MPP Clark- no response I will try again and resend previous attempted emails

Steve Clark;
It is now Sept 2024 and still no non-automated response from my MPP Steve Clark!
I guess you get to choose which constituents you wish to consider representing?

Feeling Quilty?
1. Your role in covering up medical negligence.
2. Breach of Trust by an elected/appointed Official contained within the Ontario and Canadian Criminal Code.

Ms Stiles, Mr Fraser and Premier Ford- who will represent me when my elected MPP won’t?
*****
Mr Clark,
It is now Sept 26. Still no response from you or your office! Why? Only the standardized computer response - not even a personal one from any of your constituent employees.

I am in your constituency and you fail to respond? Why?

Does it have to do with the medical negligent death of
Terra Dawn Kilby?- that you have continue to ignore- - Breach of Trust by an elected official!

If one took the time it is quite obvious there are numerous officials guilty of covering up medical negligence contributing to the death of my daughter: (and the further deaths by the same surgeon)

-Chief Coroner of Ontario
- DIOC
- HPARB
- Ontario Ombudsman
- Ontario Patient Ombudsman
- Humber River Hospital
- and every MPP since 2008 who were made aware of the circumstances

*

Previous Attempt
Trying Again Sept 7, 2023

What does one do when their own MPP, Steve Clark, won’t respond to a constituent? And has done so for a very long time. He doesn’t represent me?

Have you blocked my email so I can’t contact you as you have done with your Facebook?

Am I pissed at you? Yes, you abandoned me once the Conservatives took power.

Sent to MPP Clark’s Brockville Office on line Sept 4th, 2023

Your Office will ignore this. I am sure Karma is just beginning.

Perhaps, you will try to regain some integrity by truly exposing the medical negligence in my daughter’s death?

This would benefit not only your constituents but all of Ontario by bringing about effective transparency and accountability within Ontario’s Health Care System and within the Institutions, and Elected/Appointed Officials which you are one.

I doubt you will respond.

I’ll wait to hear before posting this to various social media

As my MPP representing his constituents when there is irrefutable evidence of medical negligence and a coverup he certainly could have brought this to the attention of the Health Ministry and other elected/appointed officials which he did do when the Conservatives were in opposition. He, however stopped all attempts once the Conservatives gained power. It was then he would have more influence but chose not to do so? Why so much support while in opposition then nothing?

Numerous deaths after my daughter’s by the same surgeon may have been preventable!

To refresh your Memory:

My daughter bled out 12 hours after discharge. Her colon resection broke down due to necrosis of the tissue. I didn’t find out until obtaining the hospital/surgical records that the open abdominal surgery was done without the mandatory antibiotic prophylaxis being administered. No antibiotics given even when the abdominal incision infected and all staples removed. No antibiotics when test results indicated “many gram negative bacilli present”!

How about the enlarged abdomen at time of release? went from flat to rounded to large

How about the foul, purulent oozing incision at time of release? And during the entire time of her stay. And all of the staples had been removed from the 10 inch abdominal incision.

How about the fact that she did not have the anti-biotic prophylaxis given at the time of induction? THIS IS A STANDARD OF CARE THROUGHOUT THE ENTIRE WORLD!

How about the fact she received no anti-biotics whatsoever at any time? Not even when the incision became infected nor when test results stated "many gram negative bacilli". (same classification as C Dificile)

How about the many gram negative bacilli seen? And not treated

How about the fact the she remained on a liquid diet for 8 days consisting of jello, juice, tea and both without any nutritional supplement?

How about the fact that she was only receiving 687 calories per day for 8 days? And records show she was not tolerating these meals.
July 12 nutrition—probably inadequate
July 13 not tolerating current diet
July 13   again--not tolerating current diet, nauseated
July 14 ate about half of what was served
July 16 not tolerating current diet, nausea, save tray to try and eat later
July 17 not tolerating current diet,

Even if she ate all of the liquid diet she still would have been lacking the daily total nutritional intake requirement:

1. LACKING 83.2% OF TOTAL DAILY IRON INTAKE!

2. LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE!

3. LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE!

4. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE!

5. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE!

6. LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE!

7. LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE!

8. LACKING 93% OF TOTAL DAILY FIBRE INTAKE!

9. LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE!

10. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE!

11. LACKING 99.9% OF TOTAL DAILY COPPER INTAKE!

12. LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE!

13. LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE!

14. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE!

15. LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE!

16. LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE!

17. LACKING 100% OF TOTAL DAILY VITAMIN B-12 INTAKE!

18. LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE INTAKE!

19. LACKING 57% OF TOTAL DAILY CALORIE INTAKE BASED ON HER BASAL METABOLIC RATE!

20. LACKING 47.3% OF TOTAL DAILY PROTEIN INTAKE!

How can a wound heal without proper nutrition?

How about that fact that the only two regular meals consumed was the last two prior to her discharge and she did not have a bowel movement? (Remember, she had a colon resection)

How about the fact her resting pulse rate was over 90?
(34/38 of Terra’s recorded pulse rates were above 90 during her stay)

How about the low Absolute Lymphocyte (type of white cells)? Which indicated the body is using up these cells fighting an infection

ABS LYMPH#
Absolute Lymphocytes Count Ref. 1.5 - 4.0 All Five Test Are Well Below Normal
July 18   0.9
Day 6 0.7
Day 4 0.5
Day 3 0.8
Day 2 1.0

How about the many temperature reading that were abnormal?
23 out 38 recorded temperatures were not in the normal range

How about the many PMN’s (polymorphonuclear Neutrophils) –? hallmark of acute inflammatory process

How about the low hemacrit counts, low red blood cell counts and low haemaglobin counts?
HCT Hematocrit Count Ref. 0.36 to 0.48   All Five Tests are Below Normal
July 18 0.35
Day 6 0.35
Day 4 0.32
Day 3 0.32
Day 2 0.34

RBC Red Blood Count Ref. 4.20-5.40   One Test at Low of Normal Range & Four Below Normal Range
July 18 4.20
Day 6 4.16
Day 4 3.80
Day 3 3.78
Day 2 3.95

HB Hemoglobin Ref. 120-160 All Five Test Results are Below Normal Range
July 18   119
Day 6 117
Day 4 107
Day 3 106
Day 2 111

Some alarms should have been heard if the Surgeon looked at the hospital records which I believe he did not.
Too many unanswered questions?

You don't need a medical degree to see from the many items above found within the Hospital records that Terra should not have been discharged until most if not all were investigated, and resolved.

Mr Shanoff who wrote the two articles in the Sunday Toronto Sun sent me this from a woman who contacted him. --a very knowledgeable nurse
*******
"I read with interest your article in the Sunday Sun October 13, 2013. titled “Why did woman die after routine surgery?”. I applaud you for bringing the circumstances surrounding this case to public attention. I feel it is a pity that innocent people must bare their hearts and their private lives in such a public fashion to get the attention they deserve and also to expose the injustice that permeated their lives.

As a former ICU nurse, who spent most of my nursing years in large academic teaching hospitals, I could say the reason for the woman’s death is a no brainer! However, not having seen the hospital records, I speak cautiously.

Several indicators from nursing records points to a “foul odour” and “purulent discharge” Both of these observations strongly point to an underlying infective process going on beneath the skin surface. Purulent discharge, as observed in this case, means the pus from the infection is significant enough in quantity that it is draining out wherever it can, which, after surgery, is usually through the operative incision. This is one of the VERY basic and elementary observations after any surgery. AND the procedure once the discharge has been observed, is to “swab” (do a culture of) the discharge, so that microbiology can determine the type of bacteria responsible. The microbiology / bacterial report then identifies which antibiotics would be best used to combat the infective process, so that appropriate antibiotics can then be ordered by the physician/surgeon. “Cultures” used to take a few days to process, but currently, preliminary results can be obtained the same day. Even without microbiology testing, surgeons have been educated to know what types of bacteria are most prevalent in certain situations.

I see no mention at all that the woman was started on antibiotics either on the 15th of July, the day the nursing records indicated the purulent drainage was first observed. or, at any point in time prior to the woman’s discharge. If this is the case would negligence be a good word to use here? It is a standard of Nursing Practice, to report such findings as “discharge” immediately to the Surgeon and obtain an order for antibiotics. If the hospital utilized the “Pathways” model of post-op care, then there should have been “standing orders” in place to give direction. Regardless, there is absolutely no excuse for antibiotics not being ordered immediately when discharge was first observed.

It would seem to me that having had this discharge for 5 days…. at least for 5 days that it was observable…… where was the surgeon doing his post-operative checks on his patients? It is also a well know fact that abdominal infections are a dangerous game to play. It is also well known that by the time the infective process is observable on the surface of the skin at the incision, there is much more going on “inside”, beneath the skin surface. You are only seeing what is “overflowing”, so to speak.

Some surgical procedures are best handled with antibiotics given prophilactically prior to surgery, especially when the risk of infection is high (such as is the case with certain abdominal surgeries). Optimal post operative care and surgical ouycome is sometimes contingent on good pre-operative care. For both agencies, the CPS and the HPARB to give minimal attention to the fact that antiobiotics were NOT given, is totally inexcusable.. It is almost like they are denying the contribution this makes to the post-operative infective process…..like they are excusing themselves from antibiotics having any responsibility or role in the woman’s health… or lack of it. Malpractice? Whatever it is, this is inexcusable, both for the two review boards and for the surgeon..

Further to the infective process ongoing in this woman’s abdomen, the infection sometimes does NOT stop here. It is also a basic concept in medicine and very elementary, that infective processes, when untreated or not affectively treated, can evolve into septicemia (infection in the blood) and septic shock (where your body starts to shut down from the infection) ….. and death. This is the NO BRAINER ! This is where I fail to see how both agencies, the College and the Review Board, don’t seem to be paying any attention, whatsoever, to rudimentary medicine !!

I am also dismayed at the length of time it took for this surgeon to complete the Hospital Discharge Summary and I also assume that the operative records are included in this five month delay. Every hospital has policies governing the length of time physicians have to complete paperwork before hospital privileges are revoked…. Which means that doc cannot practice in that hospital. Health Record Departments are very diligent in constantly reminding the offenders of unfinished paperwork and of consequential impending suspensions. Five months is a long time. Was this period of time within the framework of that hospital’s policy…. Or was his privileges suspended which prompted him to complete the operative records and then have his privileges re-instated? My biggest concern with incomplete or absence of prompt record keeping is that the margin of error increases exponentially as time passes.

I am also troubled by the reactions of the College and the Review Board. The shrugging -off of responsibility back and forth speaks to me of not wanting to address this issue and get to the bottom and be forthcoming with answers.,,,, or not wanting to give answers. Often in cases where there is compelling evidence of mismanagement and allegations of mismanagement, this behavior by The College is repeated. Is this a “big name” or prominent surgeon that is involved in this case, and both agencies are trying to minimize the impact on his career and reputation? Who is covering for who here? Having worked in the system for 46 years, I feel confident in saying that this is not an uncommon practice amongst physicians and also not an uncommon practice by the College. If you look at other “worst scenario” cases where there have been complaints or questions asked of the College, how many times have complaints been dismissed when the evidence is pretty compelling? The “Old Boys Network” is still alive and kicking even in this era of supposed accountability.

I also question the reason Humber River Regional Hospital would “create a memorial garden with a plaque in Terra’s name”. This is again not the “normal” or usual practice after a patient dies expectedly or unexpectedly, whether inside its doors or without. What does the hospital know that they are not telling….. or even worse, not admitting to. A friend of mine received a card and gift basket after being hit in an accident. Legally, this is an admission of guilt. Are we seeing the same admission of guilt here? Is this the hospital’s way of offering an “olive branch” to cloud the truth. I believe there is more to this than meets the eye.

I have many opinions about the Legal system in this great land of ours, but this may be the only way this poor father is going to get any answers to his questions. Docs are terrified of legal action, but it usually gets their attention. What is needed is a careful and shrewd lawyer who is knowledgeable in medical practice; that is, has available the academic knowledge with acceptable and competent medical practices required for this case, Armed with knowledge, should he delve into available information on this woman’s case, I am assured the answer should come pretty quickly.

No, the father has a very valid and heartfelt point of view when it comes to finding answers to his daughter’s death. Money does not bring your child back, and this reflects my own thoughts after I lost my son tragically at the same age. To lose a child, no matter the cause, is very painful, and for many years to come. The pain is magnified many times over, when negligence and stupidity is at the root of the cause of death. I admire his persistence and his thinking. However, in spite of our best hopes and well intended thinking, legal action may be the only way to eventually find the answer he seeks. My heart goes out to this father. I truly hope that some of the things I have said, will be of help in finding his answers; and maybe some day bring relief and comfort to his heavy heart."
*
Expert opinions from qualified surgeons outside of Canada (those within won’t comment)

https://www.facebook.com/652895592/posts/10165016252215593/?d=n
End of email
*****

Should you wish to express your concerns to your own MPP please do so.
My MPP, Steve Clark is a major disappointment. I believe he should go back and think about what he believed in when he served as Brockville's youngest mayor when he was 22.

Now let's work on bringing about true transparency and accountability with Ontario's Health Care System.

So sad to see my own Member of the Provincial Parliament, Steve Clark throw away his moral and ethical integrity, when the party he belongs to regained power at Queen’s Park, in order to obtain a Ministerial position within this government. He appeared to be far more vocal during the Liberal government than now. WHY? The old standard still exists— a politician in opposition or campaigning for re-election will say and do anything but this all changes once being elected!

This was merely another “Bull shit” response.

In the morning of October 31^st, 2019 Mr. Jiggens, the administrative assistant to MPP Steve Clark returned my phone call. He informed me MPP Steve Clark and Health Minister Christine Elliott could not do anything with regard to my case with both the CPSO and HPARB as it deals with an individual case--- I pointed out that there are numerous cases involving this surgeon. I told him how disappointed I was and that I do not feel this was true as the Minister does indeed have oversight over both of these institutions.

The most recent case involving this surgeons who has had multiple deaths--- far too many for a general surgeon.   Ignored by the Health Minister, the Health Ministry and my MPP.

Obviously, Dr. Klein has not changed since my daughter’s death. Before reading my story, take a look at excerpts from the following HPARB decision.From an HPARB Review held on July12, 2017

"As noted above, the Committee specifically considered the Respondent’s conduct history with the College. The Committee indicated that the Respondent’s “history with the College, which includes several complaints on a number of aspects of [the Respondent’s] care, raised some concern for the Committee”. The Board has reviewed the Respondent’s history with the College and finds that the Committee’s concern is reasonable."

"The Committee noted that Dr. Klein has a significant history with the College, which include cases raising both clinical and record-keeping issues, for which he has received advice and been cautioned. The Committee agreed with the Board that the repetition of similar concerns in this case appears to indicate that the previous remediation attempts have not been successful. This, along with the Committee’s concern about Dr. Klein’s persistent lack of insight into his shortcomings in this case, suggested that a more significant disposition was required to adequately protect the public, as outlined above."

"The Board notes that the Respondent’s conduct history with the College includes prior complaints involving the care of patients, including medication issues, that have previously been identified as concerns by the panels of Committee assigned to assess them and have resulted in advice being provided to the Respondent. The repetition of similar concerns highlighted in this case would appear to indicate that previous remediation attempts by the Committee have failed to yield the desired result. There is nothing within the Committee’s decision to indicate how the issuance of another advice in this matter will protect the public interest in light of the Respondent’s conduct history."

****************

   WHAT HAPPENED TO THIS STEVE CLARK?

A response from Mr Clark would be appreciated to explain what changed with regard to his words then and his silence now.
Could it be that back then he was an opposition MPP and now he is a Minister in today's Government???

Did he accept his own "Quid pro Quo"? Silence for a Cabinet Minister position.       ---proof is in the pudding

IT IS NO WONDER THAT CITIZENS HAVE LOST FAITH IN THEIR ELECTED OFFICIALS

Official Records for 22 October 2013

   Hansard Transcripts

MEMBERS’ STATEMENTS

HEALTH CARE ACCOUNTABILITY

Mr. Steve Clark:

"I rise on behalf of a constituent whose name should be familiar to every MPP. We’re just some of the many people Arnold Kilby has written to in his quest for truth behind the death of his daughter, Terra Dawn. She died seven years ago at the age of 28, following routine surgery at Humber River Regional Hospital."

"Since that terrible day when his daughter died shortly after being discharged, Arnold has been on a mission—not for revenge, not for money. He wanted two simple things—two things he frankly should never have had to ask for, let alone wage a seven-year battle for that continues today. He wanted an admission that basic precautions weren’t taken prior to her surgery and afterwards,when it was clear something had gone terribly wrong. He also wanted what every parent would: an assurance that Terra Dawn’s death wasn’t in vain, that the mistakes made would lead to changes."

"It proved to be a mission impossible. If the seven years of hell Arnold spent trapped in an alphabet soup of agencies tells us anything, it’s that true accountability and oversight of Ontario’s medical profession exists in name only. No patient or parent should have to endure this. I commend Sun Media columnist Alan Shanoff for bringing Arnold and Terra Dawn’s story to light."

"That’s why today I’m calling on the Minister of Health and Long-Term Care and the College of Physicians and Surgeons to create a truly open and transparent medical oversight and accountability system."


MPP Steve Clark

And this from a few years earlier:
Legislative Assembly of Ontario

Second Session, 39^th Parliament

Official Report of Debates (Hansard)

Re: Excellent Care For All Act, 2010

        Second Reading

                Tuesday, May 4, 2010

Mr. Steve Clark:

“I am pleased to rise to provide some comments to the member for Scarborough-Rouge River. I listened to his comments about quality and value, and also about accountability in this Excellent Care for All bill.

On Friday, I met with one of my constituents, Arnold Kilby from Lansdowne, whom I think has e-mailed every member of this Legislature hundreds and hundreds of times with a concern about the system. His daughter, Terra Dawn Kilby, passed away in 2006, 12 hours after her release from a Toronto-area hospital. He has many unresolved issues with respect to the care she received in that hospital. I know that he’s written to the Minister of Health and Long-Term Care and also to the Minister of Community Safety, expressing his concerns that the system let her down; that there wasn’t an accountable system; that he can’t seem to get answers on the fact that there should be things put in place at the hospital and in the health care system that make the government accountable for what happens at these facilities; and the fact that, in his case, with his daughter Terra Dawn, he still, three years after her death, cannot get answers from this government or from the hospital involved. You know, it’s not an issue of taking the government to court. All he wants is a bill that puts some accountability back in the system that would ensure what happened to him and his family never happens again.

I’ve looked at this Bill 46. I looked at Hansard from yesterday, at what the minister said, and I don’t see that this bill has that accountability for Arnold Kilby, that it has that accountability with a hospital so that it adequately addresses his concerns. I would like someone to address that at some point in the future.”   0920

HEALTH PROTECTION
AND PROMOTION
AMENDMENT ACT, 2011 /
Mr. Steve Clark:

"The freedom of information—I have a constituent, Arnold Kilby, who I think has emailed every single, solitary one of the members of this Legislature probably 100 times. His daughter, Terra Dawn, passed away a number of years ago and he has been fighting ever since to get answers from the hospital board. He has been up against a brick wall with the Health Professions Appeal and Review Board; the College of Physicians and Surgeons has been like a brick wall to him to get answers. The Death Investigation Oversight Council—this man has tried to get answers from the hospital, from ministers. I remember he wrote the Minister of Community Safety, and the OPP came to his door questioning him about his emails. I couldn’t believe it.

All the man wants are some answers. He certainly doesn’t have the means to litigate. All he wants are some answers surrounding his daughter. I can appreciate what he has gone through with these bodies, the brick wall that he has hit, and to have further provisions removed for freedom of information at hospitals—I just don’t understand that.

In my own discussions in this House, just in the last couple of weeks, about the South East LHIN and the surgery department at Brockville General Hospital, I brought up this plan twice in the House. My critics say that I’m creating this mirage. I’ve seen the plan. A doctor shared with me the plan and shared with me the discussion around the plan. All I asked was that it be taken off the table. If I was such an extreme MPP to bring this up that it was at the far end of the spectrum, why didn’t you just take it off the table? I asked for a public meeting to take place. Well, lo and behold, I read the daily newspaper in Brockville this morning, and the headline is, “Surgery Update Heard Secretly by BGH Board.” When I see schedule 15 restricting freedom of information, and I see LHINs operating in a shroud of secrecy in a significant recommendation that would gut the surgery department, and I suggest gut the Brockville General Hospital, I have every right to bring it up as the MPP in that riding. I can’t believe, when I read the local paper, that this update by the LHIN would be held in a secret meeting with the board. I can’t understand it.”

Taking away freedom-of-information rights from hospitals: I can’t support that. I can’t support it because of the issues with my surgery department, but more importantly, because of my constituent Arnold Kilby and his poor daughter and the answers that he has been trying to get. We need to make sure that he has that opportunity."

What changed from back then to now
----- from opposition MPP to Cabinet Minister
Gee, would it be nice to hear an honest explanation!

*

Besides the Health Minister, Christine Elliott and her Ministry failing to uphold her own responsibilities expressed in the Act.
Duty of Minister
3. "It is the duty of the Minister to ensure that the health professions are regulated and co-ordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board." She and the Conservative government have also failed to ensure the College of Physicians and Surgeons of Ontario uphold the “Objects of the College” which is expressed within the Act.
The Regulated Health Professions Act, Schedule 2, Section 3, sets out the objects of the College of Physicians and Surgeons of Ontario (CPSO):
Objects of College

3. (1) The College has the following objects (emphasis added):

1.    To regulate the practice of the profession and to govern the members in accordance with the health profession Act, this Code and the Regulated Health Professions Act, 1991 and the regulations and bylaws.

2.                 To develop, establish and maintain standards of qualification for
persons to be issued certificates of registration.

3.        To develop, establish and maintain programs and standards of practice to assure the quality of the practice of the profession.

4.        To develop, establish and maintain standards of knowledge and skill and programs to promote continuing competence among the members.

5.        To develop, establish and maintain standards of professional ethics for
the members.

6.              To develop, establish and maintain programs to assist individuals to
exercise their rights under this Code and the Regulated Health
Professions Act, 1991.

7.                 To administer the health profession Act, this Code and the Regulated Health Professions Act, 1991 as it relates to the profession and to perform the other duties and exercise the other powers that are imposed or conferred on the College.

So sad to see my own Member of the Provincial Parliament, Steve Clark throw away his moral and ethical integrity, when the party he belongs to regained power at Queen’s Park, in order to obtain a Ministerial position within this government. He appeared to be far more vocal during the Liberal government than now.   WHY? The old standard still exists— a politician in opposition or campaigning for re-election will say and do anything but this all changes once being elected!

In this riding it makes no difference what or who runs for the Queen’s Park Legislature. Even the following would win an election here as long as they are wearing Conservative Blue!
Bob Runciman Conservative MPP from 1981 to 2910
Steve Clark Conservative MPP from 2010 to present

Leeds-Grenville-Thousand Islands and Rideau Lakes Riding.

Progressive Conservative Candidate   -----future MPP, the Honourable Jack Ass.

They have, in fact become accomplices in the cover-up of medical negligence and have therefore put patient safety at severe risk. Once again, there is absolutely “no transparency and accountability within Ontario’s Health Care System.

Further adverse events and possible deaths by this surgeon lay completely at the foot of both Steve Clark and Christine Elliott.

Just one of many “Standards of Care” which was not adhered to by this surgeon and hospital:

–open abdominal surgery to remove a tumor and perform a colon resection without the mandatory antibiotic prophylaxis, no anti-biotics for infected abdominal incision whereby all the staples had been removed and not anti-biotics when test results indicated the “presence of many gram-negative bacilli” (in same category as C Dificille) No antibiotics given during entire hospital stay!   How have the Health Minister, Christine Elliott, my MPP, Steve Clark and the Conservative Government ensured that the standards of care are indeed upheld???

Terra Dawn Kilby, age 28, bled to death less than 12 hours after being discharged from Humber River Hospital in Toronto.

One can only hope Karma comes to those MPPs and other parties who failed to act!

PUBLIC SERVICE OF ONTARIO ACT, 2006 Made: June 27, 2007
Filed: July 25, 2007
Published on e-Laws: July 27, 2007

Oath of Office

I, Steve Clark   (Christine Elliott)    swear (or solemnly affirm) that I will faithfully discharge my duties as a public servant and will observe and comply with the laws of Canada and Ontario and, except as I may be legally authorized or required, I will not disclose or give to any person any information or document that comes to my knowledge or possession by reason of my being a public servant. So help me God. (Omit this phrase in an affirmation.)”

************

An MPP brings the riding’s concerns and needs to the table, and will have a stronger voice if he or she holds a high spot in the government. Cabinet ministers hailing from specific regon will be able to shine more light on the area.

NOT IN MY CASE.
As a representative for a particular riding, a MPP is responsible for voicing the concerns of a specific region within Ontario on behalf of the citizens who live within this riding.


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. Who really knows the real total being concealed by all?

Remember pathologist Dr. Smith whose testimony removed children from parents and sent some innocent Ontario citizens to prison before he was exposed. (Dr. Charles Smith was long regarded as one of Canada's best in forensic child pathology. A public inquiry was called after an Ontario coroner's inquiry questioned Smith's conclusions in 20 of 45 child autopsies.) I wonder how many people suspected something but failed to act??????

One must wonder how many people in my daughter's case can be seen doing the exact same thing---covering up negligence   SHAME & BREACH OF TRUST BY A PUBLIC OFFICIAL ----no their reputations far outweigh the truth being known and the public being protected.

Mr Clark, as well as many others, who have the credibility and ability to speak out should do so when it is so apparent that an injustice has occurred. Or do they share a commonality with the USA Republicans?

*

My MPP, Steve Clark and his office will not reply to my many e-mails since I receive the response from Health Minister, Christine Elliott, that there was nothing her office can do. This surgeon has multiple deaths after my daughter’s that has been concealed by all.
Latest bullshit response from Christine Elliott:

Upon receiving the useless letter from Ms Elliott, my MPP has ignored numerous e-mails sent to him until I created a new blog indicating his lack of response and outlining the incredible Breach of Trust by Officials committed by all. Then I received the following:

Jiggins, Michael

Wed 2019-09-18 11:14 AM

Good afternoon, Mr. Kilby.

I had responded to your recent email indicating my availability to speak with you at you convenience.

Let me know when you wish to arrange a call.

Regards,

Michael Jiggins | Executive Assistant
Office of Steve Clark, MPP
Leeds-Grenville-Thousand Islands and Rideau Lakes
613-342-9522
1-800-267-4408

On Sep. 16, 2019 1:48 p.m., Arnold Kilby <awkilby@hotmail.com> wrote:

Numerous e-mails have been ignored by this Office. Why? Plenty of time has gone by since you started ignoring me.

https://ontariohealthcarebetrayal-arnoldkilby.blogspot.com/

Thirteen years of cover-up is clearly irresponsible for all those who have participated and encouraged this. If you recall in a previous e-mail, HPARB had mentioned they have seen many concerns expressed regarding this surgeon and how little affect the minimal oral/written disciplinary actions had on Dr. Klein.

"The Committee noted that Dr. Klein has a significant history with the College, which include cases raising both clinical and record-keeping issues, for which he has received advice and been cautioned. The Committee agreed with the Board that the repetition of similar concerns in this case appears to indicate that the previous remediation attempts have not been successful. This, along with the Committee’s concern about Dr. Klein’s persistent lack of insight into his shortcomings in this case, suggested that a more significant disposition was required to adequately protect the public"

"The Board notes that the Respondent’s conduct history with the College includes prior complaints involving the care of patients, including medication issues, that have previously been identified as concerns by the panels of Committee assigned to assess them and have resulted in advice being provided to the Respondent. The repetition of similar concerns highlighted in this case would appear to indicate that previous remediation attempts by the Committee have failed to yield the desired result. There is nothing within the Committee’s decision to indicate how the issuance of another advice in this matter will protect the public interest in light of the Respondent’s conduct history."

So, the Hospital, CPSO, HPARB, Chief Coroner's Office, DIOC and our elected officials keep protecting the surgeon and continue to put the electorate in danger.

*

Correspondence Services (MOHLTC) <CSU.MOH@ontario.ca>

Wed 2019-05-08 9:03 AM

361-2018-4087

Mr. Arnold Kilby

awkilby@hotmail.com

Dear Mr. Kilby:

Thank you for your email regarding your concerns about the investigations into your late daughter's care at the former Humber River Regional Hospital. You and your family have my deepest sympathies.

I would like to assure you that accountability and transparency are important to me and the Ministry of Health and Long-Term Care.

I remember your daughter's case well from my time as Ontario's Patient Ombudsman, and I regret to hear that you continue to feel that your concerns regarding the investigations have not been appropriately addressed.

While I understand that you are not satisfied with the outcomes of these independent investigations; unfortunately, neither I, nor ministry staff, can intervene or become involved in individual cases.

Please accept my condolences for your loss.

Sincerely,

Original signed by

Christine Elliott

Deputy Premier and Minister of Health and Long-Term Care

*

The Ministry of Health should be questioning the following as it pertains to CPSO's role and obligations to the public:

What is the point of passing legislation if those in authority fail to enforce the laws after enacting them?

The Regulated Health Professions Act, Schedule 2, Section 3, sets out the objects of the College of Physicians and Surgeons of Ontario (CPSO):

Objects of College

3. (1) The College has the following objects (emphasis added):

1. To regulate the practice of the profession and to govern the members in accordance with the health profession Act, this Code and the Regulated Health Professions Act, 1991 and the regulations and bylaws.

2. To develop, establish and maintain standards of qualification for persons to be issued certificates of registration.

3. To develop, establish and maintain programs and standards of practice to assure the quality of the practice of the profession.

4. To develop, establish and maintain standards of knowledge and skill and programs to promote continuing competence among the members.

5. To develop, establish and maintain standards of professional ethics for the members.

6. To develop, establish and maintain programs to assist individuals to exercise their rights under this Code and the Regulated Health Professions Act, 1991.

7. To administer the health profession Act, this Code and the Regulated Health Professions Act, 1991 as it relates to the profession and to perform the other duties and exercise the other powers that are imposed or conferred on the College.

The objects of the CPSO include to "establish and maintain programs and standards of practice."

Ms Elliott;

--please Ms Elliott explain to me how a patient can undergo open abdominal surgery to remove a tumor and have a colon resection done without the mandatory antibiotic prophylaxis being administered

-- please Ms Elliott explain to me how a patient not having the above done did not receive antibiotics when the abdominal incision became so infected that all staples were removed

--please Ms Elliott explain to me not having the two above done how a patient did not receive antibiotics for the presence of "many gram negative bacilli" present-----NO ANTIBIOTICS GIVEN AT ALL!

--And there are so many more patient care issues I have presented to all many time before--- which undoubted would be shared with many of Dr. Klein's patients

I BELIEVE THAT BY RE-EXAMINING ALL CASES CONCERNING DR. KLEIN, MS ELLIOTT AND HER OFFICE WOULD BE INVOLVED IN NOT ONE INDIVIDUAL CASE, BUT MANY!

No, let us allow the public to be completely unaware of this particular surgeon so they will unknowingly allow their loved ones to be operated by this surgeon and use the facilities of this hospital that did all they could to cover up negligence. How can they possibly grant him hospital privileges?--- oh, yeah, the money and so called esteem of his bariatric program brings to them.

Why won't Ford do anything?-- cause he hired the past CEO of the hospital, Reuben Devlin as his special health advisor--- and oh yes, Miss Elliott has a close relationship with Barb Collins, the present CEO of Humber River Hospital.    Does one not smell CORRUPTION in this case.

By reviewing my daughter's case would undoubtedly bring forth the truth that there are so many failings in our system of accountability and transparency that only a Public Inquiry would be able to address them, and make the appropriate recommendations. But this would expose so many elected/appointed officials of not doing their jobs!

Ms Elliott also has a responsibility with regard to Humber River Hospital

Failure of the Hospital:

They supposed are required to do a death investigation but when asked they told the Ombudsman's office, no records were actually kept and the hospital refused to give me a copy or summation of their supposed death investigation. The Health Minister should be looking into this but of course her close friendship with Barb Collins, the CEO would prevent her from doing so. --Breach of Trust.

As you can see from below, this hospital apparently did not do this, or else they covered up their internal review of the patient's care.

Issues are directly related to hospital quality of care. The Quality of Care Information Protection Act, 2004, which sets out in Section 1, the functions of quality reviews (emphasis added):

Definitions

1, In this Act, "quality of care committee" means a body of one or more individuals,

(a) that is established, appointed or approved,

(i) by a health facility,

(ii) by an entity that is prescribed by the regulations and that provides health care, or

(iii) by an entity that is prescribed by the regulations and that carries on activities for the purpose of improving or maintaining the quality of care provided by a health facility, a health care provider or a class of health facility or health care provider,

(b) that meets the prescribed criteria, if any, and

(c) whose functions are to carry on activities for the purpose of studying, assessing or evaluating the provision of health care with a view to improving or maintaining the quality of the health care or the level of skill, knowledge and competence of the persons who provide the health care; ("comite de la qualite des soins).

In the Chief Coroner's refusal to conduct an inquest, the following is stated with regard to the above: (and to many of my recommendations contained within my submission to the CCO requesting an inquiry.)

Dr. Bert Lauwers: CCO

"The concerns raised by these potential recommendations properly belongs to the HRRH and a death review of Ms. Kilby's death"

Apparently they did not do one or at least have a written report of it. This also demonstrated the failure of the Hospital.--- keep in mind the Patient Ombudsman who at the time was Ms Elliott and her office rendered a completely useless report--    Cover-up!

You, as our new Conservative Health Minister, do have the authority to investigate holding both the CPSO and HPARB accountable for an inept, dishonest investigation into my complaints and enacting appropriate legislation in the Legislature to ensure this never happens again. You should also involve the Minister of Correction to do the same with regard to the Chief Coroner's Office and the DIOC, as both institutions are complicit in the cover up of medical negligence and covering up their own role in such.

According to Regulated Health Professions Act you do have the authority to look into the CPSO either personally or through the Advisory Council. You may erroneously consider this as possible political interference but it is your responsibility to do so, and you are mandated to do so!

According to the following act, the Minister of Health and the Ministry does have the authority to ensure that the College indeed must act first and foremost in the interest of the public. So, when I get the standard reply why they can't intervene, it is a falsehood.

The CPSO and HPARB are not operating in the public interest when they total ignore the factual, medical proof contained within the hospital records and only accept fabricated opinion.

Regulated Health Professions Act

Duty of Minister

3. "It is the duty of the Minister to ensure that the health professions are regulated and co-ordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board."

******

College supervisor

5.0.1  (1)  The Lieutenant Governor in Council may appoint a person as a College supervisor, on the recommendation of the Minister,where the Minister considers it appropriate or necessary and where, in the Minister's opinion, a Council has not complied with a requirement under subsection 5 (1). 2009, c. 26, s. 24 (2).

Factors to be considered

(2)  In deciding whether to make a recommendation under subsection (1), the Minister may consider any matter he or she considers relevant, including, without limiting the generality of the foregoing,

(a) the quality of the administration and management, including financial management, of the College;

(b) the administration of this Act or the Health Profession Act as they relate to the health profession; and

(c) the performance of other duties and powers imposed on the College, the Council, the committees of the College, or persons employed, retained or appointed to administer this Act, the Health Profession Act, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act. 2009, c. 26, s. 24 (2).

Council to comply with Minister's request

(2)  If the Minister requires a Council to do anything under subsection (1), the Council shall, within the time and in the manner specified by the Minister, comply with the requirement and submit a report. 1991, c. 18, s. 5 (2).

Regulations

(3)  If the Minister requires a Council to make, amend or revoke a regulation under clause (1) (c) and the Council does not do so within sixty days, the Lieutenant Governor in Council may make, amend or revoke the regulation. 1991, c. 18, s. 5 (3).

Powers of College supervisor

(6)  Unless the appointment provides otherwise, a College supervisor has the exclusive right to exercise all the powers of a Council and every person employed, retained or appointed for the purposes of the administration of this Act, a health profession Act, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act. 2009, c. 26, s. 24 (2).

Minister's directions

(11)  *The Minister may issue one or more directions to a College supervisor regarding any matter within the jurisdiction of the supervisor, or amend a direction. 2009, c. 26, s. 24 (2).

Directions to be followed

(12)  A College supervisor shall carry out every direction of the Minister. 2009, c. 26, s. 24 (2).**

SO MS ELLIOT, YOU CAN SEE THAT THE HEALTH MINISTER DOES HAVE THE AUTHORITY TO ENSURE THAT CPSO IS HELD ACCOUNTABLE

It disheartening to know our elected MPP’s change their attitude one they form the government. Mr Clark has been muted by Premier Ford who by the way.---- Dr. Rueben Devlin--------A $348,000 patronage appointment--must be a reward for his part in covering up medical negligence while CEO of Humber River Hospital

Very disappointing that Dr. Rueben Devlin is a special advisor to Premier Ford with regard to Health He was the CEO of Humber River Hospital where my daughter underwent surgery and later died—bled to death. Perhaps, the Premier should be asking Dr. Devlin what his role was in covering up surgical negligence! This appointment slaps me in the face!

Terra bled out and died 12 hours after being discharged from hospital. Ontario citizens, do not use Humber River Hospital nor believe what you may be told by the Chief Coroner's Office, the CPSO, the Ontario Ombudsman, the Patient Ombudsman, the Death Investigative Oversight Council nor the Health Professions Review and Appeal Board. And let us not forget the FAILURE of the Ministry of Health.

The past Ontario Liberal Government did nothing. THE PRESENT CONSERVATIVE ONE DOES THE SAME! They will do nothing in Health Care that would piss off the CPSO and CMPA. There will always be adverse events, but the number could be greatly reduced if those in authority would act. I would imagine that all provinces are infected by the same corrupt, immoral institutions that are taxpayer funded to promote and protect patient safety but in actuality do the opposite.

In Ontario, Canada, covering up medical negligence is the number one rule for our Politicians, the CPSO, the Chief Coroner's Office, the Death Investigative Council, the Health Professions Appeal and Review Board, the Ontario Patient Ombudsmen, the Ontario Ombudsman, the Hospitals, the Minister and Ministry of Health. Quite a list, and except for the CPSO, our tax dollars pay for the rest.😥

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!

A very dangerous precedence has been set by the CPSO, HPARB, THE CCO, THE DIOC AND THE ONTARIO OMBUDSMAN by allowing the CPSO and HPARB decision to stand---- they can now use my case to substantiate other citizens’ complaints should any open surgery occur within Ontario without the mandatory antibiotic prophylaxis being administered, as well as supporting the non-use of any antibiotics being administered to a patient who has undergone open abdominal surgery (all staples removed from the 8 inch incision) and developing an abdominal incision whereby test results indicated the presence of “many gram negative bacilli”.

SHAME

LET TAKE A QUICK REVIEW OF MY FAILED ATTEMPTS AT ACHIEVING ACCOUNTABILITY, TRANSPARENCY AND THE TRUTH.

THEY IGNORED ALL THE ISSUES:

1. Humber River Regional Hospital

Barb Collins, past CCO and becane CEO after Dr. Devlin

2. The College of Physicians and Surgeons of Ontario--3 decisions

3. The Health Professions Review and Appeal Board --- 3 meetings & 3 decisions

4. The Chief Coroner's Office of Ontario

Past Deputy Chief Coroner of Death Investigations--now CEO of Ross Memorial Hospital in Lindsay, Ontario

Present Chief Coroner of Ontario

Past Chief Coroner--now head of Ornge

5. The Death Investigative Oversight Councils – twice

6. The Minister and Ministry of Health

7. The Minister and Ministry of Corrections

8. The Premier of Ontario—D. McGuinty and then K. Wynne and now D. Ford

9. The Ontario Provincial Police

10. The OIPRD

11. The Ontario Ombudsman's Office ---so many times I can't count

12. P Dube, Ontario Ombudsman—met in person

13. Patient Ombudsman --This failed too!

14. All Member of the Provincial Parliament at Queen's Park in Toronto

Liberals, Conservative and NDP

MY DAUGHTER, TERRA, BLED OUT TWELVE HOURS AFTER BEING DISCHARGED FROM HUMBER RIVER REGIONAL HOSPITAL.

A very dangerous precedence has been set by the CPSO, HPARB, THE CCO, THE DIOC AND THE ONTARIO OMBUDSMAN by allowing the CPSO and HPARB decision to stand---- they can now use my case to substantiate other citizens’ complaints should any open surgery occur within Ontario without the mandatory antibiotic prophylaxis being administered, as well as supporting the non-use of any antibiotics being administered to a patient who has undergone open abdominal surgery (all staples removed from the 8 inch incision) and developing an abdominal incision whereby test results indicated the presence of “many gram negative bacilli”.

SHAME

A QUESTION OF OVERSIGHT WITHIN ONTARIO

The Health Professions Appeal and Review Board, the Chief Coroner’s Office of Ontario, the Death Investigative Oversight Council, and the Ontario Ombudsman’s Office have been created by the Legislature of Ontario to provide assistance to those citizens who have complaints. All of the above are being financed by our tax dollars at quite an expense.

The present Liberal Government has created a Patient Ombudsman who will merely carry on with the same approach as those above. What a financial waste of taxpayers’ dollars!

So, why is it that all of the above readily accept the opinions of the so-called experts without asking/demanding factual, documented support material to said opinions? If the CPSO or COO said the sky was falling, all of the above would be shuddering under their desks. Gullible, you betcha.

i.e.—HPARB disregards documental and factual material submitted to them that contradicts the CPSO’s opinions. HPARB disregards contradictions within the College’s own material.

--the DIOC and the Ombudsman refuse to effectively question the COO and merely accept unsupported opinion!

The CPSO protects its members, and the Chief Coroner protects his fellow colleagues with death investigations involving a hospital/surgeon/doctor care.

Now I realize some of the following is an absolutely absurd scenario. However, believe me; all of the above institutions would not question a single one. –which ones are true and which ones are ridiculous?

1. Surgeon performs operation “blind folded” due to his egotistical nature. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion!

They see no issues with the Standard of Care.

2. Patient goes in for elective abdominal surgery which is changed to open surgery and performed without the mandatory antibiotic prophylaxis. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care. TRUTH!

3. Surgeon has all medical instruments scrubbed down and cleansed with cat urine. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.

4. Surgeon performs abdominal incision with “utility knife” purchased at Home Depot. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.

5. Surgeon performs operation to remove a non-cancerous tumor and performs a colon resection. Surgeon reattaches the two ends of the colon with “duct tape”, and places ten inch strip of “duct tape” over the abdominal incision. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.

6. Surgeon discovers the abdominal infection is severely infected and has it cleansed with saline solution. Discharges patient with the incision still infected and open. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care. TRUTH!

7. Surgeon used “electric carving knife from Hospital Cafeteria” to cut the colon. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.

8. Surgeon discovers from test result that there was a presence of “many gram negative bacilli. Surgeon does nothing. Surgeon discovers the abdominal infection is severely infected and has it cleansed with saline solution. Discharges patient with the incision still infected and open. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care. TRUTH!

9. Surgeon kept patient on liquid diet for 8 days with no nutritional supplementation. Patient only receiving 647 calories per day if she consumed the liquid diet which records indicate she was “not tolerating current diet”. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.
TRUTH!

10. Surgeon has many more deaths associated with him after the death of this particular patient in 2006. CCO temporarily shuts down hospital department and does so without public knowledge as to why. (5 or 6 deaths) HPARB, Ombudsman and the DIOC do not question this as it may relate to the patient’s death back in 2006 and the possible avenues that may have been taken to prevent these further deaths. TRUTH!

11. Surgeon was under the influence of substance affecting judgment and skills at time of operation. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.

12. Surgeon paid no attention to hospital charts indicating numerous issues of concern and failed to investigate. Both College and Chief Coroner state this in no way factored into the patient’s death, not even in a minimal way. HPARB, the DIOC and the Ombudsman accept this unsupported opinion! They see no issues with the Standard of Care.
TRUTH!

*************************************

Terra Dawn Kilby "An Angel In Our Lives"

April 22/78 to July 21/06

A FATHER’S FAILURE

Without a doubt; a Conspiracy exists,

Self-protecting Officials; such hypocrites!

If you were a MPP’s daughter; it would cause a fit,

Because you’re mine; they don’t give a shit!

For years we have yearned for justice,

The lack of moral integrity merely disgusts us!

Government institutions that won’t expose,

The Medical negligence concealed by those!

Medical Immunity granted; regardless of guilt,

Preserving Ontario Health Care’s patchwork quilt!

So many individuals paid through our taxes,

Failing us all; what a bunch of asses!

SEE BELOW FOR THE A-HOLES

Premier of Ontario  --Premier Wynne, Premier McGuinty, Premier Ford

Ontario Minsters of Health   --Dr. E. Hoskins, D. Matthews, Rick Bartolucci, Christine Elliott

Ontario Ministers of Corrections    --Yasir Naqvi, Madeleine Meilleur

Ontario Members of Provincial Parliament --majority of them from 2006 to the present

CPSO -- Angela Bates Manager Committee Support Area Investigations and Resolutions

then Director, Regulatory Affairs at Retirement Homes Regulatory Authority no longer there and then founded her own company SIGNAL REGULATORY SOLUTIONS,

Currently,

Angela Bates: 2024

is the Conduct Director Of Ontario College Of Pharmacists. abates@ocpinfo.com

Sandra Keough CPSO Investigator

HPARB --Chair Janice Vauthier,

Past Chair Linda Lamoureux,

Linda Lamoureux

Lori Coleman Registrar, Third Appeal Chair Tom Kelly, Members Stephen Jovanovic and Brenda Petryna

Ontario Ombudsman   --Paul Dube Ombudsman, A Marin-Ombudsman, Lorraine Boucher- Investigator,

Lorraine Boucher-

Fran Cappe-Investigator,

Humber River Hospital   --CEO B. Collins, past CEO Rueben Devlin,

Ontario Chief Coroner’s Office   --Dr. D. Huyer, Dr. A. McCallum, Dr. A. Lauwers

DIOC  --Joseph C.M. James (Chair), Emily Musing (Vice-Chair), John Pearson (Vice-Chair), William (Bill) McLean, David Williams, Dorothy Cynthia (Cindy) Prince, Denise St-Jean, Fiona Smaill, Lidia Narozniak, Lori Marshall, Lucille Perreault, William (Bill) J Shearing, Michael Pollanen, Fiona Foster Manager of DIOC

Ontario Patient Ombudsman  --Christine Elliott, Investigator Marie Claire Muamba

Marie Claire Muamba

Ontario Provincial Police   --Commissioner J.V.N. (Vince) Hawkes, Inspector Bradley McCallum

OIPRD  -- Director Gerry McNeilly

All the above are well aware the ordinary citizen does not have the financial means to take them on.

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. Who really knows the real total being concealed by all?

Why is it those above ignore the consensus of surgeons around the world?
Makes one wonder who they are really protecting--- the citizens of Ontario or the surgeons/hospitals and themselves.

Unless the truth is brought forward and appropriate actions are taken, they will continue to operate as they have and the Citizens of Ontario continue to lose.

Terminology

Negligence (Lat. negligentia, from neglegere, to neglect, literally "not to pick up something") is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances. The area of tort law known as negligence involves harm caused by carelessness, not intentional harm.

According to Jay M. Feinman of the Rutgers University School of Law, "The core idea of negligence is that people should exercise reasonable care when they act by taking account of the potential harm that they might foreseeably cause to other people."

Medical malpractice is professional negligence by act or omission by a health care provider in which care provided deviates from accepted standards of practice in the medical community and causes injury or death to the patient, with most cases involving medical error.

A breach of the standard of care requires that the plaintiff establish that the defendant physician has failed to provide the care to his patient that an average physician of the same academic qualification licensed to practice in the same area would have provided to that patient.

We have found that it is necessary to establish basically to the court that no physician practicing in that area would have conducted his practice in the same manner.

Numerous examples and proof of negligent care can be seen clearly within Terra’s medical records seen below:

THE MEDICAL FACTS!

Medications

July 12 -- 2/3-1/3 + KCL premixed bag

It was taken out sometime during the night before. Terra was without this for most of the day—could not find a person to re-insert IV- IV was removed due to swollen & bruised in both hands

Stopped July 14 Ketrolac

Morphine Sulphate

Dimenhydrinate

Metoclorpramide

Diphynhydramine

Naloxone (Narcan)

IV stopped for good--- bruising in all places, ---last place was in arm inside of elbow

Stopped July 17 Morphine Sulphate

Dimenhydrinate

Dimenhydrinate Gravol

Metrocllopramide Maxeran

Diphynhydramine

Naloxone (Narcan)

From a nurse employed at HRH at the time who contacted me two years after Terra’s Death.
“I am puzzled by Narcan to be ordered for because we use Narcan only in case of overdose. I consulted with a pharmacist, just to make sure, and he also agreed with me that Narcan in her MAR sheet seems a lit bit suspicious.”

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 antibiotics
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

WITH RESPECT TO JUST THIS ISSUE:

The Medical Community: some answer the specific questions, some provide emotional support, some comment on other issues

“Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?”

1. Yes Kumar (B. Sivakumar MD)

********************************

2. Dear Mr. Kilby,
I am very sorry for your daughter. Just one question, how did you get my contact?
By the way you are telling things happened it seems to me that bowel cleansing is not mandatory although antibiotics are!
Call me if you need any help.

Best Dr Schraibman MD

*********************************

3. In general, bowel prep or bowel cleansing is somewhat controversial and is not absolutely considered standard-of-care and is clearly not related to bleeding. Now not giving antibiotic prophylaxis is a bit different - I think it is standard to receive antibiotics for a planned colon resection, at least in an adult. Still that would relate to a higher infection rate and is not related to bleeding. Bleeding happens during and after surgery. I hope this helped but I really do not know anything about the details. I have a daughter myself and I hope things worked out. Douglas Iddings MD

********************************

4. OAntibiotic prophylaxis is important and can reduce postoperative infection. Bowel cleansing has not been shown to have a positive or negative effect on outcome.
Dale D Burleson, MD

********************************

5. Mr. Kilby, First, I am very sorry for your loss. To answer your questions in general. Bowel cleansing is a matter of surgeon's preference prior to colon resection. There is evidence to show that the outcomes are not significantly different with or without a bowel preparation for colon surgery. Antibiotics are recommended for colon surgery just prior to the start of the operation but should be stopped within 24 hours unless there are clinical indications to continue beyond the 24 hour period. These are the guidelines in the US and the goal of perioperative antibiotics is to prevent wound infections from surgery.

Sincerely,    Daniel H. Hunt  MD

***********************************************************************

6.  If the situation played out as you said above, then I would have given her anti-biotic prophylaxis. I would like to know the diagnosis before the operation to be able to say if I would have had your daughter have bowel cleansing.                 W Mourad  MD

***********************************************************************

7.  Dear Sir/Madam    I am sorry to hear about your daughter's outcome. To answer your question, the colon bowel prep has been in debate for few years. Some surgeons do not feel it is necessary while others still use it. The antibiotic prophylaxis is used to prevent infection during and after surgery. As I am aware, both practices may not increase or decrease the incidence of postoperative bleeding.  I hope this will answer your question and help you deal with the event. Please feel free to ask more questions. I hope that your daughter is recovering well.      Sincerely;   Niazy M. Selim, MD, PhD, FACS

Associate Professor of Gastrointestinal/Laparoscopic,  Endoscopic and Robotic Surgery

Medical Director of Bariatric Program.    Department of Surgery

***********************************************************************

8.  I am sorry for your loss   Usually antibiotic are given iv prior to colon surgery    I hope you will find peace in your future       Amelia Grover, MD

***********************************************************************

 9.  YES      Willie Melvin  MD

*********************************

10. The antibiotic bowel prep the day before surgery has become controversial, but the antibiotic
within one hour of surgery that can be continued for up to 24hrs after surgery is standard of care. Your Welcome,

Dr. DeNoto MD

********************************

11. yes, one dose at the beginning of operation Victor Tomulescu MD

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12. Yes, that would be the standard of care. Helen Chan MD

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13. Antibiotic prophylactic cover is essential to colonic resection while bowel prep is controversial Michael LI K.W. MD

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14. Without knowing the details, I believe that most surgeons would perform some type of bowel prep and give preoperative antibiotics for elective colon surgery. Elective colon surgery without a bowel prep has been reported. Michael H. Wood, MD, FACS

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15. Both are standard practice for whoever undergoing elective colorectal surgery unless your daughter received an emergency surgery without time for formal bowel preparation. Once again the colonic surgery is a clean contaminated operation, routine antibiotics prophylaxis should have been given
Thanks C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons

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16. Hi Mr. Kirby, First of all, I am sorry for your tragic loss. The use of antibiotics in colon rectal

surgery is currently a very hotly debated topic. While most surgeons agree that IV antibiotics should be routinely used at the time of surgery, there is a widely emerging body of data that has brought the use of preoperative bowel preparation and oral antibiotics under question. Currently the evidence is supporting the use of no oral antibiotic or mechanical bowel preparation.
Gregory Gallina MD

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17. I am sorry to hear about your daughter. I hope she came through this OK. I do not have the details of the case, and clearly this opinion is not based on the details of this case. The importance of bowel prep is currently being debated. In general IV prophylactic antibiotics given preop is indicated in colon surgery. Despite this, I doubt that the absence of bowel prep or antibiotics contributed to the bleeding episode. I hope this is helpful. Harold Kennedy MD

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18. Yes I would Michael LI K.W. MD

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19. Hi Mr Kilby I am sorry for your loss. Clearly you are describing a difficult situation and it sounds like there are significant legal issues. I will only say that in the US it is considered standard of care to administer IV prophylactic antibiotics within one hour of skin incision for a clean-contaminated surgical case. Colon resection is considered a clean contaminated case. I do not know have any knowledge of the particulars involving your daughters case, nor would it be appropriate for me to be involved so these comments are in no way intended to be related to the case you are describing. I am only making a statement about what you asked with regard to prophylactic antibiotics and colon surgery.

Best of luck Elliot Newman MD

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20. Good Morning, Yes, antibiotics prophylaxis is in case of open abdominal surgery (colon resection) a routine procedure. Best Regards Dr.Tvaruzek MD

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21. Yes C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons

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22. The simple and accepted answer is yes. I am sorry for your loss

Charles Anderson MD

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23. I was able to catch Dr. Parra-Davila between cases to see if he could answer your question below. Dr. Parra-Davila said yes to your question below and said it is a US guideline to follow for this procedure. Hope this helps. Penny Griggs Advanced Minimally Invasive & Bariatric Surgery ConsultantsAdministrative Assistant to Drs. Keith Kim and Eduardo Parra-Davila

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24. Mr. Kilby: The answer is yes. I would recommend an antibiotic that is effective against the common colonic flora. Perhaps for 24-48 hours starting at the time the abdominal incision is made. I wish you good luck with your crusade. hugo gomez-engler

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25. Mr. Kilby, I am sorry for your loss and obvious anguish over your daughter’s death. In answer to your question, antibiotics are routinely given prior to colorectal operations, whether open or laparoscopic – but this does not prevent infections from occurring (still occur 10-20% of the time regardless of antibiotic use). There are rare circumstances where they are not advised (allergies, etc.). Best of luck, and thank you for your interest in our program. Hopefully your legal counsel will provide the support you need to get the answers you are seeking. PW Paul E. Wise, M.D., FACS Assistant Professor of Surgery Director, Vanderbilt Hereditary Colorectal Cancer Registry Vanderbilt University Medical Center D5248 MCN Nashville, TN 37232-2543 Office: (615) 343-4612 Fax: (615) 343-4615www.vanderbiltcolorectal.com

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26. Yes Malcolm Steel MD

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I was able to catch Dr. Parra-Davila between cases to see if he could answer your question below. ODr. Parra-Davila said yes to your question below and said it is a US guideline to follow for this procedure. Hope this helps. Penny Griggs Advanced Minimally Invasive & Bariatric Surgery ConsultantsAdministrative Assistant to Drs. Keith Kim and Eduardo Parra-Davila

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27. I see, well I certainly am very sorry to hear about such a tragedy and nothing could possibly replace her in you heart. I am a cardiac surgeon and thus general surgery is out of my expertise. However Oall patients having surgery are required to have antibiotic preoperative and Uif there is a documented infection it is mandatory to treat it with antibiotics. I would retain an attorney and have it investigated and seek damages if your attorney deems it just. Sincerely Wendel Smith, M.D.

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28. We always used to give a bowel prep including antibiotics, but recent studies suggest a bowel prep is not necessary and results are better without a bowel prep. I doubt she died because she did not receive antibiotics. Something else must have been going on. I cannot understand why the coroner would make that statement without explaining the circumstances to you.
Adrian Greenstein, MD           *********************************

29. Mr. Kilby,
I am sorry for your loss. Yes of course a patient should receive antibiotics prior to colon resection. Sanjeev Sharma MD FACS

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30. Yes Sent from my iPhone Cohen, Robbin MD

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31. Arnold. I am sorry hear about your daughter. What a loss. Regarding the antibiotics; I have not done colon surgery for some time but I used to give antibiotics prior. Go to the American colorectal website and see if they have an official policy. Matt Slater, MD Associate Professor Clinical Director, Adult Cardiac Surgery OHSU Sent from my iPhone

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32. YES todd grehl MD

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33. Just this one... yes Anthony P Furnary MD

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34. Yes, he should J.S. Smetana Josef MD

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35. Dear Arnold, The answer to your question is YES. Usually a broad spectrum antibiotics administered at the time of induction of anaesthesia. Kind regards, David Jayne MD Senior Lecturer in Surgery Leeds

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36. Yes Demeester, Steven MD

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37. The answer is yes.

I'm sorry for your loss. FF. fernando Fleischman M D

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38. Yes, she should have received "preoperative" antibiotics within One Hour if beginning operation. Whether this would have prevented her death is unclear, but infection rates are known to be significantly reduced with routine antibiotic use. I am sorry to hear about your daughter’s loss. Luis Castro. MD

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39. Mr Kilby, I am sorry for your loss. OUIt seems that there's more to it than just the lack of prophylactic antibiotics that was involved. Unfortunately with every procedure, there are potential risks. I don't know the circumstances around the death of your daughter but I can most certainly feel your pain. My condolences
Alex Ky MD,FACS,FASCRS Division of Colon and Rectal Surgery 212-241-3547

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40. 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 Oadministration of antibiotics for prophylaxis prior to surgery have been a standard of care in surgery for at least 25 years. UIn 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

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41. Yes the colon should be cleaned and antibiotic started prophilactically
Sent from my iPhone HOMAYOON Ganji

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42. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Definitely yes. Usually the day of surgery, and at least an hour before surgery. Long, William :LPH Dir. Tra

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43. It is the standard in the United States to give prophylactic antibiotics within one hour of surgery.    Ismael N. Nuno, MD, FACS, FACC, FAHA.
Chief, Cardiac Surgery Service LAC+USC Medical Center        TEL: (323) 409-8666

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44. Dear Mr. Kilby, Your anger I share, and your unresolved grief is palpable. I have tangled and lost with a family medical issue in Victoria, which still angers me. That was five years or so ago, and fortunately I have moved on to the point where it is just a bullet point in the list of reasons to keep our own medical system as it now stands. I wish truly that I could be of more help with the resolution of your problem, and also that time will allow you to move on. Cord Cordell H. Bahn MD

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45. I am very sorry for your loss. It is generally advisable to administer antibiotics just prior to skin incision. Tara Karamlou MD Sent from my iPhone

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46. Hi - sorry to hear about this sad case....It is tragic and nothing in life is perfect.
God willing and with some luck and fate, we will conquer. Best to you. Ed Yee MD
PS: pre-operative antibiotics for "clean contaminated" cases are usually recommended...

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47. The standard of care in the US is for patients undergoing any surgery is antibiotics within 1 hr of surgery, and for 24 hrs after surgery. This applies to clean and dirty procedures. Clean procedures referring to procedures where bacteria are not normally involved other than skin bacteria, and dirty procedures where bacteria are normally in-countered such as bowel surgery (colon surgery), gyn surgery, and oral surgery Your daughter should have had pre-op and peri-operative antibiotics.

Michael Wood MD

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48. Arnold I am a retired cardiothoracic surgeon who is board certified in general surgery and thoracic surgery. I can't comment on your daughter's case without the record and autopsy report but Othere is no doubt she should have been given pre-operative and post operative antibiotics. Was this the cause of her death, that I can't say without more information. I am sorry for your loss. Mike Perelman MD

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49. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Yes

Diethrich, Edward MD

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50. YES, AND YES, GET A BETTER LAWYER. RRG SWCVTS@aol.com

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51. Mr. Kilby, My sincere condolences on the loss of your daughter. You are correct that I am not a general surgeon Obut I know that it is the accepted procedure to use prophylactic antibiotic coverage for colon surgery in the hospital where I work here in Denver, CO. I believe that is true throughout the US. UIt is disheartening to hear of the lack of transparency on the part of the medical / governmental establishment in the Canadian health care system. Unfortunately, thanks to our socialist president we in the US are probably headed for a similar fate. It sounds like your daughter died of peri-operative sepsis. Prophylactic antibiotics were indicated but that treatment does not prevent this complication in 100% of cases. In all likelihood it would have reduced the probability of such a tragic outcome. Good luck in your struggle to obtain justice for your daughter.

Stanley Carson, MD

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52. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Absolutely. HP MD

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53. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? My answer is unequivocally YES I have no pressures from any organization. BBRoe Benson Roe

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54. Dear Mr. Kilby, I am a practicing Cardiovascular and Thoracic surgeon in North Dakota. I have not done a colon resection in over 20 years, although I have maintained my general surgery credentials for purposes of covering trauma cases and teaching medical students. For legal purposes, I would not consider myself an expert witness.

I would suggest that you look up the US Medicare SQIP Protocol (Surgical Quality Improvement Project) to review the current recommendations for antibiotic prophylaxis for colon resections in this country. Generally, it restricts antibiotic prophylaxis to a single pre-op dose, and less than 24 hours of coverage post-op. Antibiotic bowel preps have also fallen out of favor. Antibiotic use beyond 24 hours is only recommended for treatment of infections that are either suspected or known.
I do think it is fair to say that a preoperative antibiotic dose for a colon resection is the standard of care in this country. Whether or not it would have made any difference for your daughter is problematic, absent a proper record review. Even then, it may be difficult to be certain that the omission was causal in her death.
I am sorry for your loss. I help this will eventually help you gain some closure.
Sincerely,

A. Michael Booth MD PhD FACS

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55. www.cochrane.org/reviews/en/ab001181.html
I hope you'll find this study helpful. Said Yassin MD

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56. Yes

Grantham, Nathan MD

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57. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes John Calhoon MD Professor and Head CT Surg UTHSCSA

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58. AK: The standard of practice for prevention of wound infection in colon surgery is to use prophylactic antibiotics. The description of your ordeal following your daughter’s death suggests that a satisfactory closure will only be achieved by thinking outside the box. You are correct in your assessment of the constraints of the legal response to malfeasance. Novelists, magazine writers, television inquiry shows and personally committed politicians are the alternative methods of casting light into sordid corners. Who asked you to write me?

Bill Murphy MD

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59. Mr Kilby, I have no idea how the Canadian system works and I have to preface my remarks with the comment that I obviously only have your side of this story. Also, I am a pediatric heart surgeon so your daughter's case is not within my area of expertise.   In the US this would have been settled or tried in court. I would think antibiotic prophylaxis for colorectal surgery is routine and indicated - at least 15 years ago when I last did general surgery. Without seeing the facts I cannot determine if this played an important part in the unfortunate outcome for your daughter.   I have great sympathy for you and the lack of transparency you describe is alarming. If I were in your shoes I would sue.

Max Mitchell MD

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60. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Hello Arnold, Thank you for contacting Hadassah. The answer to your question is yes. Best Regards, Isabelle Stroweis Hadassah External Relations Division

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61. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Yes- that is standard. Blackmon, Shanda, M.D.

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62. Yes antibiotic prophylaxis prior to colon surgery is standard Whether this would have saved your daughter is unclear however. Brinkman, William T MD

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63. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Arnold, I am truly sorry for your loss. I believe pre-op antibiotics should have been given. I have included a link that may be helpful.

Derek Derek von Haag MD

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64. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Prophylaxis is standard of care to my knowledge

I am very sorry for your loss. Matt Cooper MD

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65. We still adhere to the fact that patients should have a dose of antibiotics at the time of surgery for most colorectal procedures especially those involving a resection. Some hospitals give up to three doses as prophylaxis, although there is no evidence for this.

Karen Nugent Honorary Secretary

Association of Coloproctology of Great Britain & Ireland

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66. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Likely should have received antibiotics Baron Hamman MD

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67. I’m sorry for your loss. I can’t imagine losing either of my boys (6 & 3). In the United States, it is standard of care to administer appropriate antibiotics within one hour of surgical incision for any case deemed at risk for infection. We get in trouble for any case not administered and documented as such.The US is more into malpractice and I can’t speak to Canadian law. My cousins are lawyers in Duluth and Chicago and would tell you that each case has its own issues and merits. No action will return your daughter to you; that doesn’t mean you shouldn’t pursue this with the national body and perhaps your lawyers.My parents are also retired teachers/pastor and ran Luther Village for a summer in the 60’s. Ontario is one of the most beautiful provinces in the world and I’m sure your daughter was the same. AT Trachte, Aaron Dr.

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68. Mr. Kilby, I am terribly sorry to hear about you loss. I have two children and can’t imagine the pain.As you said I am a cardiothoracic surgeon so I probably can’t help on the details of your daughter’s case. But the answer to your question on antibiotic prophylaxis is a clear yes. OUThe Surgical Care Improvement Project (SCIP) has established clear guidelines on antibiotic prophylaxis prior to all surgery (timing, type). Here in the US our hospital is literally graded on compliance with the SCIP protocols. As a department chair I am responsible for compliance on my team and have to have appropriate procedures in place to assure compliance. When a patient “falls out” (i.e. one of the SCIP guidelines was not followed), the individual doctor receives a letter from the director of the medical staff. Here is a link to one article showing that following SCIP guidelines decreases surgical site infections following colorectal surgery. http://www.ingentaconnect.com/content/sesc/tas/2008/00000074/00000010/art00028Lishan Aklog, MD Chair, The Cardiovascular Center

Chief of Cardiovascular Surgery St. Joseph’s Hospital and Medical Center

500 W. Thomas Rd, Suite 500 Phoenix, AZ

602-406-2996 (Assitant Beth)

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69. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Yes indeed. That is the standard of care Dr. MacMillan MD

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70. Dear Mr. Kilby Please accept my sympathy over the tragic loss of your daughter. Whether the lack of antibiotics before surgery was the essential factor that brought about her demise is still unclear and may always be so. There could have been some other problem during the colon resection which could have led to contamination. This remains unknown. Meanwhile, you are left to cope with your loss and the mental anguish associated. As one who has also lost a young daughter, I believe I can share your grief. I can also affirm that, while not easy, you must do all that you can to go forward with your life, honoring your daughter’s memory. Yours truly, Denton A. Cooley, MD

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71. 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). UThe 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 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,

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72. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? The short answer is “yes”. I’m truly sorry for your loss, sj Scott B. Johnson, MD Associate Professor

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73. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? The answer is yes. What was the cause of death of your daughter? She was obviously very sick. Was she diabetic? Obviously she had a wound infection but what lead to her death is not clear at all. My advice if you are not getting anywhere is to seek a legal opinion. John Reza Mehran, MD

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74. Dear Mr Kilby: I have looked over some of the material about your daughter. I am certified in surgery and thoracic and cardiac surgery. I trained at UCLA (mostly, also U of Minnesota Hospital and Johns Hopkins). I don't currently see patients, but review cases for the Arizona Medical Board. The big problem is apparently not cleaning the colon with laxatives or enema prior to surgery. Antibiotics don't help and likely are contra indicated. I can find specific references at eh our medical school. Feel free to contact me

TW Christiansen MD twc4441@aol.com

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75. 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

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76. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Arnold, I am a retired cardiothoracic surgeon who is board certified in general surgery and thoracic surgery. I can't comment on your daughter's case without the record and autopsy report but there is no doubt she should have been given pre-operative and post operative antibiotics. Was this the cause of her death, that I can't say without more information. I am sorry for your loss.

Mike Perelman MD

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77. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation

Mr. Kilby, My condolences to you and your family on the untimely death of your daughter.
It is standard of care in the United States that all patients undergoing bowel surgery should receive pre-operative prophylactic antibiotics at least 20 min before the incision is made. As a cardiothoracic surgeon, I do a fair amount of esophageal surgery. The same rule applies in regards to this issue. Sincerely, MPC

Michael P. Collins, MD, FACS
ChiefIntermountain Medical Center LDS Hospital and, Division of General Thoracic Surgery Clinical Professor of Surgery Division of Cardiothoracic Surgery
University of Utah School of Medicine

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78. Mr. Kirby: My opinion to antibiotic prophylaxis is generally yes for patients undergoing open colon resection. How this relates to your daughters care remains unknown unless the entire case can be scrutinized. My sympathies for your loss. Steven J. Phillips, MD

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79. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? yes Mark S. Allen MD

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80. Optimal bowel preparation for colon surgery includes mechanical cleansing of the colon the evening prior to surgery and an intravenous dose of broad spectrum antibiotics immediately prior to begriming the operation. This dose is usually given in pre-operative holding or by the anesthesiologist during the skin preparation and draping.
Sorry for your sorrow.

Robert L Replogle. MD.

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81. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes. Within 30 min of incision. Jbz Zwischenberger, Jay MD

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82. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? The answer to your question is "yes". I am so sorry to hear of your heart break!   Hendrick Barner   MD

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83. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? yes Walter G Wolfe MD

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84. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes – SOC Miller, Daniel Sent from my Verizon Wireless BlackBerry

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85. It is standard that all pts receive perioperataive antibiotics with a goal of administering them within 30 minutes prior to skin incision. It is a well validated quality outcome parameter.

John V. Conte, M.D. Professor of Surgery

Johns Hopkins University School of Medicine

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86. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Dear Sir The answer to your first question is yes. Marcelo Cardarelli, MD

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87. Dear Mr. Arnold,

I am very sorry for your loss, however, as you pointed out in your message, I am not the right person to review your daughter’s case. While your frustration with the system and the responses you have gotten to your questions is very clear, I find it difficult to believe that the Canadian medical system is engaged in a conspiracy of some sort involving British surgeons and everyone involved in the case. I think you are giving them far too much credit with regard to organization and cohesive intent. In my opinion, your frustrations are more likely the result of the disorganization and delays that are typical of large medical administrative units. Again, I am sorry for your loss and I hope you find the answers you are looking for.
Sincerely, Paul Kirshbom, MD Emory University School of Medicine

Dear Mr. Kilby,

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

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88. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? In answer to your question, she should have received prophylactic antibiotics and a bowel prep prior to surgery.

Ron Hill, MD, FACS

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89. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? OAbsolutely yes, it is malpractice not to! Sorry about your loss. Regards, Luca A. Vricella, MD, FACS Associate Professor of Surgery and Pediatrics Johns Hopkins University

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90. I assume this was an elective (i.e. not an emergency) colon resection. In the United States, the practice is to perform at least a mechanical bowel prep before an elective colon resection and in all circumstances perioperative antibiotics are given, usually prior to the incision. The duration of antibiotic administration depends somewhat on what is found at operation, but in most circumstances they are stopped not later than 48 hours post-op. I hope this is helpful and am sorry for your terrible loss.

Lynn H. Harrison, Jr., MD Clinical Director

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91. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Yes 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

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92. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes Sent from my Verizon Wireless BlackBerry Joshua Sonett MD

*********************************************************************** 93. 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. OAdditionally, 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.

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94. Mr. Arnold Kilby: I feel sorry for your daughter outcome. Most of your observations and questions make sense. The legal system should be able to address them. I do not believe that anyone outside Canada can be of any help. Sincerely R. Neirotti Rodolfo A. Neirotti, M.D., Ph.D., FETCS

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95. 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.

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96. Dear Mr. Kilby, I feel very sorry and regret what you are experiencing, and completely understand your reaction. A patient undergoing open surgery should always have antibiotics at the time of inducing anesthesia and repeat the dose if the operation last more than 6 hours. I hope this may help you. Good luck and best regards,

Paolo Macchiarini MD pm pmacchiarini@thoraxeuropea.eu

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97. I am indeed a CVT surgeon and not qualified in General Surgery but it is my understanding that prophylactic antibiotics are given with induction for colonic surgery. I regret your loss and hope you find answers to your questions.

Goldman, Dr. Bernard Bernard.Goldman@sunnybrook.ca

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98. Dear Mr Kilby Your questions seem utterly reasonable As you rightly note I am a cardiothoracic surgeon, so through this reply I am asking John Black, President of the Royal College of Surgeons in England to put you in touch with someone better equipped to answer your questions. I am sorry that the immense pain you must be feeling at the loss of your daughter is being made worse by difficulty in having some very simple questions answered. I hope we can help you.

Bruce Keogh Bruce.Keogh@dh.gsi.gov.uk
Sir Bruce Keogh NHS Medical Director Message sent from a Blackberry handheld device.

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99. Mr. Kilby
I feel for your sorrow and please accept my sincere feelings. As a cardiothoracic surgeon, it is not appropriate for me to answer a question regarding abdominal surgery. However, I support using of prophylactic antibiotics before major surgery.    Sertac Cicek,   MD

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100. Mr Kilby- First and foremost, I am ever so sorry for your loss and terrible tragedy. Obviously, I am in no position to legitimately comment on the adequacy of care your daughter received. But I certainly can answer your question.
Generally speaking, pts undergoing colon surgery should receive intravenous antibiotics within 60 minutes prior to their incision. The specific goal is to prevent wound infection-the antibiotics do not seem to decrease the incidence of any other surgical complication (such as a leak or abscess). Again, my sincerest sympathies

Neil Hyman MD

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101. Intravenous Antibiotic prophylaxis is standard when performing a colon resection regardless of whether it is done laparoscopically or via open methods.
Best of luck. RL Whelan

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102. 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 may have 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

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103. Receiving ATBs preoperatively before an abdominal surgery is a standard of care. Regards feza

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104. Dear Mr. Kilby: As a father of a twenty-something daughter, and a long-time practioner of colorectal surgery for over 30 years, I can relate to your circumstances and your grief. The short answer is obviously YES, your daughter should have been prepared for elective colon surgery with both a mechanical (purgation) and an antibiotic bowel preparation. These have been the standard for at least the last 30 years, spanning to the time before I began training as a surgeon in 1972. Extensive clinical research had provided data as to the efficacy and safety of that approach, so it was completely standard to do both preps prior to elective colon surgery. Having said that, and believe me when I say it, I STILL use both preps for my own operative cases and am rewarded with very low sepsis and very low overall complication rates. However, some less-than-brilliant surgeons have in the last 5 or so years begun to advocate for colon surgery without mechanical preparation beforehand! I believe both the data and the conceptual rationale for this approach to be very flimsy indeed. They claim that bowel prep is "expensive" (pure B.S., to use the American vernacular), is "intolerable" to the patient (we do it all the time for colonoscopy, for example), and that purgation interferes with the "microcirculation" of the colon. That latter "factoid" is trotted out as the reason for why those publishing surgeons claim to have LOWER complication rates when the bowel is left unprepped before surgery. They claim that interfering with the microcirculation impairs colon healing, leading to higher rates of anastomotic leakage and postoperative sepsis. In American jurisprudence, you would have no trouble finding dozens of surgeons who would be happy to testify that bowel preparation is still mandatory ("standard of care") for elective, safe colon surgery. I do not know the consensus of opinion on this topic in Canada. Suffice it to say, on the basis of the few facts of your daughter's case presented in your short email to me, I would conclude that she was poorly, even negligently served by the surgeon entrusted with her care. Unfortunately, I have seen in the American system, that if we did not have strong legal sanctions against negligence, many doctors would literally get away with murder. There will always be failures of judgment which lead to patient harm, as long as physicians remain fallible human beings. But my belief is that the surgeons who are promulgating colon surgery without suitable bowel preps are willfully ignoring decades of safety experience. They are trying to "reinvent the wheel", when bowel prep has an established safety record over many decades. One might reasonably ask the question "why" they would tamper with success, and that is a long, fruitless discussion from your standpoint. In brief, I believe it boils down to a question of surgical ego, where some surgeons are hell-bent to prove that they are so good they can evade the norms established by mere mortal surgeons such as myself.
Again, my condolences to you and your family. You are experiencing tragedy of the first order, and it always pains me especially when such stories come at the hands of intelligent, well-motivated surgeons who are charged above all to "do no harm" (primum non nocere).
Sincerely yours, Mark Helbraun, MD, FASCRS

***********************************************************************

105. Dear Sir:

I am so sorry for the loss of your daughter. The clinical picture that you describe is that she died from infectious complications related to a peritonitis and sepsis from post operative complications. The causes are multiple, but after colonic surgery a usually fatal complication is an anastomotic suture leak (breakdown).
Most colo-rectal surgeons will prepare the colon and give pre operative antibiotics. But this will not prevent a technical suture problem. The autopsy report should have those details. The operative report should help.

*********************************************************************

106. Taken from article entitled When is Primary Anastomosis Safe in the Colon? 2005 Surgery in Africa Monthly Reviews and 2010 update
Antibiotics with activity against aerobic and anaerobic bacteria need to be given parenterally in the peri-operative period alone. Their post-operative use should be restricted to cases with established infection. Pre-operative oral antibiotics may have an added

value. In elective colon operations there appears to be no value to mechanical bowel preparation. Even as I write this, my surgical prejudices rebel against such a notion.Brian Ostrow MD, FRCS(C)

Guelph, Ontario Canada
Adjunct Lecturer Office of International Surgery
University of Toronto Canada

********************************************************************

107. Dear Mr. Kilby I'm very sorry to hear of your loss

The short answer to your question is yes, giving an antibiotic prior to an elective colon resection is the standard of care in the US. In the US the sequence of events that you describe would usually generate a lawsuit.

You may find the following websites helpful http://www.qualitymeasures.ahrq.gov/search/search.aspx?term=Colorectal+Surgery+Specialty&umls=1 (the website for the national guidelines regarding standard surgical practices)

www.fascrs.org (website of the American Society of Colon and Rectal Surgeons)

www.facs.org (website for the American College of Surgeons)

http://www.cags-accg.ca/ (the Canadian Association of general Surgeons)

Sincerely Tonia Young-Fadok MD

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
youngfadok.tonia@mayo.edu

*******************************************************************

108. 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

************************************************************************

109. 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.

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
Office (804) 828-3500

*****************************************************************************************

110. Mr. Kilby:                                                                                                                        Were peri-operative prophylactic antibiotics administered? There is a suggestion that they may not have been. It is standard of care to do so for a limited time around the time of operation.
Matthew M. Cooper, MD FACs

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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

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 possibly 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.

NOW WITH RESPECT TO ALL THE MEDICAL FACTS LISTED BELOW, LET US LOOK AT THE EXPERT OPINIONS PROVIDED PREVIOUSLY AND BY OTHER QUALIFIED SURGEONS OUTSIDE OF ONTARIO AND CANADA:

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???

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, 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 23298-0015While 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 M

“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

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,
**********************************************************************

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
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H. GET A BETTER LAWYER. RRG SWCVTS
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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
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.

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                                                                                                                                           *********************************************************

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 *************************************************************

N. 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
****************************************************************

O. 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
*********

NOW IS THERE AN HONEST SURGEON/DOCTOR/MEDICAL EXPERT WITHIN ONTARIO OR DO THEY ONLY EXIST OUTSIDE OF ONTARIO AND NOT A MEMER OF THE CPSO AND CMPA? OBVIOUSLY, NOT! THE PROVINCIAL GOVERNMENT MUST CHANGE THIS IMMEDIATELY.

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 air
This 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
Description of Terra’s Abdomen   high pulse rate? 34/38 above 90
1.         July 11th

1133 hrs 105

            1143                                                                105
            1630    flat                                                      106
            1709                                                                98
            1730                                                                101
            2000    flat                                                      104
2.         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
3.         July 13th

0820 rounded 110

            1130    rounded                                             105
            1615    rounded                                              102
            2100    rounded
            2015    rounded                                             107
4.         July 14th

0500 rounded 126

            0815   rounded                                             97
            1200    rounded                                             95
            1500    rounded                                              117
            1600 rounded
            1857    rounded
            2000    rounded                                             110
5.         July 15th

0530 rounded 94

            0910    rounded                                             97
            1300    rounded
            1800    rounded                                              108
            2107    rounded
6.         July 16th

0530 rounded 98

            1130    rounded                                              105
            1310    rounded                                             96
            2000    large                                                   102
7.         July 17th

0700 large 93

            0951    large                                                   104
            1437                                                                98
            2200    large                                                   108
8.         July 18th

0517 large

            0600    large
            1000    large                                                   86
            1510    large
            1600    large                                                  90
            2000    large                                                   85
9          July 19th

0925 large 93

1957 large 96
10. July 20th

0039 large

            0800    large                                                   88   Terra was released

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
Day 3              0.32    range
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 &
Day 3              3.78    other 4 below normal range
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
Day 3             0.8   normal range
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
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               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 18^th
Page 62           0045                foul odour
Page 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
TAKEN FROM USDA National Nutrient Database for Standard References 2004

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
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!

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.
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!

3.     LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE! Supports a healthy immune system, energy metabolism and protein synthesis
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!

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.
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!

5.     LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE! Blood coagulation is dependant on calcium.
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!

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.
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!

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.
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!

8.     LACKING 93% OF TOTAL DAILY FIBRE 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!

9.     LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE! protects against infection, and enhances the immune system;
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!

10.   LACKING 82.7% OF TOTAL DAILY ZINC INTAKE! protects against infection, and enhances the immune system; Zinc is also required in wound healing.
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!

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.
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!

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
12. 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!

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
13. 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.

14.   LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE! Necessary for red blood cell formation, anti-body production, cell respiration, and growth
14. 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!

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

15. 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!

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.
16. 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!

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
17. 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!

18. LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE 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.

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.
All 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)

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.   ---according to the autopsy report
This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS

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
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 normally 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
Definition of eupnea --normal, good, unlaboured ventilation, sometimes known as quiet breathing or resting respiration

*******************************************************************************

Let us look at the copious notetaking by this surgeon: Can you read them”

Which I think substantiates my assertion that Dr. Klein did not look at the nurses notes regard the abdomen, the incision and all records. If he did I’m sure he would have commented on the size of the abdomen and the oozing, purulent foul discharge from the abdominal incision.

Example of Dr. Klein’s writing. How on earth could a nurse or anyone read and understand. The chances of misinterpreting his orders/notes are quite high!

WHY DOES IT APPEAR THAT Dr. Klein’s Partner, John Hagen partner in MIS, has his signature on these notes?? Please keep in mind Ms. Collins had at one point suggested I meet with a medical expert who by the way was JOHN HAGEN?????

Note: July 18, 1248 is not Dr. Klein’s handwriting—who wrote it for him?

July 19, 06 at 1730 SEE Chart below:

1 – Home tomorrow with H/C

[Please be advised that this was not either Doctor’s handwriting or mentioned that the order was documented on behalf of attending physician. The discharge order was actually written by a nurse]

HOW WOULD ANYONE BE ABLE TO READ HIS NOTES? A transcribe version is seen further below.—I have no idea if the written scribble matches the typed version.

Inadequate and meaningless physician progress notes.

Physician must write their progress note in SOAP system [ CPSO requires that all physician's note to be written in SOAP method.

S: subjective, means what patient is telling me

O: Objective, what I observe,

A: assessment, vital signs and physical assessment,

P: Plan, what I am going to do for this patient in order to address her complaints and her abnormal physical findings]

Surgeon’s Daily Records

Letter dated Nov 14/07 to Dr Klein from the College

“Upon review of the above file, I note that some of your records are not legible and do not meet the College’s expectation that records can be interpreted by the average health care professional.”

“Would you please provide a typed transcription of the enclosed records? Additionally, would you please comment on the legibility of your records?”

July 11, 2006 Surgeon’s Daily Notes Upon visitation

OR Note:

Proc: Lap - open Right hemicolectomy and excision of large mesenreric cyst

Surg: Klein, Esser, Shedletsky

GA: Zadic No comp.

July 12, 2006

VSS afeb No gas Abdo soft Comfortable

July 13, 2006

HR: 100, Temp 38.1 Feels better today No gas

Wound: ok Abdo soft Hungry

July 14, 2006

Temp: 36.0 (Max 38.1) HR:80 + gas (passing gas) abdo still tender incision okay

WBC: N (normal) Con't clears (fluids)

July 15, 2006

VSS, afeb Wound infection -> opened + gas Con't as is

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

July 17, 2006

Some diarrhea, otherwise well Plan: home 1-2 days

July 18, 2006

Afeb Well, eating well Plan: home 2 days

July 19, 2006

VSS, afeb Well

Decreased pain, decreased diarrhea, C. diff. Negative

Plan: home in am

***********************************************************

NOTICE – THE ABOVE DOES NOT INCLUDE WHO WROTE WHAT NOTES??? Why?

Why is it the Chief Coroner’s Office, the CPSO are unable to find any medical support material to go along with their opinion why I can locate numerous support material to address my concerns?

ANSWER---BECAUSE THERE ARE NO MEDICAL JOURNALS, BOOKS, ARTICLES THAT SUPPORT THEIR B.S. AND THEY MERELY WANTS TO PROTECT THEIR FELLOW COLLEAGUE AND CPSO MEMBER AS WELL AS THEIR INEPT INVESTIGATIONS.

The CCO’s and the CPSO’s expert did not provide one single resource to support their opinions!

How can HPARB and th DIOC not place any importance on the non-use of the mandatory antibiotic prophylaxis when they are the institutions Ontario Citizens are to go to with their concerns?

TERRA ©

“Remember Me"

Remember that my favourite colour is blue, and my love of Care Bears.

How I was nervous meeting new people, and yes, I did make many new friends just like you said I would.

Remember our special days together; the many camping trips, dance recitals, graduations, and visits to Wonderland.

Remember how I could raise one eyebrow and could make my ears wiggle.

How I loved spaghetti and peach crepes.

My favourite ice‑cream was chocolate chip cookie dough.

I believed in fate, angels and yes, UFO's.

I am still with you, close your eyes and think of me.

Picture my face and my smile and the brightness of my eyes.

Remember: the smell of my hair and my perfume, the warmth and love of my embrace, the feel of my tears against your cheek, the softness of my skin, the sound of my voice and the deepness of my love.

You hold all the precious memories of me in your heart and in your mind.

No one can take them away; I will be with you always.

"Please, Remember Me"

I know you are sad right now.

It may hurt you so to think of me.

But, I ask you to please remember me.

You may be remembering me at this moment with your tears.

It is ok; tears heal and cleanse.

Don't block out your memories of me; I know you miss me, cause I miss you too.

Someday, hopefully soon, your memories of me will make you smile, and perhaps chuckle.

Remember our times of happiness, laughter and yes, some tears.

Perhaps not every moment was perfect.

Please, no regrets, never regrets.

Life is too precious for regrets.

If everything was perfect we would never really appreciate life; because it would all be the same.

We would never learn to grow or aspire to be a better person.

We learn from the many challenges life presents.

Everything that happened in my life made me the person I am, so I say again, no regrets.

I say, "I am" because I am still with you.

You will come to know this once your grief passes.

In Loving Memory,

The following is just for the antibiotic prophylaxis and antibiotics concerns regarding open abdominal surgery and the treatment of an abdominal infection and the presence of “many gram negative bacilli”.

None of which was administered to my daughter!

Why is it I can find articles but the CPSO’s and the CCO’s experts only offer their opinion unsupported by any documented literature.---THEY CANNOT FIND ANY!

Reducing Harm | Improving Healthcare |

Protecting Canadians

PREVENT SURGICAL SITE INFECTIONS

Getting Started Kit March 2011

www.saferhealthcarenow.ca

Prevent Surgical Site Infections

GSK Contributors

We also wish to thank and acknowledge our Canadian faculty who has contributed

significantly to the work of the Surgical Site Infection (SSI) teams and the revisions to this kit.

Dr. Elijah Dixon Assistant Professor of Surgery, Alberta Health Services, Calgary Region

Foothills Medical Centre, Calgary, AB

Cari Egan Consultant, Western Node, Safer Health Care Now!

Dr. Claude Laflamme

Director of Cardiac Anesthesia/TEE,

Sunnybrook & Women's College Health Science Centre, Toronto, ON

and Physician Lead for the SHN Surgical Site Infection Intervention

Dr. Nicholas Leyland Chief, Obstetrics and Gynaecology, St. Joseph's Health Centre, Toronto, ON

Kelly Campbell A/Vice President, Clinical Planning, Hamilton Health Sciences, ON

Susan Fryters ACPR Antimicrobial Utilization/Infectious Diseases Pharmacist

Alberta Health Services, AB

Shirley Gobelle Patient Safety Consultant, Winnipeg Regional Health Authority, MB

Gillian Gravely Nurse Manager, OR - Toronto General Hospital /OR/PACU - Princess Margaret Hospital

Bonnie McLeod President, Operating Room Nurses Association of Canada (2009-2011)

Dr. Peter Riben Consultant in Community Medicine, BC

Tanis Rollefstad Safety and Improvement Advisor, Western Node, Safer Healthcare Now!

Wendy Runge Infection Control Practitioner, Alberta Health Services, Calgary Region, AB

Safer Healthcare Now! Prevent Surgical Site Infections Getting Started Kit

March 2011 5

Dr. Adelia A.M. Santos Consultant, Certified Hospital Epidemiologist, Calgary, AB

Dr. Tim Tang Anaesthetist, Foothills Medical Centre, Alberta Health Services, Calgary Region, AB

Daniel Thirion Professeur agrégé de Clinique, Faculté de Pharmacie

Université de Montréal, Montréal, QC

Marlies van Dijk SSI Lead/Western Node Leader, Safer Healthcare Now!

Diane White Manager of Infection Prevention and Control, North York General Hospital, Toronto, ON

PAGE 9

a. Appropriate Use of Prophylactic Antibiotics

One of the most important interventions in preventing surgical site infections is the

optimization of antimicrobial prophylaxis. Appropriate use of antibiotics has been shown

to reduce surgical site infections1, 5-16. While the necessity and efficacy of preoperative

prophylactic antibiotics are not in question, the type, dose, timing, and duration of

antibiotic prophylaxis continue to be debated in the literature.

Where are we now?

The Surgical Care Improvement Project (SCIP) reported the following US national averages

for the fourth quarter of 2007. These data are self-reported by hospitals but are subject

to validation review17.

• Antibiotics are given within 1 hour of surgery 89.5% of the time, on average

(benchmark 99%).

• Correct antibiotics are given 95.2% of the time, on average (benchmark 99.5%).

• Antibiotics are discontinued within 24 hours of the end of surgery 86.2% of the time,

on average (benchmark 98.2%).

PAGE 10

(i) Timing

All systemic antibiotic infusions must be started and completed up to 60 minutes

before first surgical incision18, except vancomycin and fluoroquinolones which need to

be infused over more time (120 minutes) to avoid Red Man Syndrome. However,

vancomycin infusions must be completed no more than 60 minutes prior to first

incision. This allows time to achieve minimum inhibitory concentration (MIC) of

antibiotic in serum and tissue levels from the start of surgery. Re-dosing of antibiotics

may be required during prolonged surgeries (more than 4 hours) in order to maintain

therapeutic levels perioperatively. This strategy will contribute to the reduction of

surgical site infections1.

PAGE 11

(ii) Dosing

There is limited published data on appropriate antimicrobial dosing for

prophylaxis. The dosage of the antibiotic needs to be adequate based on the

patient’s body weight, adjusted dosing weight, or body mass index34. Additional

doses may be necessary during prolonged surgery in order to ensure an

adequate antimicrobial level until wound closure.

Canadian healthcare facilities who have reported a high rate of success with timely

prophylactic antibiotic administration often reassign antibiotic administration

responsibilities to anesthesia or holding area nursing staff in order to optimize timing

of antibiotic delivery.

PAGE 12

Weight Based Dosing

Rationale and expert opinion point to the adoption of weight based dosing as an added

strategy to lower SSI rates. There is evidence that applying weight based dosing to

cefazolin and vancomycin surgical prophylaxis regimens will lower SSI rates among

obese patients35. However, there are pharmacokinetic considerations that pose

challenges when determining adequate dosages of antibiotics in obese patients36.

It appears the most common weight based dosing regimen practiced in Canadian

hospitals surveyed is 2 grams of cefazolin for people weighing more than 80 kg.

However, there is current discussion evolving that questions whether 1 gm of Cefazolin

is adequate for normal weight adults – and some institutions in North America are

moving to a standard protocol of giving 2 grams of Cefazolin for all surgical adult

patients even though sufficient evidence has not been published at this point.

PAGE 13

(iii) Duration

Single Dose Antibiotic Prophylaxis

Institutions across the country are starting to adopt single dose prophylaxis for

non-complex surgeries. Published literature on antibiotic prophylaxis shows that

for non–complex and uncomplicated surgical cases a single dose of antibiotic may

be sufficient in preventing infections37-47. The Medical Letter Treatment Guidelines

state the following: “most Medical Letter consultants believe that postoperative

doses are usually unnecessary and can increase the risk of antimicrobial

resistance”48. Yet, there is no definitive evidence that this be adopted as a

general rule for all types of surgery, therefore guidelines from international

organizations (CDC, NICE, WHO and SHEA) are not emphatic in recommending

single dose prophylaxis1, 18, 26, 29. Many local institutions are giving prophylaxis up to

24 hours post-operatively for cardiac, thoracic, orthopaedic, and vascular surgery.

At this point, the literature has not shown whether single dose prophylaxis is equal

or superior to 24 hour regimens in preventing surgical infections for all major

surgeries.

************************************************************************************

PAGE 14

RECOMMENDATION

Based on the evidence, the Safer Healthcare Now! faculty recommend that prophylactic antibiotics be completely absorbed up to 60 minutes before first surgical incision, and

should be repeated for surgeries lasting longer than the half-life of the antibiotic (4 hours

for cephalosporins). Antibiotics administered for cardiac, thoracic, orthopaedic and

vascular patients should be discontinued within 24 hours of the end of surgery, whereas

non-complex and uncomplicated surgeries require no further administration of antibiotics

PAGE 22

Accreditation Canada

Accreditation Canada (AC) has performance measures in place for surgical site infections

(2008). They focus on the rate of post-surgical infections and rate of timely administration of prophylactic antibiotics. The protocol attached to these measures allows an

organization to select a surgical procedure that has the highest risk, highest surgical

volume, or both. They recommend the following selected procedures to include:

• cardiac surgery

• colorectal surgery

• hysterectomy

• c-section

• total joint arthroplasty

• craniotomy

• CSF shunts

• spinal surgery

They recommend that the indicators of post op infection rates and timing of prophylaxis

be applied to the same surgical procedure, but it is not a necessity.

The definition of both collecting postoperative surgical infection and timing of prophylaxis

is synonymous with the Safer Healthcare Now! data collection measures. Accreditation

Canada specifies for each organization to establish their own post operative surveillance

time period. Safer Healthcare Now! recommends a 30 day post operative time period.

PAGE 23

Ontario - Ministry of Health and Long Term Care

The Ministry of Health and Long Term Care of Ontario (MOHLTC) has instituted mandatoryreporting of patient safety indicators, some of which are aligned with Safer Healthcare Now! measures.

The MOHLTC indictor refers to prophylactic antibiotic use to help prevent surgical site

infections in hip and knee joint replacement surgeries. SSI data is to be reported for all

primary total, partial and hemi hip and knee joint replacements (not revisions) by all

hospitals performing these surgeries. Time for antibiotic administration will be measured

from the antibiotic infusion start time to skin incision start time. The goal should be to have the antibiotic completely infused within 0 to 60 minutes of skin incision for regular antibiotics (such as cephalosphorins, i.e. clindamycin or cefazolin). For vancomycin the start time is extended to 0 to 120 minutes prior to skin incision.

The MOHLTC indicator for SSI (antibiotic timing) and the SHN measure for antibiotic timing

are identical. Safer Healthcare Now! does not limit the population for this measure to hips

and knees, but recommends reporting data separately for each population for which data is

being submitted.

***************************************************************************************************

From:cmalibrary (cmalibrary@sympatico.ca)

Sent:September-23-11 2:59:45 PM To: awkilby@hotmail.com

	2 attachments \| Download all as zip (472.4 KB)
	prep for ...doc (28.5 KB) View online , operative...pdf (443.9 KB)

Information from the websites they suggested:

Keith R. Gardiner, MD, MCh, FRCS (Gen) Bobby V.M. Dasari, MS, MRCS
Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK The Queen’s University of Belfast, Belfast, UK

Prophylactic antibiotics (third-generation cephalosporin and metronidazole) should be given at induction and for up to 24 hours. A treatment regime (5 days of antibiotics) may be necessary if there is significant intraoperative contamination.

Antibiotic use in colorectal surgery is a well-established practice that reduces infectious complications. Elective colorectal cases are classified as clean-contaminated and, as such, benefit from routine single-dose administration of parenteral antibiotics 30 minutes before incision. There is evidence to show that when operative times are prolonged, additional doses at 4-hour intervals reduce wound infection.

**********************************************************************************

ANTIBIOTIC PROPHYLAXIS IN SURGERY

Florida Administration (AHCA) website (www.floridacomparecare.gov).

Colorectal Surgery       Enteric Gram(-) bacilli, Enterococcus, anaerobes
NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.
Cefazolin + Metronidazole         Clindamycin + Aminoglycoside
The performance measures currently mandated are as follows:
1. Prophylactic antibiotics must be administered to the patient within 1 hour prior to surgical incision.
2. Prophylactic antibiotics must be discontinued within 24 hours from the end of surgery.
******************************************************************

Bard C. Cosman, M.D., M.P.H.
VA San Diego Healthcare System

Perioperative Management

V. Antibiotic prophylaxis
It is very clear that an intravenous antibiotic given within two hour before starting an abdominal operation lowers the wound infection rate significantly. If the operation is long (> 4 hours), the antibiotic should be administered intraoperatively as well. The antibiotic should cover enteric gram-negative bacilli and anaerobes

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.
******************************************************************

Antibiotic prophylaxis in colorectal surgery.

Rovera F, Diurni M, Dionigi G, Boni L, Ferrari A, Carcano G, Dionigi R.

Source

Department of Surgical Sciences, University of Insubria, Azienda Ospedaliero-Universitaria, Fondazione Macchi, Varese, Italy. francesca.rovera@uninsubria.it

Abstract

Nosocomial infections are the most frequent complications observed in surgical patients. In colorectal surgery, the opening of the viscera causes the dissemination into the operative field of microorganisms originating from endogenous sources, increasing the chance of developing postoperative complications. It is reported that without antibiotic prophylaxis, wound infection after colorectal surgery develops in approximately 40% of patients. This percentage decreases to approximately 11% after antibiotic prophylaxis. Specific criteria in the choice of correct antibiotic prophylaxis have to be respected, on the basis of the microorganisms usually found in the surgical site, and on the specific hospital microbiologic epidemiology.

PMID:

16207170

[PubMed - indexed for MEDLINE]

Can J Surg. 2003 Aug;46(4):279-84.

******************************************************************

The Encyclopedia of Surgery (Copyright © 2007-2011 Advameg, Inc) has been written by various experts in the field of surgery and has been written specifically for healthcare students and patients. The Encyclopedia covers 450 surgical procedures and topics such as laser surgery, hysterectomy, endoscopy, cryosurgery, anesthetics, biopsy, angioplasty, medications and postoperative care, and many related subjects. Each entry in the Encyclopedia of Surgery consists of a standardized format which includes the definition, purpose, diagnosis, aftercare risks, mortality rates, and alternatives.
“Preoperative bowel preparation involving mechanical cleansing and administration of intravenous antibiotics immediately before surgery is the standard practice. The patient may also be given a prescription for oral antibiotics (neomycin, erythromycin, or kanamycin sulfate) the day before surgery to decrease bacteria in the intestine and to help prevent post-operative infection.” ****************************************************************

GRAM-NEGATIVE SHOCK AND DEATH IN SURGICAL PATIENTS

â Usually anaerobic bacteria, streptococcus, and staphylococcus are gram positive, and the enterobacteria are gram negative.

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.

Postoperative infection is a medical malpractice often concealed in the patient record, or dismissed as unimportant, or even blamed on the patient herself.

Many doctors now use broad-spectrum antibiotics to prevent postoperative infections by these gram-negative inhabitants of all hospitals.

Although antibody prophylaxis did not lower the infection rate, it prevented the serious consequences of gram-negative infections and thus improved the overall prognosis.

Almost 90%-95% Gram Negative bacteria are considered to be harmful for the host, in other words Gram Negative bacteria are pathogens.

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.

There are dozens of different species of gram-negative bacilli, with many species normally found in the intestinal tract. In the intestinal tract they have a beneficial effect on the body by preventing overgrowth of potential pathogens. However, if by surgery or trauma these bacteria get out of the intestine, they can cause serious, life-threatening disease.

*********************************************************************

DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They

are intended to serve as a general statement regarding appropriate patient care practices based upon the available medical

literature and clinical expertise at the time of development. They should not be considered to be accepted protocol or policy, nor are intended to replace clinical judgment or dictate care of individual patients.

Revised 10/17/06

ANTIBIOTIC PROPHYLAXIS IN SURGERY

In December 2005, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicaid and Medicare Services (CMS) mandated reporting of the following performance measures on a monthly basis.

Procedure Likely Pathogen(s) Recommended Druga Alternative Regimend

General Surgery

• Appendectomy (non-perforated) Enteric Gram(-) bacilli Cefazolin + Metronidazoleb Clindamycin + Aminoglycoside

• Colorectal Surgery Enteric Gram(-) bacilli, Enterococcus,

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.

anaerobes Cefazolin + Metronidazoleb Clindamycin + Aminoglycoside

• High-risk esophagealc, gastoduodenal,

or biliary surgery3 Enteric Gram(-) bacilli, Gram(+) cocci Cefazolin Clindamycin + Aminoglycoside

• Penetrating abdominal trauma Enteric Gram(-) bacilli, Enterococcus,

anaerobes Cefazolin + Metronidazoleb Clindamycin + Aminoglycoside

Gynecologic Surgery Clindamycin + Aminoglycoside

• C-section (after cord-clamping) Staph epi, Staph aureus, Group B Strep,

Enterococcus Cefazolin Clindamycin + Aminoglycoside

• Hysterectomy Enteric Gram(-) bacilli, Group B Strep,

Enterococcus Cefazolin Clindamycin + Aminoglycoside

Head and Neck Surgery

Anaerobes, Staph aureus, Gram(-) bacilli Clindamycin Cefazolin + Metronidazole

Neurosurgery

• Clean Staph aureus, Staph epi Cefazolin Clindamycin

• Skull fracture, CSF leak Anaerobes, Staph epi, Staph aureus Cefazolin Clindamycin

• Penetrating trauma Staph, strep, Gram(-) bacilli, anaerobes Ceftriaxone, Clindamycin N/A

• Spine Staph aureus, Staph epi Cefazolin Clindamycin

Orthopedic Surgery

• Closed fracture Staph epi, Staph aureus Cefazolin Clindamycin

• Open fracture Staph, strep, Gram(-) bacilli, anaerobes Cefazolin + Gentamicin Clindamycin + Gentamicin

Urologic Surgery

• Genitourinary (high risk only)e Gram(-) bacilli, Enterococcus Cefazolin Ciprofloxacin

Vascular Surgery Staph epi, Staph aureus, Gram(-) bacilli,

Enterococcus Cefazolin Clindamycin

Cardiothoracic Staph epi, Staph aureus, Streptococcus,

Corynebacteria, enteric-Gram-negative bacilli Cefazolin Clindamycin

************************************************************************************

www.saferhealthcarenow.ca

Safer Healthcare Now! Prevent Surgical Site Infections Getting Started Kit

1. Perioperative Antimicrobial Coverage

a. Appropriate Use of Prophylactic Antibiotics

One of the most important interventions in preventing surgical site infections is the

optimization of antimicrobial prophylaxis. Appropriate use of antibiotics has been shown to reduce surgical site infections1, 5-16. While the necessity and efficacy of preoperative prophylactic antibiotics are not in question, the type, dose, timing, and duration of antibiotic prophylaxis continue to be debated in the literature.

Where are we now?

The Surgical Care Improvement Project (SCIP) reported the following US national averages

for the fourth quarter of 2007. These data are self-reported by hospitals but are subject

to validation review17.

• Antibiotics are given within 1 hour of surgery 89.5% of the time, on average

(benchmark 99%).

• Correct antibiotics are given 95.2% of the time, on average (benchmark 99.5%).

• Antibiotics are discontinued within 24 hours of the end of surgery 86.2% of the time,

on average (benchmark 98.2%).

RECOMMENDATION

Based on the evidence, the Safer Healthcare Now! faculty recommend that prophylactic antibiotics be completely absorbed up to 60 minutes before first surgical incision, and should be repeated for surgeries lasting longer than the half-life of the antibiotic (4 hours for cephalosporins). Antibiotics administered for cardiac, thoracic, orthopaedic and vascular patients should be discontinued within 24 hours of the end of surgery, whereas non-complex and uncomplicated surgeries require no further administration of antibiotics following surgery.

*****************************************************************************************

When is Primary Anastomosis Safe in the Colon?

By Dr. Brian Ostrow MD, FRCS(C) Guelph, Ontario, Canada

ptolemy.info@utoronto.ca

Of all the traditional recommendations concerning colon surgery only those relating to peri-operative antibiotics have withstood scientific scrutiny and are uniformly practised.

While the value of peri-operative antibiotics has stood the test of scientific scrutiny, the other “sacred cow” of elective colon surgery, the mechanical bowel prep, has not.

Antibiotics with activity against aerobic and anaerobic bacteria need to be given parenterally in the peri-operative period alone. Their post-operative use should be restricted to cases with established infection. Pre-operative oral antibiotics may have an added value.

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.

*********************************************************************

Antimicrobial prophylaxis in surgery. Committee on Antimicrobial Agents, Canadian Infectious Disease Society

T. K. Waddell and O. D. Rotstein
Department of Surgery, University of Toronto, Ont.

RECOMMENDATIONS:

Antibiotic prophylaxis is recommended for operations with a high risk of postoperative wound infection or with a low risk of infection but significant consequences if infection occurs. These operations include clean-contaminated procedures and certain clean procedures. Drugs should be administered intravenously immediately before the operation.

VALIDATION: The guidelines were compared with others in standard textbooks of surgery and peer-reviewed articles. The guidelines were prepared and revised by the Committee on Antimicrobial Agents of the CIDS. They were then reviewed and revised further by the Council of the CIDS. SPONSOR: The CIDS was solely responsible for developing, funding and endorsing these guidelines.

********************************************************

Mayo Clinic Standards of care for Surgery

The quality measures listed in the table below are known as the "standards of care" for managing patients undergoing surgery in a hospital setting. This list includes the medical care widely accepted as the most appropriate care guidelines for the majority of patients undergoing surgery in a hospital.

*Standards of care for surgical care improvement project*	*Explanation of this care*
Percent of patients given preventive antibiotic within one hour before the surgical incision	*Research has shown that receiving an antibiotic within the hour before surgery ensures the lowest incidence of postoperative infection.*

********************************************************

Agency For Health Care Research and Quality

Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery. A national clinical guideline.

Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2008 Jul. 71 p. (SIGN publication; no. 104).

[218 references]

Guideline Summary NGC-6684 Guideline Title

Antibiotic prophylaxis in surgery.

A national clinical guideline.

Benefits of Prophylaxis

In many ways, the value of surgical antibiotic prophylaxis in terms of the incidence of surgical site infection (SSI) after elective surgery is related to the severity of the consequences of SSI. For example, in the presence of an anastomosis of the colon, prophylaxis reduces postoperative mortality.

In total hip replacement surgery prophylaxis reduces long term postoperative morbidity. For most operations, however, prophylaxis only decreases short term morbidity.

Surgical site infection increases the length of hospital stay. The additional length of stay is dependent on the type of surgery. Prophylaxis has the potential to shorten hospital stay. There is little direct evidence that it does so as few randomised trials have included hospital length of stay as an outcome measure. There is evidence to indicate that prevention of wound infection is associated with faster return to normal activity after discharge from hospital. This summary was completed by ECRI on October 17, 2001. The information was verified by the guideline developer as of December 17, 2001. This NGC summary was updated by ECRI Institute on January 14, 2009. The updated information was verified by the guideline developer on January 19, 2009.

*********************************************************************

World Journal of Surgery

Preventing surgical-site infections after colorectal surgery

Mao Hagihara, Mieko Suwa, Yumi Ito, Yuki Muramatsu, Yukiko Kato, Yuka Yamagishi and Hiroshige Mikamo

Journal of Infection and Chemotherapy, 9 September 2011

Surgical-site infection (SSI) is a major contributor to patient mortality rates and health care costs. Due to the high risk of bacterial contamination, colorectal surgery is associated with a particularly high risk of postoperative infection.

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED. ********************************************

Efficacy of Protocol Implementation on Incidence of Wound Infection in Colorectal Operations

http://www.journalacs.org/article/S1072-7515%2807%2900578-9/abstract - article-footnote-1

Presented at the Annual Meeting of the American Society of Colon and Rectal Surgeons, Seattle, WA, June 2006.

Traci L Hedrick, MD, Department of Surgery, University of Virginia, PO Box 801380, Charlottesville, VA 22908.

James A. Heckman, BS Robert L. Smith, MD Robert G. Sawyer, MD, FACS

Charles M. Friel, MD Eugene F. Foley, MD

Conclusions

After implementation of a multidisciplinary wound-management protocol, incidence of SSI improved 39%.

These results demonstrate that compliance with a prospectively designed protocol for perioperative care can effectively reduce operative morbidity in patients undergoing colorectal operations.

Endotoxin is synonymous with the Gram-negative cell wall, in particular the LPS component. It is responsible for many of the toxic manifestations of infections with Gram-negative bacilli. The intravascular presence of endotoxin stimulates a cascade of pro-inflammatory cytokine production that produces the dreaded clinical picture of “Gram-negative septicemia” manifest by fever, leukopenia, disseminated intravascular coagulation, shock and often death.

Gram-negative bacillary sepsis with shock has a mortality rate of 30 to 50 percent; mortality varies depending, in part, on whether the patient receives timely and appropriate antibiotic therapy. Kang CI, Kim SH, Park WB, Lee KD, Kim HB, Kim EC, Oh MD, Choe KW

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.

****************************************************************

CHICA-Canada Standards & Guidelines Committee

CHICA-CANADA POSITION STATEMENT

Perioperative antibiotic prophylaxis has been demonstrated to prevent surgical site infections in designated clean and clean-contaminated procedures. To be effective, the following must be considered:

Antimicrobial Prophylaxis (AMP) should be used for all clean contaminated procedures, and for certain clean procedures in which clinical trials have proven their use will reduce surgical site infection (SSI) rates.

Original: November 2004

Last revision: March 2005

********************************************************************

Current Guidelines for Antibiotic Prophylaxis of Surgical Wounds

RONALD K. WOODS, M.D., PH.D., and E. PATCHEN DELLINGER, M.D.

University of Washington Medical Center, Seattle, Washington

Appropriately administered antibiotic prophylaxis reduces the incidence of surgical wound infection. Prophylaxis is uniformly recommended for all clean-contaminated, contaminated and dirty procedures. It is considered optional for most clean procedures, although it may be indicated for certain patients and clean procedures that fulfill specific risk criteria. Timing of antibiotic administration is critical to efficacy. The first dose should always be given before the procedure, preferably within 30 minutes before incision. Readministration at one to two half-lives of the antibiotic is recommended for the duration of the procedure. In general, postoperative administration is not recommended. Antibiotic selection is influenced by the organism most commonly causing wound infection in the specific procedure and by the relative costs of available agents. In certain gastrointestinal procedures, oral and intravenous administration of agents with activity against gram-negative and anaerobic bacteria is warranted, as well as mechanical preparation of the bowel. Cefazolin provides adequate coverage for most other types of procedures.

Postoperative wound infections have an enormous impact on patients' quality of life and contribute substantially to the financial cost of patient care. The potential consequences for patients range from increased pain and care of an open wound to sepsis and even death. Approximately 1 million patients have such wound infections each year in the United States, extending the average hospital stay by one week and increasing the cost of hospitalization by 20 percent.¹ This translates to an additional $1.5 billion in health care costs annually.²

It is generally agreed that antibiotic prophylaxis is warranted in all procedures in the categories of clean-contaminated, contaminated or dirty.

… The most commonly administered drug is cefazolin (Ancef, Kefzol). For procedures of the alimentary tract, genitourinary tract and hepatobiliary system, coverage should be additionally influenced by site-specific flora, such as gram-negative and anaerobic microorganisms. In such cases, cefotetan (Cefotan) or cefoxitin (Mefoxin) is a suitable agent. For patients with documented allergy to cephalosporins, vancomycin (Vancocin) is a reasonable alternative for coverage of Staphylococcus, and metronidazole (Flagyl) or clindamycin (Cleocin) and an aminoglycoside may be used for coverage of anaerobic and gram-negative organisms, respectively. Aztreonam (Azactam) can be combined with clindamycin but not with metronidazole in the same setting.¹⁴ A quinolone, such as ciprofloxacin (Cipro), may also be effective for coverage of gram-negative organisms, although data for the context of prophylaxis are not available.

NOTE: TERRA’S MEDICAL RECORDS INDICATE THE PRESENCE OF “MANY GRAM NEGATIVE BACILLI AND THIS WAS NOT TREATED.

…Colorectal procedures have a very high intrinsic risk of infection and warrant a strong recommendation for prophylaxis. Several studies have demonstrated efficacy, with rates of infection decreasing from over 50 percent to less than 9 percent.^3,25-27 Antibiotic spectrum is directed at gram-negative aerobes and anaerobic bacteria. Different strategies using parenterally or enterally administered antibiotics are used,
*****************************************************************************************

RONALD K. WOODS, M.D.,
is a fifth-year resident in surgery at the University of Washington. He completed a Ph.D. in biophysics at the University of Illinois College of Medicine Medical Scholars Program, Champaign-Urbana, where he also received his medical degree.

E. PATCHEN DELLINGER, M.D.,
is professor and vice-chair of surgery, chief of the division of general surgery, and associate medical director of the University of Washington Medical Center, Seattle. He received his medical degree from Harvard Medical School, Boston, and completed a surgical residency at Beth Israel Hospital, Boston, and a fellowship in infectious diseases at TuftsNew England Medical Center, Boston. Copyright © 1998 by the American Academy of Family Physicians.

ASHP Therapeutic Guidelines on

Antimicrobial Prophylaxis in Surgery

Ideally, an anti-infective drug for surgical prophylaxis should achieve the following goals:

(1) prevent postoperative infection of the surgical site,

(2) prevent postoperative infectious morbidity and mortality,

(3) reduce the duration and cost of health care (when the costs associated with the management of postoperative infection are considered, the cost-effectiveness of prophylaxis becomes evident),

(4) produce no adverse effects, and

(5) have no adverse consequences for the microbial flora of the patient or the hospital.

To achieve these goals, an anti-infective drug should be

(1) active against the pathogens most likely to contaminate the wound,

(2) given in an appropriate dosage and at a time that ensures adequate concentrations at the incision site during the period of potential contamination,

(3) safe, and

(4) administered for the shortest effective period to minimize adverse effects, development of resistance, and cost. The benefits of preventing postoperative infection pertain to both outpatient and inpatient surgeries.

Antimicrobial prophylaxis is justified for the following types of surgical procedures:

cardiothoracic, GI tract (e.g., colorectal and biliary tract operations), head and neck (except clean procedures), neurosurgical, obstetric or gynecologic, orthopedic (except clean procedures), urologic, and vascular.

Colorectal:

Neomycin sulfate 20 mg/kg plus erythromycin base 10 mg/kg p.o. (after mechanical bowel preparation is completed) at 19, 18, and 9 hr before surgery; if oral route is contraindicated, cefoxitin or cefotetan 30–40 mg/kg i.v. at induction of anesthesia; for patients undergoing high-risk surgery (e.g., rectal resection), oral neomycin and erythromycin plus an i.v. cephalosporin

**************************************************************************

Should you wish to send your MPP your concerns please do so!

Tuesday, September 17, 2019

INSTITUTIONAL BETRAYALS—BREACH OF TRUST

This was merely another “Bull shit” response.

The most recent case involving this surgeons who has had multiple deaths--- far too many for a general surgeon. Ignored by the Health Minister, the Health Ministry and my MPP.

Obviously, Dr. Klein has not changed since my daughter’s death. Before reading my story, take a look at excerpts from the following HPARB decision.From an HPARB Review held on July12, 2017

WHAT HAPPENED TO THIS STEVE CLARK?

Did he accept his own "Quid pro Quo"? Silence for a Cabinet Minister position. ---proof is in the pudding

And this from a few years earlier:

HEALTH PROTECTION AND PROMOTION AMENDMENT ACT, 2011 /

One can only hope Karma comes to those MPPs and other parties who failed to act!

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."

************************************************

What is the point of passing legislation if those in authority fail to enforce the laws after enacting them?

LET TAKE A QUICK REVIEW OF MY FAILED ATTEMPTS AT ACHIEVING ACCOUNTABILITY, TRANSPARENCY AND THE TRUTH.

1. Humber River Regional Hospital Barb Collins, past CCO and becane CEO after Dr. Devlin

2. The College of Physicians and Surgeons of Ontario--3 decisions

3. The Health Professions Review and Appeal Board --- 3 meetings & 3 decisions

4. The Chief Coroner's Office of Ontario Past Deputy Chief Coroner of Death Investigations--now CEO of Ross Memorial Hospital in Lindsay, Ontario Present Chief Coroner of Ontario Past Chief Coroner--now head of Ornge

5. The Death Investigative Oversight Councils – twice

6. The Minister and Ministry of Health

7. The Minister and Ministry of Corrections

8. The Premier of Ontario—D. McGuinty and then K. Wynne and now D. Ford

9. The Ontario Provincial Police

10. The OIPRD

11. The Ontario Ombudsman's Office ---so many times I can't count

12. P Dube, Ontario Ombudsman—met in person

13. Patient Ombudsman --This failed too!

14. All Member of the Provincial Parliament at Queen's Park in Toronto Liberals, Conservative and NDP

Terra Dawn Kilby "An Angel In Our Lives"

April 22/78 to July 21/06

is the Conduct Director Of Ontario College Of Pharmacists. abates@ocpinfo.com

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."

July 12, 2006

July 13, 2006

July 15, 2006

July 17, 2006

“Remember Me"

ANTIBIOTIC PROPHYLAXIS IN SURGERY

Florida Administration (AHCA) website (www.floridacomparecare.gov).

Perioperative Management

Antibiotic prophylaxis in colorectal surgery.

Source

Abstract

Antimicrobial prophylaxis in surgery. Committee on Antimicrobial Agents, Canadian Infectious Disease Society

Mayo Clinic Standards of care for Surgery

Preventing surgical-site infections after colorectal surgery

Surgical-site infection (SSI) is a major contributor to patient mortality rates and health care costs. Due to the high risk of bacterial contamination, colorectal surgery is associated with a particularly high risk of postoperative infection.

Efficacy of Protocol Implementation on Incidence of Wound Infection in Colorectal Operations

http://www.journalacs.org/article/S1072-7515%2807%2900578-9/abstract - article-footnote-1

Presented at the Annual Meeting of the American Society of Colon and Rectal Surgeons, Seattle, WA, June 2006.

Conclusions

Current Guidelines for Antibiotic Prophylaxis of Surgical Wounds

INSTITUTIONAL BETRAYALS—BREACH OF TRUST

HEALTH PROTECTION
AND PROMOTION
AMENDMENT ACT, 2011 /

"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."

1. Humber River Regional Hospital

Barb Collins, past CCO and becane CEO after Dr. Devlin

4. The Chief Coroner's Office of Ontario

Past Deputy Chief Coroner of Death Investigations--now CEO of Ross Memorial Hospital in Lindsay, Ontario

Present Chief Coroner of Ontario

Past Chief Coroner--now head of Ornge

14. All Member of the Provincial Parliament at Queen's Park in Toronto

Liberals, Conservative and NDP

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."