMMISSIONS THEY SAY HAD ABSOLUTELY NO CONTRIBUTING FACTOR IN MY DAUGHTER'S DEATH.
--NO MENTION OF ALL THE STAPLES BEING REMOVED FROM THE ABDOMINAL INCISION AND THAT TEST RESULTS INDICATED THE PRESENCE OF MANY GRAM NEGATIVE BACILLI (SAME CATEGORY AS C DIFFICILE) No mention of the many Gram Negative Bacilli Seen and how it should be treated? Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This results in reduction of oxygen transported to the tissues thus explaining the necrosis of the tissue surrounding the re sectioned colon.--NO MENTION OF MANDATORY ANTIBIOTIC PROPHYLAXIS NOT BEING ADMINISTERED
--NO ANTIBIOTICS GIVEN AT ANY TIME? THIS IS APPROPRIATE?
--NO MENTION OF ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid (Ascites is an accumulation of fluid in the abdominal cavity.), or air
--NO MENTION OF LOW HEMACRIT, LOW RED BLOOD CELL COUNT AND LOW HEMACRIT COUNT Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia. Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding etc Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body. No mention of low hemacrit, red blood cells & hemoglobin indicates anemia (iron deficiency)
--DOES NOT MENTION LOW ABSOLUTE LYMPHOCYTE (type of white cells to fight infection)?
--NO MENTION OF HIGH PULSE RATE 34/38 readings above 90
--DOES NOT COMMENT ON MANY PMN'S. (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process. The presence of many PMN’s implies an inflammatory process. PMN’s are the hallmark of acute inflammation PMN’s are rapidly recruited to tissues upon injury or infection
--NO MENTION OF THE SERIOUSNESS OF THE OOZING, INFECTED ABDOMINAL INCISION -- ALL STAPLES WERE REMOVED DUE TO INFECTION Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.
THERE WERE FAR TOO MANY ISSUES NOT COMMENTED ON, DELIBERATELY, AND THE COO OFFICE FAILED TO FURTHER INVESTIGATE MY CONCERNS SENT TO THEM!
************************************
I don't know if I have the right to request an investigation by the OPP into the 'breach of trust' criminal offence. If I do, they I truly am requesting one.
I think after reading the medical information and the rather inept death investigation, you would agree the COO not only failed my daughter but all citizens of Ontario.
***********************************************
"We speak for the dead to protect the living'
The Office of the Chief Coroner for Ontario serves the living through high quality death investigations and inquests to ensure that no death will be overlooked, concealed or ignored. The findings are used to generate recommendations to help improve public safety and prevent deaths in similar circumstances.
The College of Physicians and Surgeons of Ontario, and the Chief Coroners Office are guilty of the following:
Confirmation bias = seeking or interpreting information that (one thinks) will support one's favored hypothesis or diagnosis.
Ego bias = biasing probability estimates in a self-serving way.
This Office has decline multiple requests:
a. my request for a public inques
t b. MPP Runciman's, now Canadian Senator, request to reconsider the public inquest
c. my request for Terra's death to go before the Patient Safety Death Panel
d. my request for an Eastern Ontario Coroner's Review since Terra passed in Kingston
e. my request to initiate the Chief Coroner's Review Process
f. refused the Ombudsman Office request to meet with me and respond to my concerns g. refused the OPP Detective's request to meet with me and respond to my concerns.
What do all of the above say about transparency and accountability?WHAT ARE THEY HIDING?
Note: Dr Huyer did meet but the meeting was useless. He was careful to state that there were many patient care issues, (did not use the words patient safety) and they should be dealt with by the CPSO and Hospital--- this was a cop out and he neglected his duty to all of Ontario. When I bought up the other two names (McCallum and Lauwers) he basically said they no longer work here so no comment.
I BELIEVE PAST CORONER, DR ANDREW MCCALLUM, PAST DEPUTY CHIEF CORONER DR BERT LAUWERS AND THE PRESENT CHIEF CORONER MAY WELL HAVE "BREACH OF TRUST" OF THE CITIZENS OF ONTARIO
122. Every official who, in connection with the duties of his office, commits fraud or a breach of trust is guilty of an indictable offence and liable to imprisonment for a term not exceeding five years, whether or not the fraud or breach of trust would be an offence if it were committed in relation to a private person.
* R.S., c. C-34, s. 111.Breach of Trust By Public OfficialAccused intended to use his/her public office for purpose other than public good.
Interpretation of the Offence The purpose of this offence is to ensure that the public retains "the confidence of the public in those who exercise state power"
The offence is a codification of the common law offence of "misconduct in office"
Misconduct of officers executing process 128. Every peace officer or coroner who, being entrusted with the execution of a process, wilfully * (a) misconducts himself in the execution of the process, or * (b) makes a false return to the process, is guilty of an indictable offence and liable to imprisonment for a term not exceeding two years.
* R.S., c. C-34, s. 117.
Actus Reus A "breach of trust" can include "any breach of the appropriate standard of responsibility and conduct demanded of the accused by the nature of his office as a senior civil servant of the Crown."
Mens Rea The mens rea requires a prohibited act that is done intentionally or recklessly, with the knowledge or wilfully blind to the facts making up the offence.
There must also be an "subjective foresight of the consequences" (that their actions will result in a benefit).
There is no need for an intent to act dishonestly. The accused need not be aware that he was breaching trust, it only requires that a reasonable person would conclude that there was a breach of trust.
Pleadings Breach of public trust is a straight indictable offence. The defence has an election under s. 536.
The prohibited act must cause a personal benefit to the accused and must be contrary to the duties imposed upon them. The breach does not need to be in respect of trust property. The offence does not capture mere nonfeasance or neglect of duties. There must be a marked departure from the standard expected from the official.
*********************************************************************
I believe this would apply: Regarding breach of trust offences under s. 122, commission of offences was done in connection with duties of accused’s office and accused breached standard of responsibility and conduct demanded of his/her by nature of his/her office. His/Her conduct also represents serious and marked departure from standards expected of an individual in his/her position of public trust. Accused also acted with intention to use his/her public office for purpose other than public good. ie--to conceal the truth, to cover up negligence by a fellow member of the CPSO and others within the CCO.
SHOULD THE CHIEF CORONER LIE TO YOU OR AVOID ANSWERING DIRECTLY TO QUESTIONS POSED, AND/OR REFUSES TO PROVIDE FACTUAL DOCUMENTED EVIDENCE TO SUPPORT HIS OPINION THEN HE MAY BE CHARGED WITH THE FOLLOWING:
Misleading Justice:
Perjury 131. (1) Subject to subsection (3), every one commits perjury who, with intent to mislead, makes before a person who is authorized by law to permit it to be made before him a false statement under oath or solemn affirmation, by affidavit, solemn declaration or deposition or orally, knowing that the statement is false.
Fabricating evidence 137. Every one who, with intent to mislead, fabricates anything with intent that it shall be used as evidence in a judicial proceeding, existing or proposed, by any means other than perjury or incitement to perjury is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years. * R.S., c. C-34, s. 125.
Obstructing justice 139. (1) Every one who wilfully attempts in any manner to obstruct, pervert or defeat the course of justice in a judicial proceeding, * (a) by indemnifying or agreeing to indemnify a surety, in any way and either in whole or in part, or * (b) where he is a surety, by accepting or agreeing to accept a fee or any form of indemnity whether in whole or in part from or in respect of a person who is released or is to be released from custody, is guilty of * (c) an indictable offence and is liable to imprisonment for a term not exceeding two years, or * (d) an offence punishable on summary conviction.
139. (2) Every one who wilfully attempts in any manner other than a manner described in subsection (1) to obstruct, pervert or defeat the course of justice is guilty of an indictable offence and liable to imprisonment for a term not exceeding ten years.
**********************************************************************
Breach --a failure to perform some promised act or obligation --act in disregard of laws and rules
That HPARB, the CHIEF CORONER OF ONTARIO, The DIOC and the ONTARIO OMBUDSMAN would actually fulfil their duties/responsibilities according to the Ontario Health Regulations Act and the Coroner’s Act of Ontario!
Trust
1. firm belief in the reliability, truth, ability, or strength of someone or something.
2. acceptance of the truth of a statement without evidence or investigation.
That HPARB, the CHIEF CORONER OF ONTARIO, the DIOC and the ONTARIO OMBUDSMAN would actually do this, but in reality did the complete opposite!
Instead ALL have done their utmost to conceal the truth, misrepresent the facts, and prevent Ontario citizens from learning the truth and thus has placed Ontario citizens at serious risk to their physical well-being.
3. the state of being responsible for someone or something.
That HPARB, the CHIEF CORONER OF ONTARIO, the DIO and the ONTARIO OMBUDSMAN would actually fulfill their duties/responsibilities according to the Ontario Health Regulations Act and the Coroner’s Act of Ontario!
Instead ALL have appear to do their utmost to conceal the truth, misrepresent the facts, and prevent Ontario citizens from learning the truth and thus has placed Ontario citizens at serious risk to their physical well-being.
THE PAST AND CURRENT HEALTH MINISTERS AND MINISTERS OF CORRECTION BY REFUSING TO INVESTIGATE HAVE ALSO NOT FULFILLED THE DUTIES/RESPONSIBILITIES OF THEIR POSITIONS AND THUS ARE: “IN BREACH OF TRUST” according to the Criminal Code Of Canada and the Criminal Code of Ontario.
Code of Ethics for Coroners July 2005 DR LAUWERS , Dr McCallum and Dr.Huyer have all FAILED THE FOLLOWING:
Coroners shall exercise their duties and responsibilities without fear, favour, prejudice, bias or partiality towards any person.
4. Coroners shall proceed in the public interest to carry out diligently, and with all due dispatch, their duties and responsibilities as set out in the Coroners Act 5. Coroners shall have due regard for the fact that they are performing a public duty and that their actions and decisions affect the public interest as well as the interests of private individuals. 8 Coroners shall not, in the discharge of their duties, make decisions beyond the scope of their personal expertise and knowledge but shall seek guidance from the appropriate source or sources. 21. Coroners shall not conduct themselves in a manner which might tend to bring their office into disrepute or affect public confidence in that office.
**************************
The Chief Coroner's Office feels it is perfectly within the accepted Standard of Care to: and can see any concerns with:
A)--have open abdominal surgery without the mandatory antibiotic prophylaxis--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibioticsThis is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
B)**-- ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE --the enlarged abdomen?---That is a sign of something wrong. Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid (Ascites is an accumulation of fluid in the abdominal cavity.), or airThis is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
C) Abdomen and Resting Pulse Rates Nursing Records above 90 **Description of Terra’s Abdomen high pulse rate? 34/38 above 90
July 11th
1133hrs 105
1143 105
1630 flat 106
1709 98
1730 101
2000 flat 104
July 12th
0000 flat 104
0400 flat 105
0800 flat 116
1300 flat 194???? this is not a typo from me. It is in the record!
1605 flat 101
2000 103
July13th
0820 rounded 110
1130 rounded 105
1615 rounded 102
2100 rounded
2015 rounded 107
July 14th
0500 rounded 126
0815 rounded 97
1200 rounded 95
1500 rounded 117
1600 rounded
1857 rounded
2000 rounded 110
July 15th
0530 rounded 94
0910 rounded 97
1300 rounded
1800 rounded 108
2107 rounded
July 16th
0530 rounded 98
1130 rounded 105
1310 rounded 96
2000 large 102
July 17th
0700 large 93
0951 large 104
1437 98
2200 large 108
July 18th
0517 large
0600 large
1000 large 86
1510 large
1600 large 90
2000 large 85
July 19th
0925 large 93
1957 large 96
July 20th
0039 large
0800 large 88
Terra was released
Breathing It should be noted that Terra’s breathing to the most part indicated concern. (see hospital records) Also comments regarding eating.
July 11
1133 short of breath on exertion, occasional cough
July 12
0000 eupnea, air entry decreased, occasional cough
800 eupnea, air entry decreased, short of breath on exertion
1300 eupnea, air entry decreased,
1605 nutrition—probably inadequate
1605 eupnea, air entry decreased,
July 13
820 short of breath on exertion, occasional cough
1130 eupnea, air entry decreased, short of breath on exertion
0415 not tolerating current diet, shortness of breath on exertion
1615 eupnea, decreased air entry – lower lobes
1730 not tolerating current diet, nauseated
July 14
0500 eupnea, decreased air entry – lower lobes, shortness of
breath on exertion
815 eupnea, decreased air entry – lower lobes, occasional cough
1200 eupnea, decreased air entry – lower lobes, cough in am
1338 ate about half of what was served
1856 eupnea, decreased lower lobe
2000 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes, oxygen delivered nasal
July 15
0530 eupnea, decreased air entry – lower lobes, oxygen
delivered nasal,
0910 air entry decreased – lower lobes, not able to clear airway of secretion,
1300 air entry decreased – lower lobes, not able to clear airway of secretion,
eupnea --normal, good, unlaboured ventilation, sometimes known as quiet breathing or resting respiration
July 16
0530 oxygen delivery – room air
0830 not tolerating current diet, nausea, save tray to try and eat later
0835 eupnea, decreased air entry – lower lobes
1310 eupnea, decreased air entry – lower lobes
2000 unable to clear airway of secretion, oxygen delivery – room air
July 17
0700 oxygen delivery – room air
0800 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes,
0900 not tolerating current diet, does not nomally eat in morning, save tray to try and eat later
1400 eupnea, decreased air entry – lower lobes
According to the records from 2200, July 17 through to Terra’s release, it appears there was no difficulty with her breathing and eating her liquid diet
--low hemacrit, red blood cells & hemoglobin indicates anemia (iron deficiency) This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
D)**HCT Hematocrit Count Ref. 0.36 to 0.48
July 18 0.35
Day 6 0.35
Day 4 0.32 All 5 tests are below normal range
Day 3 0.32
Day 2 0.34
Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia.
Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding etc This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
E)*RBC Red Blood Count Ref. 4.20-5.40
July 18 4.20
Day 6 4.16
Day 4 3.80 1 test at well low of normal range & other 4 below normal range
Day 3 3.78
Day 2 3.95
Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body. This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
F)**ABS LYMPH# Absolute Lymphocytes Count Ref. 1.5 - 4.0
July 18 0.9
Day 6 0.7
Day 4 0.5 All 5 tests are well below normal range
Day 3 0.8
Day 2 1.0 This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
G)**many PMN’s (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process. The presence of many PMN’s implies an inflammatory process. PMN’s are the hallmark of acute inflammation PMN’s are rapidly recruited to tissues upon injury or infection
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
H)**low Absolute Lymphocyte (type of white cells to fight infection)? B cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. are responsible for making antibodies T cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. enhance the production of antibodies by B cell
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
I)**HB Hemoglobin Ref. 120-160
July 18 119
Day 6 117
Day 4 107
Day 3 106
Day 2 111 ALL BELOW THE STANDARD
The vital role of hemoglobin in transporting oxygen from the lungs to the rest of the body is derived from its unique ability to acquire oxygen rapidly during the short time it spends in contact with the lungs and to release oxygen as needed during its circulation through the tissue
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
Individually, perhaps the test scores may be dismissed but collectively there is an indication of something going wrong and required further investigation!
J)** seriousness of the oozing, infected abdominal incision. Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.FROM NURSES’ CHARTS
Note: An example of something purulent is an open wound that's not healing properly.
July 15th
Page 109 853 hrs incision oozing
910 no odour, no oozing ????
Page 105 1300 no odour ???? but dressing soaked with purulent foul smelling fluid
Page 103 1430 foul odour
Page 98 2000 site #1 leaking Page 94 2152 foul odour
July 16th
Page 86 1030 foul odour
Page 83 1310 no odour, but larger purulent foul drainage from the umbilicus
Page 78 2000 no odour, but larger purulent foul drainage from the umbilicus
Page 76 2200 foul odour
July 17th
Page 74 0445 hrs foul odour
Page 73 0630 foul odour
Page 71 0700 no odour but large purulent foul drainage from umbilicus
Page 66 1400 large amount of drainage from umbilicus
Page 65 1700 foul odour
July 18th
Page 62 0045 foul odourPage 60 0900 foul odour
Page 58 1300 foul odour
Page 56 1560 7 staples removed — wound gaping wound oozing copious amount of purulent fluid
Page 55 1600 oozing incision
July 19th
Page 51 0815 foul odour
Page 49 0925 wound oozing copious amount of purulent fluid
Page 48 1500 foul odour
Page 45 1957 oozing incision
Page 44 2100 foul odour
July 20th
Page 43 0039 oozing incision
Page 41 0800 oozing incision
1000 foul odour Terra was released.
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"K)**no nutritional supplementation to ensure her nutritional needs were met. Terra was on a liquid diet of juice, jello, brothe and tea for 8 ½ days. (last two meals were regular)
This diet should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. Terra received no nutritional supplements.
She was receiving only 687 calories per day that equates to a starvation diet. With no nutritional supplementation!!!!!
The full liquid diet is low in iron, vitamin B12, vitamin A, and thiamine. It should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added.
The full liquid diet does not provide enough energy, protein and many other nutrients. This diet is temporary and should not be used for more than 5 days
1. LACKING 83.2% OF TOTAL DAILY IRON INTAKE! Iron is required for the formation of haemoglobin in red blood cells, which transport oxygen around the body. Iron is also required for normal energy metabolism
2. LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE! Vitamin K is not readily stored within the body, thus the importance of the daily requirement. The over riding effect of nutritional Vitamin K deficiency is to tip the balance in coagulation toward a bleeding tendency.
3. LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE! Supports a healthy immune system, energy metabolism and protein synthesis
4. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE! Vitamin E is the major lipid-soluble antioxidant in the cell antioxidant defence system and is exclusively obtained from the diet. Vitamin E significantly strengthens the immune system; supplies oxygen to the blood, which is then carried to the heart and other organs.
5. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE! Blood coagulation is dependent on calcium.
6. LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE! It is also required for cell differentiation and therefore for normal growth and development, and for normal vision and for the immune system.
7. LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE! assists the body in the production of collagen, a basic component of connective tissues. Collagen is an important structural element in blood vessel walls, gums, and bones, making it particularly important to those recovering from wounds and surgery. IMPORTANT: Inflammation in the tissues causes the breakdown and destruction of collagen fibers. Sutures will pull away from damaged tissues whether the tissues are damaged by disease or medical negligence. Any infected tissue which is separated by surgery will be slow to heal, or may fail to heal.
8. LACKING 93% OF TOTAL DAILY FIBRE INTAKE!
9. LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE! protects against infection, and enhances the immune system;
10. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE! protects against infection, and enhances the immune system; Zinc is also required in wound healing.
11. LACKING 99.9% OF TOTAL DAILY COPPER INTAKE! Needed for the formation of red blood cells and body needs copper to be able to use iron properly.
12. LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE! In immune function and infection prevention, and selenium deficiency has been reported in patients after intestinal surgery
13. LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE! Because of its constant demand and limited storage thiamine is required daily. enhances circulation, assists in blood formation, carbohydrate metabolism and digestion; plays a key role in generating energy acts as an anti-oxidant, protecting the body from degenerative effects
14. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE! Necessary for red blood cell formation, anti-body production, cell respiration, and growth Necessary for red blood cell formation, anti-body production, cell respiration, and growth
15. LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE! the maintenance of the gastrointestinal tract. It is required for the release of energy from food
16. LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE! Vitamin B6, also called pyridoxine, is essential in the breakdown of carbohydrates, proteins and fats. Pyridoxine is also used in the production of red blood cells.
17. LACKING 100% OF TOTAL DAILY VITAMIN B-12 INTAKE! Helps in the formation of red blood cells Vitamin B12 deficiency impairs the body’s ability to make blood, accelerates blood cell destruction
19. LACKING 57% OF TOTAL DAILY CALORIE INTAKE BASED ON
HER BASAL METABOLIC RATE. **TERRA WAS OBTAINING ONLY
687 CALORIES PER DAY AND THAT IS IF SHE CONSUMED ALL OF HER LIQUID DIET FOR THE DAY.* A starvation diet (Starvation diets (less than 800 calories per day) does not mean the absence of food. It means cutting the total caloric intake to less than 50% of what the body requires.
20. LACKING 47.3% OF TOTAL DAILY PROTEIN INTAKE! Nutritional depletion has been demonstrated to be a major determinant of the development of post-operative complications. Gastrointestinal surgery patients are at risk of nutritional depletion from inadequate nutritional intake and surgical stress.
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"
L)**ALL THE STAPLES BEING REMOVED FROM THE ABDOMINAL INCISION AND THAT TEST RESULTS INDICATED THE PRESENCE OF MANY GRAM NEGATIVE BACILLI (SAME CATEGORY AS C DIFFICILE)
No mention of the many Gram Negative Bacilli Seen and how it should be treated? Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This pathogenic capability is usually associated with certain components of gram-negative cell walls, in particular the lipopoysaccharide (also known as LPS or endotoxin layer). The LPS is the trigger, which the body’s innate immune response receptors sense to begin a cytokine reaction. It is toxic to the host. Gram-negative bacteremia is today's hospital scourge. Although antibody prophylaxis does not lower the infection rate, it prevents the serious consequences of gram-negative infections and thus improved the overall prognosis. Did the expert ever consider endotoxin shock due to release of endotoxins by gram-negative bacteria. Or hematogenic shock which is the loss of fluid from the circulating blood volume, so that adequate circulation to all parts of the body cannot be maintained. This results in reduction of oxygen transported to the tissues thus explaining the necrosis of the tissue surrounding the resectioned colon.
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS
WHY SHOULD AN ONTARIO CITIZEN HAVE TO GO OUTSIDE OF ONTARIO AND THE COUNTRY TO GET THE TRUTH AND WHY SHOULD THE FATHER OF THE DECEASED HAVE TO CONDUCT HIS OWN DEATH INVESTIGATION OF HIS DAUGHTER???
Just some of the qualified opinions from surgeons outside of Canada:
Hello again, Mr. Kilby: I have reviewed what you have sent to me via the attachments to your last email In your original email to me, you alluded to the fact that your daughter underwent her elective surgery without mechanical or antibiotic bowel preparation. As I mentioned to you previously, that is an ongoing issue in surgical discussions and decision making, but personally, I would believe it to be a grave mistake to have NOT prepared a patient's bowel if there was any chance the bowel would need to be entered during the surgery.
What troubles me from the material you sent is the expert's/ coroner's opinions as to the cause of death. Patients do not die from bleeding at the staple line of an intestinal anastomosis. When such bleeding occurs, it is manifested by significant BLEEDING PER RECTUM, which to my knowledge your daughter did NOT demonstrate. If she died of "intraperitoneal bleeding", that could have come from either a disrupted anastomosis or from larger blood vessels ligated during the resection of the mesenteric cyst and her right colon.If indeed her abdomen was distending, and her pulse rate rising over an observable period of time, then the really important issue was why was she not rushed back into the operating room when it was clear that an intra-abdominal catastrophe was occurring? I would agree that CAT scans are not necessary to establish an emergency situation, so what was the time delay between what her condition was upon discharge until she was brought back to the hospital? I think it more likely you would get more useful information from the dictated operative report from her original surgery, from personal review of her medical records to see what her condition was when leading up to her discharge, and from the coroner's report of the autopsy findings.
Anastomotic disruption following a RIGHT colon resection is quite rare actually, and the range stated in the expert's report probably reflects the overall leakage rate from ALL colon anastomoses. Such leakage/disruption is much more common in lower (or "distal") anastomoses, closer to the rectum. If her anastomosis did "disrupt", as alluded to, then it is usually a TECHNICAL ERROR on the part of the operating surgeon, especially because of the young age and apparently excellent former health of the patient. If there is sufficient proof of the above, then an investigation of the surgeon's performance both in this case and others might lead to "systemic" issues which deserve correction.
The main thrust of such investigations should be prevention of similar outcomes, with a willingness to confront all the causative factors, including surgeons' performances. I hope the above clarifies your thinking, from an insider's perspective. Please let me know your thoughts.
yours sincerely, Mark Helbraun, MD, FASCRS
Hello again Mr. Kilby: Now you are getting to the important issues in this case! If indeed she died 12 hours after discharge, then the emphasis in your investigation should focus on what was happening to your daughter in the 24 hours prior to discharge from the hospital.It is inconceivable to me that the autopsy report would not contain more detail than what you have given me regarding the status of her ileal-to-colonic anastomosis, since that would be the area that would demonstrate what (if any) disruption of the bowel occurred.
Since there was "no rectal bleeding" prior to discharge, what bleeding she was having would have been intra-abdominal, and if those counts were falling in the hours prior to discharge, that also should have sent up red flags of warning to anyone who was paying attention. The time plot becomes critical to reconstructing events in a fair and honest way. Again, look carefully at the autopsy results, the operative note, and the version of events leading up to discharge that you have been given. I suspect you would agree that there is a more fitting memorial to your daughter than a garden, and that memorial would be a living, breathing accountability system which would ensure that events like what occurred to Terra would never happen again. These are sometimes called "never events" in our system here, and they are investigated to the maximum. Keep me posted.....
Mark Helbraun MD, FASCRS Mark Helbraun, MD, FASCRS Member of the 2010-2011 International Council of Coloproctology 35 years experience Academic Colon & Rectal Spec Hackensack, NJ Hackensack University Medical Holy Name Hospital Holy Name Hospital, Teaneck, NJ Hackensack University Medical Center, Hackensack
******
Dear Mr. Kilby, I am sorry for your loss, having children myself of similar age I can only imagine how difficult it has been for you. In answer to your question, bowel preparation and administration of antibiotics for prophylaxis prior to surgery have been a standard of care in surgery for at least 25 years.
In my opinion you have every reason to deserve frank answers about what happened to your daughter. Cases involving perioperative death are always reviewed by hospital morbidity/mortality committees, as well.
Regards, Douglas Boyd Professor of Surgery University of California Davis
*****
I am very sorry for your loss. I am sure the wounds are still very painful 4 years later. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter).
The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. Having said all of that it the lawyers for the doctors are correct; medicine is an art (sometimes performed very poorly) not a science. See the SCIP initiatives available online (Google SCIP initiatives) to better understand when, and what type of antibiotics are recommended prior to colon surgery. Good luck with your inquiry and again I'm sorry for your loss......................
Moe Lyons, Maurice Lyons,
I have reviewed the data you supplied and the data from the colorectal surgeon (acting as an independent peer review).
I am at a loss to understand the opinion he offered given the abdominal incision was leaking foul discharge which would mandate re-exploration, or at the very least, a CT scan of the abdomen which would likely have shown significant intra-abdominal fluid, suspicious for anastamotic issues.
I have four children and my only prayer is to be in the ground before any of them……Short of not agreeing with the expert opinion offered by the independent physician I don’t know how I can help. Your daughter’s loss was tragic and it would appear to me preventable.Good luck with your appeal if that is the direction you chose……………….Moe Lyons
*****
Hello I have reviewed the material. My opinion is you should try to hire an attorney to proceed with this case. I have done a lot of expert work in the field of cardiothoracic surgery which is what I do daily. I have always worked with a lawyer.
I think there are a lot of problems with this case and you have a strong case to proceed. There are lawyers who could guide you with proceeding with this case. I am not familiar with the Canadian procedures for medico-legal cases.
Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case Thanks Ron Hill, MD, FACS
*****
Mr Kilby- I read with great interest your email and I am very sorry for your tremendous loss. You are right, I am a cardiothoracic surgeon, but I completed a General Surgery Residency as well. All patients used to receive pre-operative antibiotics prior to any colonic surgery. I would be surprised if this has changed. Unfortunately, this did not cause her death, but from what it sounds like may have contributed to it. As I am sure you know, when we have poor outcomes, it typically stems from a series of errors/omissions/etc.
Again, a tragic story, and I hope that you may find some resolution and closure. Kypson, Alan MD
*****
The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter).
The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. In this business, patients sometimes die (and as a pediatric cardiac surgeon, when that happens, it is truly devastating for all involved). It is unavoidable sometimes, but the one thing that can be avoided is lack of communication and clarity with the family. I think that if you had received that from the beginning, you likely could have moved past this painful time in your life. I honestly hope that you get the information you seek and that you can move on. The loss of your daughter was certainly a tragedy, regardless of the circumstances. The greater tragedy would be to allow that event to rule the remainder of your own life. I wish you the best of luck.
Paul Kirshbom, MD
*****
It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics.
It does not seem that her nutritional supplementation was adequate.
Finally, it seems that she was discharged while still infected. Allan Stewart MD I'm sorry to hear about the death of your daughter. A parent should never lose a child.
****
Dear Mr. Kilby, Based only on the information you have provided I find it difficult to justify what appears to be a "whitewash" of the patient's cause of death. The points you have raised are--in my opinion--legitimate reasons to question the validity of classifying her death as "natural" and would support your complaint of inadequate investigation. She unmistakably died of surgical complications that were arguably survivable with less flawed management. Under ordinary circumstances I would be willing to consider testifying on your behalf after undertaking an appropriate first-hand examination of the records. Please accept my regrets and best wishes.
Benson B.Roe, MD,FACS, Professor Emeritus. Department of Surgery, University of California at San Francisco Medical Center
*****
I can only say by the description here that there must have been some kind of contamination either during or after surgery most likely coming from the bowel itself based on the gram negatives you describe. Good luck with your search for answers, I hope you get them. God Bless.
Cristy Smith MD
*****
Dear Arnold Kilby Anti-biotic prophylaxis should be given at time of surgery according to practice guideline in US and in China as well while performing transabdominal colon resection based on evidence-based colorectal surgery, I think.
In my opinion, your daughter my die from postoperative infection or sepsis. Regards Wan-Jin Shao Chief Consultant Colorectal Surgeon, Clinical Professor American Society of Colorectal Surgeons(ASCRS )member Department of Colorectal Surgery Nanjing University of Chinese Medicine Hospital
*****
Dear Father: I am not an authority on laproscopic surgery or mesenteric cysts. I practiced cardiac surgery.
Having said that I recognize that there were serious complications, and probably unnecessary complications, with your daughter’s care.
From what I have read I believe that the standard of care was not met which caused your daughters demise.
My recommendation is that you try to find a laporscopic surgeon who is familiar with the procedure your daughter underwent. In addition you should determine the medical history -morbidity and mortality results -of the surgical team who cared for your daughter. I am not familiar with the Canadian system but in the U.S. a lawyer would be hired to investigate this case which appears to be or at least border on malpractice. I wish you solace and good luck in resolving this matter.
Steven J. Phillips, MD
*****
Mr. Kilby, Again, I am sorry about the delay in my response and, more importantly, very sorry about your daughter's death and the difficulty that you are having in trying to get the system to recognize the errors that seem to have been made in her tragic death. To preface my comments, as you know, I am a pediatric surgeon and do not operate on adults. That being said, I did complete an adult general surgery residency prior to my peds surgery fellowship and am Boarded in adult general surgery in addition to pediatric surgery by the American Board of Surgery.
As I review the file that you attached, there are several concerns that come to mind. You indicated that she did not receive appropriate bowel preparation prior to surgery. Even though there is some controversy re: bowel preps and performing surgery on the right colon, I think most surgeons would proceed with a mechanical bowel prep prior to an operation where possible right hemicolectomy was possible. However, there is very good evidence that mandates that patients receive broad spectrum IV antibiotics prior to having colon surgery, especially if they haven't received a bowel prep. If this wasn't done this is not in line with the standard of care in the US.
Also, I have concerns that the nurses documented for Terra's abdominal exam that her abdomen was "large" for the last several days of her stay in the hospital. More importantly, they document for a number of days prior to her discharge that there was a foul smelling odor and that the wound was "oozing copious amount of purulent discharge" during this entire time as well is very concerning. This doesn't happen with a superficial wound infection. These things happen when there is an anastomotic breakdown and leakage through the wound and possibly into the peritoneal cavity. If I recall, you indicated that a physician didn't even see Terra or examine her for the last couple of days while she was in the hospital? I would be very curious to read their last few notes in the chart and if they didn't document anything b/c they didn't see her, that is inexcusable.
In regards to colon anastomoses breaking down and causing an acute hemorrhagic event to where someone would bleed out within 12 hours, I have a hard time believing that and have never heard of this happening before, especially over a week out from surgery. She clearly should have been tolerating a diet fairly well before she was released. Again, all of my comments have to be considered in light of the fact that I don't practice on adults and may not be absolutely up to date on everything re: colon surgery in adults.
However, I doubt that any of my above concerns are too far off base, if at all. Ideally, you would be able to find a surgeon that practices on adults, is credentialed by the ABS if in the US or one in Canada that co- corroborate my concerns. I hope my comments help and wish you the best in your efforts to correct the system that appears to be failing you and your family.
All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015
*****
Mr. Kilby, I have reviewed the document and stand by the comments and concerns that I have sent to you through various emails. In addition to those, my only other comments are:
1. It is very concerning that the nurses repeatedly documented in the chart that her abdomen was large and there was foul odor coming from the wound. Since there was no documentation from the surgeon re: an exam on multiple days, then one can only infer that no surgeon examined her on those days.
2. Gram-negative bacteria on the cultures from a wound with foul drainage suggest an intestinal injury or anastomotic leak.
3. Preoperative antibiotic prophylaxis is the standard of care in the US and, I would imagine, the same in Canada.
4. I can't believe that any physician or surgeon would release a patient from the hospital without seeing the patient or, at least, speaking with the nurses caring for the patient by phone.
Hope these comments, as well as those that I have made in the past, help your cause. All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015
*****
Mr. Kilby: I looked over the materials you sent. I am once again sincerely sorry for your loss and trust that your daughter will live on in your hearts and thoughts. There are several items here that in combination raise concern. Individually, they may have been overlooked as insignificant. Further, hindsight may allow piecing together a potential pattern that may not have been detected as they occurred. 1. Were peri-operative prophylactic antibiotics administered? There is a suggestion that they may not have been.
1.It is standard of care to do so for a limited time around the time of operation.
2. I am concerned about the description of the abdominal examination progressing from "rounded" to "large" in the context of no clear normalization of bowel function. Is that to be interpreted as a distended abdomen? Were there normal bowel sounds? Was flatus present indicative of returning function? Or was there a postoperative ileus? If function was not returning normally in the presence of a progressively distending abdomen, that should raise concerns that might require imaging of the abdomen but certainly resolution prior to discharge.
3. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered.
4. Such a bleeding complication after such surgery is certainly a possibility but should be exceedingly rare. If, as you suggest, your daughter's complications were part of a series of such problems then, indeed, a system or operator issue is suggested which satisfies the stated requirement for a complete investigation.
If I were in your place, I would do the following:
1. Contact the American Board of Surgery to see if they have an Expert Review Panel to which you could send this case for review.
2. Canada must have a physician licensing board to whom the above questions could be raised - particular to your daughter's care as well as the potential system issues.
3. If you have not already, you may address these questions to your daughter's surgeon. Keep a paper trail of the questions, and the response.
Matthew M. Cooper, MD FACs
*****
Chief Corner’s expert states: “There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigations. Discharge on July 20, 2006 was therefore clinically appropriate.”
From my own unnamed source within Canada. Releasing name would mean reprimand and discipline by the Omnipotent College and I promised to never do so and I am a man of honour.
Mr Kilby I am going to respectfully disagree with the coroner. If you take a look at the chart, it seems to me that nurses and doctors are talking about two different patients. Doctors are talking about a stable patient who is afebril, and her wound is healing, and their plan is to discharge the patient within 1-2 days. On the other hand, nurses are talking about a patient who has a fluctuating vital signs [particularly her Temperature], patient is refusing food while she is stating to nurses that she is hungry, and she tells nurses that she does not have pain but nurses are giving her pain medications anyway, and finally patient's abdomen is going from flat to round and large. Don't you think, these people either did not know what they were talking about or something serious was happening to patient. Maybe the thing that was happening was not septic shock but it was ileus, maybe it was not ileus but it was leaking from perforated site. Something was definitely wrong.
It is easy to conclude that both nursing and medical care provided to patient was inadequate and below the standard of care. The definition of negligent malpractice in law is " failure to meet the standard of practice by health care professionals" and " omission of act that the fiduciary relationship of a nurses and physician with their patient, obligate them to do for their patients"
Two omissions here :
a) timely prescription of antibiotics, and
b) reporting and recording abnormal findings by nurses. I have to tell you that it is a major problem that you could not find not even one nursing progress note, very big problem, huge. How is nurses did not even write one nursing note during 9 days of her hospitalization!!!!!!! WERE THEY PULLED AFTER TERRA DIED?
Physician notes are not consistent with the nursing notes, for example on July 16 nurses noted: July 16 Chest assessment 0530 oxygen delivery – room air 0830 not tolerating current diet, nausea, save tray to try and eat later 0835 eupnea, decreased air entry – lower lobes 1310 eupnea, decreased air entry – lower lobes Abdominal assessment July 16th 0530 rounded 1130 rounded 1130 rounded 1615 rounded 1310 rounded 2100 rounded 2000 large On July 16, the attending physician did visit the patient but the fellow wrote: July 16, 2006 (This note was written by the clinical fellow) AVSS (afcbrile, vital signs stable) c/o nausea, no vomiting wound packed incisional pain I/P (impression plan): stable, blood work
How a patient who has a large abdomen, can not tolerate food, and has decreased air entry be stable?
Fellow wrote vital signs stable, no I disagree look at the vital signs, and they were fluctuating even in 24 hours and throughout her hospitalization. That is why Meditech , an electronic documentation, provides vital sign graphs so physician can see the trend of the patient’s vital signs throughout their hospitalization.
Dear Mr. Kilby I am puzzled by Narcan to be ordered for because we use Narcan only in case of overdose. I consulted with the hospital pharmacist , just to make sure , and he also agreed with me that Narcan in her MAR sheet seems a lit bit suspicious. From your e-mail, I understand that she was on PCA pump therefore there was no need for Narcan. Yet Narcan was ordered!
*****
Dear Mr Kilby: I have read the sad account of your daughter's illness and Other medical society's review and find the review flawed and inadequate. I cannot be an expert witness since I am no longer a practicing surgeon. However, I formerly served on our San Francisco Medical Society's Review Panel.
Your daughter's surgeon was wrong and failed to observe your daughter's presenting laboratory and physical findings of intra-abdominal sepsis and wound infection. The surgeon's "slap on the wrist" and review submitted by the Society must have been upsetting to him as a caring surgeon. This may be the only consolation you can ever see for your daughter's death. Hopefully he will have learned from this experience and it will help him provide better care for future patients.
James P. Geiger, MD, FACS COL. MC US ARMY, Retired
*****
Dear Mr. Kilby, I just read through the attachment, and I recall reading your prior email.
My personal opinion based only on what you have provided is that your daughter died of septic shock related to dehiscence of her bowel anastomosis complicated by acute hemorrhage.
Apparent lapses in care are:
1) Lack of peri-operative antibiotics (I am not a general surgeon and do not know if this fails to meet standard care for right colon surgery).
2) Discharging your daughter with ongoing diarrhea of unexplained etiology,
3) Prolonged period of inadequate nutrition,
4) Nursing records that appear to be at odds with the physician record of the abdominal exam,
5) Failure to distinguish the intra-abdominal catastrophe from the wound infection.
It is self-evident that she was discharged prematurely or she would not have died outside the hospital of a devastating post-operative complication.
The big questions are: would a reasonable general surgeon have acted differently, and did her surgeon practice according to the standard of care – I seriously doubt that he did and I think a good surgeon would have done a more thorough investigation prior to discharge.
Things to consider:
1. The low hematocrit prior to discharge is not evidence of malpractice as this is common with acute illness such as what your daughter exhibited.
2. It would be interesting to see if there was a platelet count prior to discharge.
3. The temperature curves and the reported abdominal fullness are concerns that seem discounted by the College assessment.
As I told you previously, I am a father of an almost 3 year old girl and I now have a 6 month old son and a 4 year old son. I cannot imagine losing any of them particularly in such circumstances. Only you can decide if your quest for justice is worth further fight. I do not understand the Canadian system, so I cannot judge. Your case would be helped if you could find a Colorectal surgeon to review it. Unfortunately, most surgeons would not take interest and I do not personally know anyone who can help you. I do wish you the best and I hope that at some phase you can find peace.
Max Mitchell
*****
Dear Mr. Kilby: From what I remember and my review of the information you sent me my opinion is that your daughter received suboptimal care approaching malpractice-at least by US standards.
I would have to assume that Canadian standards are equivalent to US standards but from the response I read perhaps they are not.Best wishes,
Steven J. Phillips, MD
*********************************************************
Arnold KilbyJune 19,1949
Terra Dawn Kilby "An Angel In Our Lives"
April 22/78 to July 21/06
http://anangelinourlives-awk.blogspot.ca/
*************************
