INSTITUTIONAL BETRAYAL==ONTARIO PATIENT OMBUDSMAN'S OFFICE--
INSTITUTIONAL BETRAYALall were given the medical
facts and expert opinions mentioned previously
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?
*******************************************************
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?
*******************************************************
ONTARIO PATIENT OMBUDSMAN'S OFFICE--another government fantasy! AND COMPLETE WASTE OF OUR TAX DOLLARS.
Patient Ombudsman
Every experience matters
July 11, 2017
Arnold W. Kilby 888 County Rd 2 Lansdowne Ontario KOE ILO
Dear Mr. Kilby:
Re: File #0148
I am writing to confirm that our office's review of your complaint is complete and the file is closed on the basis of the information I provided to you in my letter of June 2, 2017.
In that previous correspondence, I provided a summary of the information our office received during the review and our attempts to facilitate resolutions of concerns deemed to be within the mandate of the Patient Ombudsman. As is part of our process, I invited you to contact me once you have reviewed the information.
AWK – In your report there was not one negative comment or suggestion with regard to the hospital’s role of “putting patients first; being completely transparent and being accountable; nor any wrong doing by HRH; their actions or lack thereof; remain squeaky clean!
You responded to my June 2 letter by emails dated June 14 and 18, 2017. In your emails you declined my invitation for a discussion of the information contained in the June 2 letter as you indicated that in your view no useful purpose would be served in having the discussion.
AWK-- AND I STILL MAINTAIN THIS OPINION!
I appreciate that you are disappointed that our office could not review and address questions related to the medical or clinical care and decisions by regulated health professionals involved in your daughter's care in July 2006.
AWK – disappointed is not the word I would use--- “Disgusted and Betrayed” are more appropriate and relative words.
In our meeting of September 22, 2016 and in subsequent communication, I clearly made you aware of the scope of our office's review of your concerns. This fact was confirmed in my letter to you dated January 18, 2017.
AWK – The scope of your review makes it impossible for you to truly represent an Ontario Citizen! Legislation needed to expand your scope, otherwise your office is a complete waste of taxpayer’s dollars!
I can confirm that our office carefully examined the information you provided as well as the information received from HRRH and we did so fairly and without taking sides. As an impartial, fact-gathering, oversight agency, when we indicate that a complaint with our office is resolved, we mean that it's resolved to the point that we are satisfied that no further action is warranted. Sometimes, this doesn't always mean that everyone who contact us will be satisfied.
AWK – which effectively means this Hospital will ot look into the surgeon’s use of pre and post-operative administering of anti-biotics and does not care how many of Dr. Klein’s patients die due to negligent care!
I certainly hope that you nor any of your relatives and friends do not go under the knife of this surgeon. But how do you feel for those Ontario Citizens who will do so and suffer adverse events including death?
I thank you for your commitment in bringing your concerns to the Patient Ombudsman's office. Although many of your concerns were outside the scope of our mandate, we do believe every experience can help us find ways to tackle system-wide issues, which can lead to better care for everyone.
AWK – You can’t possibly tackle system wide issues when so many of my concerns are outside your scope. Upon looking at the issues and medical support; you certainly should have realized the failings of the other institutions/individuals who I have sought out. There is no way your investigation and experiences lead to better care for everyone!
Regardless of the restricted mandate you have; further deaths by this surgeon and the continued cover-up by the hospital and other institutions/individuals, may in a small way, make you accountable for further adverse events which will undoubtedly occur!
When Ms Elliott submits her yearly report she should include Terra’s case to substantiate why the Patient Ombudsman’s Role should be enhanced, and to point out the failings of the other parties of which I dealt with.
Marie-Claire Muamba -- Investigator
Patient Ombudsman Ombudsman des patients
Box 130, 77 Wellesley St. West, Toronto, Ontario M7A IN3
*****************************
LET TAKE A QUICK REVIEW OF MY FAILED ATTEMPTS AT ACHIEVING ACCOUNTABILITY, TRANSPARENCY AND THE TRUTH.
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.
When you look at the PATIENT OMBUDSMAN'S REPORT, I think one might feel the above is relevant.
- Humber River Regional Hospital IN 2010, "With the help of the Coroner's Office, the program was shut down while an external review was done by a well-known expert." (according to this power point display which mentions 5 deaths within 30 days of operation of patients) --this was referencing bariatric deaths--one can only wonder about other general surgeries conducted by Dr. Klein. Government funded through our tax dollars and FAILED.
There must be something written in legislation that mandates they do so and should they not, then the hospital administrators should be held accountable! AND the PATIENT OMBUDSMAN SHOULD BE REPORTING THIS TO THE MINISTER OF HEALTH FOR ACTION.
2. The College of Physicians and Surgeons of Ontario -- 3 decisions "Physicians have been granted the privilege of self regulation. Society allows physicians to regulate themselves in return for the covenant that this regulation will occur in the public interest."
3. The Health Professions Review and Appeal Board --- 3 meetings plus two attempts at a Reconsideration. Totally ignored College's conflicting statements to the actual operation records.
Government funded through our tax dollars and FAILED.
4. The Chief Coroner's Office of Ontario "We speak for the dead to protect the living'
The Office of the Chief Coroner for Ontario serves the living through high quality death investigations and inquests to ensure that no death will be overlooked, concealed or ignored. The findings are used to generate recommendations to help improve public safety and prevent deaths in similar circumstances.
THEY DID ALL THEY COULD TO CONCEAL THE CONTRIBUTING FACTORS INTO MY DAUGHTER'S DEATH FIRSTLY TO PROTECT THE SURGEON/HOSPITAL'S REPUTATION AND THEN TO COVER THEIR OWN ASSES! Government funded through our tax dollars and FAILED.
5. The Death Investigative Oversight Council -- twice The DIOC waiting TWO YEARS before they handled my complaint against the Chief Coroner and only started after both Dr. McCallum and Dr. Lauwers left. WHY? And then they say they can not investigate the medical aspects of my complaint. Government funded through our tax dollars and FAILED.
6. The Minister and Ministry of Health "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." THIS MINISTRY AND THE THREE MINISTERS HAVE NOT ADHERED TO THE ABOVE AND THUS FAILED ALL ONTARIO CITIZENS!
7. The Minister and Ministry of Corrections
8. The Ontario Provincial Police --stated that Breach of Trust by a Public Official is not within their jurisdiction to investigate???? It is contained within the Criminal Code of Canada and Ontario. Government funded through our tax dollars and FAILED.
9. Ontario Independent Police Review Director Government funded through our tax dollars and FAILED.
10 The Ontario Ombudsman's Office ---so many times I can't count ---P Dube totally ignored the contradiction within the College's third decision which HPARB had dismissed at well. Government funded through our tax dollars and FAILED.
11. Next up: Patient Ombudsman -- Am I confident this institution will do anything---NO GEE, I got this prediction correct! Government funded through our tax dollars and FAILED.
12. Forget about accessing the Freedom Of Information --- waste of time and money
Not a single institution/person above could find a single systemic or patient care issue??
HPARB, THE OMBUDSMAN'S OFFICE, THE HEALTH MINISTER must be incredibly dumb, or they willingly participated in concealing the truth and thus jeopardizing the citizens of Ontario to further medical harm by this surgeon! The contradictory CPSO's opinion with their own expert as well as the factual documentation within Terra's medical records!In response to a request for further information from the College, the IO provider also set out the following information:
• The standard of practice for open bowel resections is to provide antibiotic prophylaxis.
However, such administration would not reduce the risk of anastomotic leak.
• The standard of practice would be to administer prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only and not opening the bowel, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.
AWKILBY’s Response: The above is pure BS. He knew before he converted to a laparotomy!!
Note the following: This proves that Dr. Klein was going to attempt
laparoscopically a colon resection for a mesenteric mass. This was before he converted to a laparotomy!!!
Procedure One Desc. “Laparoscopic Colon Resection Attempted For Mesenteric Mass”
The second Procedure Desc. indicates the laparotomy.—the open procedure
LET US LOOK AT THE MEDICAL FACTS:
A. How about the fact that she did not have the anti-biotic prophylaxis given at the time of induction?
Prophylactic Antibiotics The need of prophylactic antibiotics is indisputable in colorectal surgery in order to reduce the rate of postoperative infectious complications.
B. How about the enlarged abdomen? Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem.
C. How about the foul, purulent oozing incision? Excessive or prolonged serosanguinous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence
D. How about the fact she had no colon cleansing? The colon contains bacteria and waste products that can cause infection if they leak into the abdomen during surgery. Therefore, a number of precautions are taken to reduce this risk. First, oral antibiotics may be prescribed several days before the operation. Secondly, the colon is emptied as much as possible to reduce the risk for infection during surgery.
E, How about the fact she received no anti-biotics what so ever? It is no wonder that the colon tissue died and separated causing internal bleeding leading to death. Have you ever been prescribe antibiotics for an: ear infection? eye infection? bladder infection? throat infection? chest infection? for a cut? etc, etc, etc, Yet my daughter received nothing???
F. 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 can a wound heal without proper nutrition?
Terra’s diet from July 11th/06 to & including lunch on July 19th/06 The clear-liquid diet is used for one or two days or until you are able to drink or eat other things. It cannot meet daily nutritional needs, but it helps keep fluids in your body as you recover and become able to eat a regular diet. 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.
G. How about the fact her resting pulse rate was over 90 Resting heart rates that are consistently high (Pulse Rates >90) (tachycardia) may indicate a problem, and you should consult a health care provider 34/38 of Terra’s recorded pulse rates were above 90 during her stay
H. How about the fact that she was only receiving 687 calories per day for 8 days? A healthy individual on a safe weight losing diet should not have fewer than 1200 calories per day. A healthy individual on a safe weight losing diet should not have fewer than 1200 calories per day.
I. How about the many gram negative bacilli seen? And not treated. Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This pathogenic capability is usually associated with certain components of gram-negative cell walls, in particular the lipopolysaccharide (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.
J. How about the low Absolute Lymphocyte (type of white cells)?
K. How about the many PMN’s (polymorphonuclear Neutrophils) –? hallmark of acute inflammatory process. PMN’s are the hallmark of acute inflammation PMN’s are rapidly recruited to tissues upon injury or infection
L. How about the below the standard scores for red blood cell count, hemoglobin counts and hemacrit counts?
The ONLY meeting assessment written by Terra's Aunt who attending this meeting: HRRH’s
Communication Efforts?
“The general attitude of senior staff at HRRH (we met five senior staff members, including Dr Jack Barkin, Chief of Staff, at our meeting of May 15, 2008) appears to be one of complete haplessness: as they have been cleared (by the College of Physicians/Surgeons) of not meeting standards in Terra’s post-operative care, they have expressed a lack of interest in further discussion and have given us the impression that they consider Terra’s death to be a fluke/bad luck/ “just one of those things” / a medical mishap for which there is no explanation and show absolutely no inclination to conduct their own inquiry.
Their truculence to say anything at all, indicates to us that any discussion initiated by them may be taken as an admission of culpability. Is it not incumbent upon hospitals, when these types of totally unexpected deaths occurs, to conduct an investigation, to shed some light on the situation (in Terra’s case, the cause of death was DIC) as some measure of solace to relatives, and also to educate other medical professionals and to advance the body of knowledge on the subject - in other words, perform a public service?
Our family expected HRRH would provide this kind of service to us - that they would tell us what happened/may/could have happened. On the contrary, we have had to conduct our own research, much of it via the internet, via journals, but it can be accessed only by subscribing and paying a fee.
This state of affairs should be unthinkable in our province. Our family knows the CAUSE of Terra’s death - what should be investigated are connections between the events of Terra’s hospital stay and their connections to the onset of DIC. This is the heart of the matter. Terra’s father, has done a meticulous job, researching medical records, organizing documents etc. while at the same coping with his overwhelming grief. He deserves credit for this.”
“It is common knowledge that on very rare occasions, a patient, even a young healthy patient dies
after surgery. However, until every detail of the surgery/post-operative period in HRRH have been examined by specialists in the field, we are not prepared to accept the fact that Terra’s death has no explanation.”
Note: Terra's Colon Resection broke down (necrosis of the tissue--what caused this tissue to die?) and she bled to death. We had been told that she had DIC which the Chief Coroner later retracted.
AS WELL,---NO correspondence were ever responded to my concerns. It was two years after Terra's death that Ms. Collin via a phone call admitted that there was no record of Terra not receiving the antibiotic prophylaxis---TWO YEARS & they supposedly uconducted an internal review???
***************************************
MPP STEVE CLARK --I AM DONE!
--perhaps you might ask to be included in the dinner mentioned below to give you the opportunity to question this report.
STEVE, what is your impression of this report if it was about one of your own adult children?
Note—Ms. Elliott discharged herself from my complaint due to the close friendship between herself and the CEO of Humber River Hospital.
Tremendous effort to support HRH, a piss poor effort for Terra and the citizens of Ontario!
Ms. Collins (CEO of Humber River Hospital) and Ms. Elliott (Ontario Patient Ombudsman) should take Patient Ombudsman, Marie-Claire Muamba out for a congratulatory dinner recognizing her for producing this indifferent, sterile, partisan and whitewashed report.
READ THIS REPORT to form your own opinion.—“swept under the carpet, glossed over, explained away, dodged, masked, buried, screened, camouflaged, concealed, suppressed, disguised, hushed up, veiled, kept under wraps, buttoned lip, kept mum, kept the cat in the bag, etc.”
I have failed my daughter, and all the citizens of Ontario as have all the other institutions/parties I have contacted. One only has to look at the medical evidence to see how negligence continues to be covered up. This newly created Patient Ombudsman’s Office is just another waste of tax dollars to merely create a political fantasy of another institution that, in actuality; does not place Ontario citizens high on the integrity priority list. Another institution lacking teeth, not to mention ethical integrity!
AWKilby
Discussing this report would be an obvious complete waste of time. So many have ears but are unable to listen.
BELOW: The reply from the Patient Ombudsman's Office.
NOTE THE REPORT, IN NO WAY, INDICATES ANY CRITICISM OF HUMBER
RIVER HOSPITAL'S ACTIONS AND/OR LACK OF ACTIONS BACK IN 2006 BUT
APPARENTLY COMMENDS THEM ON HOW HRH OPERATES IN 2017. FAT LOT
OF GOOD THIS MAKES AT THIS POINT.
Ms Muamba --you mentioned in your letter posted further down that I had multiple meetings with HRRH---May I remind you that at my ONE meeting in May of 2008 with the 5 administrators, I was told by Scott Jerrit (hospital administrator) that they found nothing wrong in their investigation??? ----- Gee, what about the failure to administer the antibiotic prophylaxis??? What else have they hidden from me?? They did not address one single issue I brought up at this meeting. My brother and his wife and their son, a Bay Street lawyer attended this meeting. Dr. Barkin only tried to defend the hospital's record of in-hospital deaths which at the time of Terra's death was the second highest in ALL OF CANADA!
Dear Mr. Kilby, February 9, 2017Thank you for your email. I acknowledge your frustration that we cannot look into every aspect of your complaint, and very much appreciate your acknowledgement of same. Your complaint is a priority for us and we will move forward with the issues we are able to handle.
Ms. Muamba is still your main contact throughout this process, but please do not hesitate to reach out to me if you would like to discuss your complaint or any questions or concerns about our processes.
Yours truly, Karyn Wasserstein Senior Legal Counsel Patient Ombudsman
********************************
Dear Mr. Kilby,
Ms. Muamba and Ms. Elliott have shared with me the email that you sent them on February 5, 2017 (included below). Please accept my deepest condolences on the loss of your daughter and I am very sorry to hear of the struggles and frustration you have experienced over the last ten years.
Your complaint and your concerns about us are a priority for us, which is why I am reaching out to you. We are transparent in how we work and I would be more than happy to explain our processes in more detail.
We are committed to working with you and with the hospital to try to resolve your complaint to help you meet your goal of improving the health care experience for other patients and their families. We share your goal and we will do everything we can to resolve all aspects of your complaint that fall within our mandate.
Ms. Muamba will be obtaining further information from the hospital as she explores your complaint about the hospital’s processes around discharge and its internal investigations into concerns raised by patients and their caregivers, and the hospital’s communication of the outcome of those internal investigations. She is working to get you the information and clarity you are seeking about what improvements the hospital has made since your daughter’s death and how those improvements are linked to your daughter’s experience. At the same time she will explore whether there are other ways in which the hospital could improve the experience for patients and families in similar circumstances. We ask for your patience as we continue this important work.
I invite you to contact me if you would like to set up a time to discuss your concerns and any questions you have about our processes.
Yours truly, Karyn Wasserstein Senior
Legal Counsel
And apparently, the hospital has no responsibility to ensure their patients received the appropriate care by their employees and/or the surgeons/doctors who have been granted hospital/surgical privileges. Again, what a farce!
THE INVESTIGATIVE FINDINGS ARE NOT MADE PUBLIC!
SO REALLY HOW EFFECTIVE CAN THIS NEWLY CREATED INSTITUTION BE WITH REGARD TO IMPROVING PATIENT SAFETY AND ADDRESSING CONCERNS PRESENTED TO THEM BY ONTARIO CITIZENS? They are not independent and autonomous but under the Ministry of Health.
AK Recommendations/goals from 2 emails sent on Oct 6, 2016—compiled by the Patient Ombudsman Investigator.
Recommendations (original)
|
Outcome of discussion on Jan
11
|
Doctor in charge
must see patient on day of discharge
|
Apparently not in the Patient Ombudsman’s investigative mandate Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Doctor to
provide adequate visitation time, start and end time to be recorded on
patient’s chart
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Doctor’s surgery
schedule should not be too busy to curtail adequate post-operative care i.e.
visit time with patient
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Doctor should
review nurses notes to chart and results of lab tests, sign off with date and
time reviewed
Consider other
patient needs (i.e. nutritional)in view of this information
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Doctor to ensure
that patient with colon resection surgery pass solid stools 2-3 times prior
to discharge
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Patient with
colon resection surgery should stay a min of 11 days prior to discharge to
ensure no leaking
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Patient diet
progression should include blended diet before regular meals are introduced
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Patient meal
should not be removed without patient knowledge or prior to ensuring that
patient doesn’t want it.
|
This can be investigated. —Cannot enact changes.
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Doctor’s notes
to chart should be detailed enough for others to understand the situation.
|
Apparently not in the Patient Ombudsman’s investigative mandate Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Ensure proper
discharge papers given to patient including a brief description of the
operation and instructions
|
This can be investigated. —Cannot enact changes.
|
Ensure that the surgeon/doctor is not overly busy, so time
is available for communication between the patient's nurses and the patient's
doctor.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Ensure that a member of the family is present when the
surgeon/doctor speaks to the patient about the patient's personal care.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Ensure that a surgeon's/doctor's visit to the patient
occurs when the patient is awake so that the patient can communicate to the
doctor.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Ensure that the
hospital administration, patient representatives are more open, receptive and
able to communicate to the patient's family and in particular with family
members when a death occurs with regard to their concerns.
|
This can be investigated. —Cannot enact changes.
|
Encourage and recommend that the Canadian Patient Safety
Institute document entitled "Disclosure of Adverse Affects" is in
use by the hospital.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Recommend Bill 89 be made law to allow an Ontario
Ombudsman to step in to assist families of patients who have been unable
to have easy, transparent communication with hospitals and other medical
facilities
and health care professionals.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Ensure doctors are
aware of the fact that it takes 24 hours before a change of diet
occurs.
|
This can be investigated. —Cannot enact changes.
|
Investigate the
effectiveness of the Hospital’s Patient Representative System
and to recommend that Patient Safety Representatives be employed, paid by and
be responsible to the Ministry of Health and Long Term Care. Then, they
would not be in a conflicting position trying to represent patients’ or
families’ concerns versus their obligations towards & pressure from the
hospital.
|
This can be investigated. —Cannot enact changes.
Second part = Apparently not in the Patient Ombudsman’s
investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
Encourage and
recommend that correspondence from the hospital to patients or to the family
of patients who have died be done so in a timely manner and the hospital take
the initiative and not leave it to the grieving family.
|
This can be investigated. —Cannot enact changes.
|
Ensure steps are made to educate the cleaning staff to
which patients' toilets are not to be flushed until the nurse has check the
bowel or bladder movement.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To investigate all aspects of
Terra Dawn Kilby’s surgery and post-operative care by all who were
responsible for her overall well being during her hospital stay
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To
establish an inquiry, so that its findings and recommendations would be a
precedent for future patient care inquiries/investigations so that Health
Care Institutions will learn from it and avoid similar situations
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To bring to a satisfactory
conclusion a frustrating, and at times disrespectful, treatment, and a
lengthy period of time trying to find answers and thus help the family’s
grieving process.
|
This can be investigated.
And especially with regard to the internal death investigation
withheld by HRH and not allowing Mr. Kilby to obtain a copy. —
Cannot enact changes.
|
To improve overall transparency within the health care
system. This would in turn improve Ontario citizens’ confidence and restore
their faith, especially in post-operative care.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To remind the professionals engaged in health care of
their prime responsibility, which is to their patients.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To allow other members of the public to see that their
concerns, which may have never been address before, for a variety of reasons,
have now been brought forth.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To allow members of the public to be better aware of
patient rights and family rights prior to hospitalization and what should be
expected from their health care providers during hospitalization.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To improve Humber River Regional Hospital's patient care
by having them assess their policies, practices and procedures and improve
upon them when it comes to the overall care of patients from the day of admission,
throughout their hospitalization to their discharge from hospital.
|
Apparently not in the Patient Ombudsman’s investigative mandate.
But may question what procedures were in place at the time and
what changes may have taken place since Terra’s death—Cannot enact changes.
|
To discover any other inadequacies, inefficiencies,
deficiencies etc., with respect to patient care and improve patient/doctor/hospital/family
interactions.
|
Apparently not in the Patient Ombudsman’s investigative mandate
---only this part—Cannot enact changes.
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To provide a "Wake-Up" call to HRRH with regard
to their overall practices, procedures and treatment of patients and their
families.
|
Apparently not in the Patient Ombudsman’s investigative mandate
|
To encourage the implementation of the Canadian Patient
Safety Institute’s “National Guidelines For The Disclosure of Adverse
Events”
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
To speak for Terra to protect the living.
|
Apparently not in the Patient Ombudsman’s investigative mandate
Humber River Hospital not responsible to ensure this is done. Changes needed in Ontario’s Health Care Act.
|
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But Humber River Hospital will not respond.
1. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to change to an open abdominal surgery to perform a colon resection and removal of a tumor after attempting a colon resection laparascopically without administering the mandatory antibiotic prophylaxis???2. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide the patient with antibiotics when the abdominal incision became so infected that all staples had to be removed, considering the patient did not receive the mandatory antibiotic prophylaxis at the time of surgery???
3. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide antibiotics to the patient when test results indicated the "presence of many gram negative bacilli" considering the patient had not received any antibiotics whatsoever???
4. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide supplemental nutrition after five days of the patient only receiving a liquid diet and where records indicate the patient was "not tolerating current diet"???
5. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to keep a patient on a liquid diet for nine days without nutritional supplementation??
6. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to ensure the patient had a solid bowel movement after consuming her only two solid meals just prior to discharge?? Keep in mind she had a section of her colon removed and then stapled together. No solid bowel movement occurred while on a liguid diet.
7. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to not see the patient the day of discharge??
8. Is it hospital policy and the standard of care for Humber River Hospital take over two years to substantiate my assertion that the mandatory antibiotic prophylaxis was not administered even though the surgeon kept telling the COO that he had done so???? And this was only done so during a phone call I had with Ms Collins. They supposedly conducted an internal death investigation after Terra's death.
9. Would HRH not consider all of the above to be negligence on the part of the surgeon and perhaps the hospital???
PLUS SO MANY MORE QUESTIONS WHICH HRH CAN EASILY SEE BY STUDYING THE HOSPITAL RECORDS.
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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!
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Ms Elliott & Investigator Ms Muamba:You may be interest in the part where I considered there are many SYSTEMIC ISSUES dealing with HRH that everyone seems to ignore. I would like someone to tell me where I turn to in order to get answers to so many concerns ignored by the Chief Coroner's Office, the DIOC, the CPSO, HPARB, the Ontario Ombudsman's Office, Ministry of Health, OPP, OIPRD and of course your limited ability.
HOW CAN THE OBVIOUS FLAWS IN THE SYSTEM BE FIXED TO ENSURE TRUE TRANSPARENCY AND ACCOUNTABILITY?
Why is it I can get these answers from qualified surgeons outside of Canada but not here in Ontario?----
DIOC
“Based on its legislative mandate, the purpose of the complaints committee is to review complaints with a goal of providing advice and recommendations in order to help improve Ontario's death investigation system.”
Note: The DIOC did not conduct an investigation into my complaint against the Chief Coroner and Deputy Chief Coroner until 2 years after I submitted it and after the two of them left the Chief Coroner’s Office of Ontario??? And then they said they do not deal with the medical issues---why else would I have put in the complaint regarding an inept death investigation???
Chief Coroner Dr. Andrew McCallum “As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter's death. The Patient Safety Review Committee's mandate is to look at systems issues contributing to a death. As there were no systems issues contributing to your daughter's death identified by our investigation, it would not be appropriate to refer her case to that committee.”
I wrote to Chief Coroner Dr. Andrew McCallum and received no response.
With regard to the above:
You state there were no system issues. There are numerous issues that would qualify it for the Patient Safety Review Committee.
They would be able to determine the role some or all did play in the colon resection breakdown, thus her death. & There are more.
When the laproscopic surgery was determined not to be done, why was the open abdominal surgery not postponed to another date so as to properly prepare the patient for major abdominal surgery? After all, this was supposed to be elective day surgery.
Systems Issue YES
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Why was she not
given anti-biotic prophylaxis and a bowel cleansing for this major abdominal
surgery that involved the colon? Systems
Issue YES
The need of prophylactic antibiotics is indisputable in colorectal surgery
in order to reduce the rate of postoperative infectious
complications. IT WAS NOT DONEIt is a time tested widely accepted fact among surgeons that efficient mechanical bowel clearance prevents anastomotic dehiscence. IT WAS NOT DONE
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Why was she not given any anti-biotics at all? . Systems Issue YES
NONE WHAT SO EVER, AT ANY POINT
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4. Why no nutritional supplements as she was on the liquid diet for 24 of 26 meals? Why no Parental Nutrition? Why a more substantial Enteral nutrition not started? Why was a nutritionist not called in to assess her nutritional intake? Systems Issue YES
Major surgery causes serious stress to the body. The body’s immune system is weakened and gastrointestinal function is changed after major surgery, leaving the body vulnerable to infection and in a state of nutritional insufficiency.
LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE INTAKE! Systems Issue YES
LACKING 57% OF TOTAL DAILY CALORIE INTAKE BASED ON HER BASAL METABOLIC RATE.
Basal metabolic rate is the minimum calorific requirement needed to sustain life in a resting individual. Terra should have been receiving 1,649.98 calories but in fact she was only receiving 687 calories on the full liquid diet. Systems Issue YES
Since Terra’s hemacrit count, red blood cell count and haemoglobin count were below standard, Nuitrition does play a major role.
Iron is required for the formation of haemoglobin in red blood cells, which transport oxygen around the body. LACKING 83.2% OF TOTAL DAILY IRON INTAKE! Systems Issue YES
Vitamin K is not readily stored within the body, thus the importance of the daily requirement. The overriding effect of nutritional Vitamin K deficiency is to tip the balance in coagulation toward a bleeding tendency. LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE! Systems Issue YES
Magnesium is required for normal energy metabolism and electrolyte balance. LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE! Systems Issue YES
Vitamin E significantly strengthens the immune system; supplies oxygen to the blood, which is then carried to the heart and other organs. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE! Systems Issue YES
Blood coagulation is dependant on calcium. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE! Systems Issue YES
LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE! Systems Issue YES
Phosphorus protects against infection, and enhances the immune system; LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE! Systems Issue YES
zinc is another mineral nutrient protects against infection, and enhances the immune system. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE! Systems Issue YES
Copper is needed for the formation of red blood cells. Copper is a constituent of many enzyme systems and the body needs copper to be able to use iron properly. LACKING 99.9% OF TOTAL DAILY COPPER INTAKE! Systems Issue YES
Thiamin assists in blood formation. LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE! Systems Issue YES
Riboflavin is necessary for red blood cell formation, anti-body production, cell respiration, and growth. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE! Systems Issue YES
Vitamin B-6 Pyridoxine is also used in the production of red blood cells. LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE Systems Issue YES
Vitamin B12 deficiency impairs the body’s ability to make blood, accelerates blood cell destruction. It helps in the formation of red blood cells. LACKING 83.6% OF TOTAL DAILY VITAMIN B-12 INTAKE! Systems Issue YES
LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE! Systems Issue YES
LACKING 93% OF TOTAL DAILY FIBRE INTAKE! Systems Issue YES
LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE! Systems Issue YES
LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE! Systems Issue YES
LACKING 47.3% OF TOTAL DAILY PROTEIN INTAKE! Protein depletion can affect the rate and quality of wound healing. Systems Issue YES
5. Why was something not done when it was discovered she had “many negative gram bacillia present”? . Systems Issue YES
One of the most common results of joint negligence (doctor and hospital) is postoperative infection. It is also one of the deadliest. Gram negative bacteremia is today's hospital scourge.
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6. The description of Terra’s
abdomen going from “flat” just after the operation for a couple of days to then
be described as “rounded” and then “large” for the last two or three days of
her hospital stay not have been a concern?” Why was this ignored by
Terra’s surgeon? Systems
Issue YES
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Why was the Many PMN (Polymorphonuclear Neutophils
greater than 15/LPF ignored by the surgeon? Systems Issue YES
PMN’s are rapidly recruited to tissues upon injury or infection
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