INSTITUTIONAL BETRAYAL==Ontario Provincial Police Commissioner J.V.N. (Vince) Hawkes

INSTITUTIONAL BETRAYAL 

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?

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Ontario Provincial Police Commissioner J.V.N. (Vince) Hawkes re: Past Deputy Chief Coroner, Dr. B Lauwers & Past Chief Coroner, Dr. A McCallum

OPP Commissioner Hawkes

& Office of the Independent Police Review Director

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

DO THE OPP HAVE A RESPONSIBILITY TO THE CITIZENS OF ONTARIO OR DO THEIR DUTIES LIE WITH PROTECTING THE UPPER  ECHELON THUS MAKING THE ELITE "ABOVE THE LAW"?

Commissioner Hawkes,

I am formally requesting the OPP conduct a thorough investigation for Breach of Trust by a Public Official with regard to past Deputy Chief Coroner of Death Investigations, Dr. Bert Lauwers, past Chief Coroner, Dr. Andrew McCallum and present Chief Coroner, Dr. Dirk Huyer.

Their cover-up of negligent care contributing to my daughter’s death not only failed Terra’s relatives and friends but also the citizens of Ontario.  There were further deaths after my daughter’s that may well have been prevented had the Chief Coroner’s Office not conducted such a flawed death investigation.  They did so to protect the surgeon/hospital instead of serving to “Speak for the Dead to Protect the Living”.  Then, they continued the cover up to protect themselves.

Humber River Regional Hospital had at the time in 2006 the second highest in-hospital mortality rate in all of CANADA.

In 2010, the Chief Coroner’s Office temporarily shut down the surgical team of the department due to several deaths (5 or 6) during 2009 to Feb of 2010.  This was kept from the public.   Only a police investigation will discover how many deaths have occurred prior to and from the time of my daughter’s death onward to date.

I tried accessing through the Freedom of Information only the number of deaths associated with Terra’s surgeon after July 21, 2006 that the CCO had investigated.

I did not ask for names.   That number would not be released!    WHY?

I believe, yes, this will open up a can of worms, much the same as the now disgraced Dr. Smith, head pathologist at the CCO years ago.  His actions led to numerous fathers/mothers being jailed.

An injustice must never be covered up!  

Well, the illegal actions of these three may have quite possibly led to further deaths in Ontario and they breached the confidence and trust citizens of Ontario have in the Office of the Chief Coroner.

Their inaction also contributed to the truth not being told to HPARB whom I met with three times, to the Minister of Health, to the Minister of Corrections, to the Premier of Ontario and all MPPs, but most importantly to the Citizens of Ontario.

I firmly believe this Office and those in charge have conducted flawed death investigations involving hospital deaths for years and years.

The DIOC won’t look into the medical aspect of my complaint which of course is the basis for my assertion of an inept death investigation and cover-up by the CCO!

Hey, check this out -- I kind of think OPP Inspector Brad McCallum may very well be related to Past Chief Coroner Dr. Andrew McCallum.  Or is this their way of showing me that there is no way the OPP would ever really consider my request?
 
OPP REPLY--- I guess they won't uphold "Breach of Trust by a Public Official" which is contained within the Criminal Code of Canada and Ontario

 

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! 

The OPP, Commissioner Hawkes -- an obvious liberal supporter
"As an organization, the Ontario Provincial Police (OPP) commits to working continually to earn the confidence of the citizens of and visitors to Ontario—a confidence that will not be taken for granted. The OPP fulfills this commitment by providing the best and most professional service possible and by striving to build a culture of trust, and open and honest dialogue, with the communities it serves and among the people it employs."

Holy, Lord---- The above underlined portion does not apply!

I guess it's time for another Intimidation visit by the OPP!

The Office of the Commissioner  "The Commissioner is responsible for overseeing all aspects of what the OPP does. His or (her role) determines the priorities and goals for the OPP does each year. The Commissioner works (TOO) closely with the Provincial Government to ensure the OPP has the resources and support it needs to keep Ontario safe." and play a role in the "Terra Dawn Conspiracy

And will do whatever it takes should the Present Minister of Corrections and Premier says to cover-up the obvious Breach of Trust by a Public Official --- the Past Chief Coroner, Past Deputy Chief Coroner and Present Chief Coroner.. Firstly, to cover up negligence of a surgeon by conducting an inept death investigation and then to protect themselves due to the many deaths that followed my daughter's by the same surgeon! 

I just received a reply from the RCMP. They stated the OPP do have the jurisdiction to investigate Breach of Trust by a Public Official with regard to the Chief Coroner's Office. On must wonder why they sent me a letter stating they didn't???? Massive cover-up! The RCMP suggested I contact the OIPRD.
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So, I have filed a complaint with the Ontario Independent Police Review Director.  Just a small portion is found below: Should you wish to express your viewpoint to him send e-mail to:

UPDATE: They said there was nothing for them to do.

OIPRD@ontario.ca

Director G. McNeilly,

This morning I faxed your office with regard to the policies and services provided by the Ontario Provincial Police and my complaint concerning them.    I believe my request to them is sound and factual if they took the time to read what I had sent to them. They have already refused another party's request to investigate the Chief Coroner's Office of Ontario. This e-mail with its attachments provide more information.

I can provide you with even more names of citizens throughout Ontario who have similar complaints about Dr. Lauwers, Dr. McCallum and Dr. Huyer.  When any of these three are investigating a death related to a surgeon/doctor/hospital, it appears they will do whatever it takes to conceal the entire truth with regard to these deaths. Their allegiance appears not to be to the citizens of Ontario as their motto suggests but instead to protect their colleagues and fellow members of the CPSO!

I believe by reading what I sent to the OPP and if you or the OPP took the time to investigate they could quite easily make a case of "Breach of Trust by a Public Official"   I fail to understand the OPP's response by stating this was not in their jurisdiction.  The Canadian Criminal Code and Ontario does cover Breach of Trust.

I BELIEVE THEY ARE NOT WILLING TO CONDUCT SUCH AN INVESTIGATION DUE TO THE THREE IMPORTANT PARTIES MENTIONED ABOVE AND/OR THEY HAVE BEEN INSTRUCTED NOT TO DO SO BY THOSE WHO WOULD WANT THE TRUTH TO REMAIN CONCEALED IE--the past two Premiers, the past two Ministers of Corrections, the past two Ministers of Health, the Liberal MPPs, CPSO, DIOC and HPARB

Their suggestion to contact the DIOC is a waste of time as you can see by reading the two attachments of their previous decisions. They will not or cannot investigate the medical issues of my complaint to them regarding those names above.

The OPP according to their motto is for the citizens of Ontario. They should be placed over the elected and/or appointed.
 SERVITUTE CLARIORES = “More illustrious through serving”

By not conducting a complete and thorough investigation, the OPP are tarnishing what was once considered an honourable police force.

At the very least, an official police investigation would force those three mentioned above to tell the truth as they certainly would not want to risk having further charges applied due to being deceitful and outright lying to a police officer!  

Ontario Provincial Police Commissioner Hawkes,

I am formally requesting the OPP conduct a thorough investigation for Breach of Trust by a Public Official with regard to past Deputy Chief Coroner of Death Investigations, Dr. Bert Lauwers, past Chief Coroner, Dr. Andrew McCallum and present Chief Coroner, Dr. Dirk Huyer.

Their lack of concern regarding negligent care contributing to my daughter’s death not only failed Terra’s relatives and friends but also the citizens of Ontario. There were further deaths after my daughter’s that may well have been prevented had the Chief Coroner’s Office not conducted such a flawed death investigation. It appears they did so to protect the surgeon/hospital instead of serving to “Speak for the Dead to Protect the Living”. Then, they continued to remain silent protect themselves.
Humber River Regional Hospital had at the time in 2006 the second highest in-hospital mortality rate in all of CANADA.

In 2010, the Chief Coroner’s Office temporarily shut down the surgical team of the department due to several deaths (5 or 6) during 2009 to Feb of 2010. This was kept from the public.  Only a police investigation will discover how many deaths have occurred prior to and from the time of my daughter’s death onward to date.

I tried accessing through the Freedom of Information only the number of deaths associated with Terra’s surgeon after July 21, 2006 that the CCO had investigated.

I did not ask for names.  That number would not be released!  WHY?

I believe, yes, this will open up a can of worms, much the same as the now disgraced Dr. Smith, head pathologist at the CCO years ago. His actions led to numerous fathers/mothers being jailed. An injustice must never be covered up!

Well, the actions of these three may have quite possibly led to further deaths in Ontario and it is my belief a breach of confidence and trust to the citizens of Ontario has taken place within the Office of the Chief Coroner.

Their inaction also contributed to the truth not being told to HPARB whom I met with three times, to the Minister of Health, to the Minister of Corrections, to the Premier of Ontario and all MPPs, but most importantly to the Citizens of Ontario.

I firmly believe this Office and those in charge have conducted flawed death investigations involving hospital deaths for years and years.

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Letter sent by registered mail requiring a signature upon delivery:

ATT: Commissioner J.V.N. (Vince) Hawkes

General Headquarters Lincoln M. Alexander Building 777 Memorial Avenue Orillia, ON L3V 7V3     (705) 329-6111    1-888-310-1122

This should not be shoveled off to my local OPP station as it is an Ontario Issue, not a local issue. I believe should you investigate all deaths associated with a hospital the CCO looked in to, you would find the death investigations quite flawed.

SERVITUTE CLARIORES = “More illustrious through serving”

College’s Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. Klein in this case.”

The College recommended to the surgeon that perhaps "he might consider the use of antibiotic prophylaxis in the future when converting to open surgery" HE MIGHT CONSIDER???????

The Chief Coroner's Office believes it is perfectly within the accepted Standard of Care as opposed to my over 100 surgeons’ opinions to:

--have open abdominal surgery without the mandatory antibiotic prophylaxis
--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed
--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics

A VERY DANGEROUS PRECEDENCE HAS BEEN SET BY ALL OF THE ABOVE AS THIS DECISION CAN NOW BE USED TO JUSTIFY SIMILAR COMPLAINTS. EVEN THOUGH, IT WAS AN OBVIOUSLY WRONG DECISION.                  

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Surprisingly an answer from Dr. Huyer--- notice this is the first time he responded to any of my e-mails and also notice he refuses to put into writing his comments given during the meeting. Does not want anything put in writing --- Gee, I wonder why?

From: Huyer, Dirk (MCSCS) Dirk.Huyer@ontario.ca>Sent: February 24, 2016 11:21 AM 
To: Arnold KilbyCc: Noonan, Julia (MCSCS)Subject: RE: Formal Requests

 Dear Mr. Kilby,
 I am writing as a reminder of how we concluded the meeting between you, your family members, Ms. Noonan and I on June 26, 2014.

 You requested the meeting so that you could present your questions to me and I provided responses based on my review of the information.

 At the meeting I told you that I would not be responding to future dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest as our investigation is complete.

 You acknowledged my position at the June 26th meeting and in a subsequent e-mail on July 3, 2014.

 Respectfully, Dirk
 Dirk Huyer, MD  Chief Coroner for Ontario  25 Morton Shulman Avenue
Toronto, Ontario  M3M 0B1    647-329-1814

Acknowledging your position does not mean agreeing with it.
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I did get a response from the Ministry saying they don't have the authority and I should contact the Minister of Corrections and the Chief Coroner's Office???
So, I sent the same letter to Minister Naqvi. He has never responded to me before so I doubt I will receive anything now.

ATT: Attorney General of Ontario-- Madeleine Meilleur attorneygeneral@ontario.ca    mmeilleur.mpp.co@liberal.ola.org

I should note that that a few years ago, I inquired her assistance with regard to the DIOC. I asked a question as to why the DIOC could not look into the medical aspect of my complaint to them against the Chief Coroner and what she could do. She was Minister of Corrections then.

The answer came back from her constituency office with merely the following letters.   "FYO"

After thinking what the three letters meant, I got it. I think you can figure it out. "f--k you over"  Surprisingly, I received a further e-mail from her office asking me to disregard the previous e-mail as it was sent by mistake.

No, someone in her office was actually stating the truth.

re:  DEATH INVESTIGATION OF TERRA DAWN KILBY--totally inept death investigation whereby their own independent opinion provider investigating Terra's overall care contained numerous omissions that were very relevant to her death.

PLEASE READ THE INEPT REPORT SUBMITTED BY DR. LAUWERS INDEPENDENT OPINION PROVIDER AND SUPPORTED BY BOTH DR. McCALLUM AND DR HUYER.  THEN LOOK AT THE OMISSIONS FROM THIS REPORT. KEEP IN MIND, ALL THREE LOVE TO QUOTE FROM THIS REPORT. 


November 17,2008Dr. A.E. Lauwers,CCFP, FCFP   Associate Deputy Chief Coroner   Office of the Chief Coroner 26 Grenville Street   Toronto, Ontario   M7A 2G9
Dear Dr. Lauwers: RE: Terra Kilby  
 Deceased: July 20,2006  
OCCFileNo.: 2006-11425 

As you requested, I have reviewed the file on the above person and provide my report. In reaching my opinion, I have reviewed the following materials: 1. The hospital record from Humber River Regional Hospital related to admissions from March 3 to March 4, 2006 and July 11 to July 20, 2006. 2. The Coroner's investigation statement (statement number 2006-054-8). 3. The report of postmortem examination by Dr. Caroline G. Rowlands dated March 22, 2007. 4. A compact disk containing images taken at autopsy and provided to me by Dr. Rowlands. In summary, the deceased presented to Humber River Regional Hospital on March 3rd with abdominal pain. She was found to have a large mesenteric cyst. There were no acute issues, and she was therefore discharged for further investigation as an out-patient. She was assessed by Dr. Klein and underwent further investigation. A decision was reached to resect the mesenteric cyst. On July 11th she underwent attempted laparoscopic resection of the cyst, but because of intraoperative concerns the procedure was converted to laparotomy. Removal required right hemicolectomy with resection of the associated mesentery that contained the cyst. On the second postoperative day, the patient did have a low-grade fever but this resolved by the following day. 

However on the fourth postoperative day it was noted that she had a wound infection. The skin was opened and the infection appeared to be confined to the subcutaneous space and not extend below the fascia. She then had some diarrhea and cultures for Clostridium difficile were negative. This seemed to settle and she was discharged home on the ninth postoperative day. Arrangements were made for Home Care visiting nurses to manage the abdominal wound with the intent that it would heal by secondary intention. The records indicate that on the evening of discharge she collapsed at her parent's home and was returned to hospital by ambulance but died in the emergency room despite resuscitation efforts. A Coroner's investigation was undertaken and a forensic autopsy carried out. The pathologist concluded that the patient died from hemorrhagic shock secondary to acute intraperitoneal bleeding. It was noted that on arrival in the emergency room on the evening of death, the patient had a marked coagulopathy. The pathologist concluded that a clear source for the bleeding was not identified and that the underlying coagulopathy could have been a contributing factor. You have requested that I review the quality of care that this patient received and I have done so. In preparing this report, I have given consideration to the concerns that the patient's family expressed specific to the quality of medical care provided.

I believe that the initial assessment and care plan on March 3rd and 4th was entirely appropriate. Dr. Klein subsequently carried out an appropriate investigation and reached a management plan that reflects a good standard of care. The operative procedure was carried out according to the appropriate standard and good decision making is evident. 

The postoperative care was appropriate.  Specifically, treatment of a superficial wound infection is opening of the wound and allowing drainage. Subsequently allowing the wound to heal by secondary intention is the correct management. The use of antibiotics in the absence of systemic sepsis is not necessary, and does not improve the outcome. Unnecessary use of antibiotics does have risks including increasing the probability of development of antibiotic resistant infections including Clostridium difficile. There were no clinical indications for a CT scan or other investigation. It is not unusual for patients to be discharged without having had a solid bowel movement and there certainly are care paths for bowel resection that do not even require passage of flatus. There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no indication for supplements of things like vitamin K and calcium.

Postoperatively, the hemoglobin, white cell count and platelet count remained within expected ranges. Culture from the infected wound grew the expected bowel related organisms. Samples of the loose stool for Clostridium difficile were negative. The last hemoglobin measurement that I can identify was on July 18\. There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigations. Discharge on July 20, 2006 was therefore clinically appropriate.I concur with the pathologist that the cause of death was hemorrhagic shock. It is my opinion that the coagulopamy was a dilutional coagulopathy as a result of the hemorrhage, rather than a cause of the hemorrhage. I believe that the bleeding came from one of the staple lines on the anastomosis. Following removal of the right colon, the bowel was reconstructed using mechanical staplers and a technique known as a functional postoperatively, or be delayed. When it is delayed it is not uncommon for this to happen 6 to 10 days postoperatively. This complication end-to-end anastomosis. This is the predominant technique in use today for joining two ends of bowel together. This was properly done by Dr. Klein. 

One of the risks of any anastomosis is bleeding or leak from the anastomosis. This can occur very early happens in spite of proper surgical technique. Its incidence varies based on numerous factors, but is generally quoted to be in the order of 1 -5% of all bowel resections. I believe that the defect occurred because of ischemic necrosis at the intersecting staple lines created by the functional end to end anastomosis. This led to an open edge of bowel that subsequently bled. This led to hemorrhagic shock, subsequent dilutional coagulopathy and the patient ultimately expired from these events. I find no area of concern with respect to the standard of care that she received. If you have any further questions, I would be happy to discuss this at any time

UNSIGNED
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 Now check out the responses from the Chief Coroner's Office and notice how they fully agree with the above expert and also what they state about there being "NO OMISSIONS OR COMMISSIONS" 
In their own words I believe they confirm their own breach of trust.

Letter dated Oct 27, 2008 from Dr A. McCallum

 “As I write this, I am very mindful of the tragedy that you and your family have experienced.  Please be assured that all of our staff, including Dr. Lauwers, will do their utmost to provide helpful information to you.”

Letter dated November 17, 2008 from Dr A. Lauwers

“You have requested that I review the quality of care that this patient received and I have done so.”
“The operative procedure was carried out according to the appropriate standard of care and good decision making is evident.” (Dr Lauwers repeating from consultant’s report.)

“There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no need for supplements of things like Vitamin K and Calcium.” (This was Dr Lauwer’s repeating verbatim from the expert’s report) 

“While the patient suffered the most devastating complications of an operation, and specifically one of the common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care she received.”

JUST ONE YEAR LATER, HOW THIS CHANGE FROM THE DR. McCALLUM'S LETTER TO THIS ONE. THIS IS WHAT HAPPENS WHEN YOU ASK QUESTIONS THAT PUT THEM ON THE SPOT AND THEY DON'T WANT TO ANWSER!

Letter dated November 5, 2009 from Dr. A Lauwers

Nov 5, 2009
Dear Mr. Kilby:

I am writing to acknowledge our telephone conversation of October 30, 2009.

As previously stated by Dr. McCallum in his letter of July 8, 2009, all the information that our office can provide has been conveyed to you in previous correspondence. The investigative mandate of the Office of the Office of the Chief Coroner is concluded.

To that end, our office will not be in a position to return phone messages to you in the future.

Sincerely, A.E. Lauwers, MD, CCFP, FCFP        Deputy Chief Coroner-Investigations

It should be noted the telephone call referred to became somewhat heated as he refused to answer very pertinent questions posed to him and merely state his expert found nothing to be concerned about. They also would not respond to my e-mails or letters.

Letter dated March 4, 2009 from Dr. A Lauwers  

“The last issue that the coroner must consider when making a determination about whether or not an inquest is necessary, is the likelihood that the jury on an inquest might make useful recommendations directed to the avoidance of death in similar circumstances.”…. How could HRRH have known that Terra would bleed to death hours following discharge from a site along the line of anastomosis?”

 Letter dated March 13, 2009 from Dr A McCallum

 “As you are aware, I have some background knowledge regarding your daughter’s untimely and tragic death because I met with you and your wife after your daughter’s death in my capacity as Regional Supervising Coroner for Eastern Ontario, prior to my appointment as Chief Coroner.”

 “There has been a great deal of scrutiny or your daughter’s case. As part of that scrutiny, an expert review was obtained from an independent surgical consultant. Based on my review of the independent expert, review’s opinion, I conclude that there are no omissions or commissions during your daughter’s treatment that contributed to or caused your daughter’s death.”

 “Given that the care was appropriate, it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance.” 

 “Based on the foregoing, I conclude that the mandatory questions can be answered, and have been answered in the attached Coroner's Investigation Statement. Your daughter died due to natural causes as a complication of treatment and the cause of her death was intra-abdominal hemorrhage consequent to dehiscence or disruption of the joining line in her bowel that had been closed with staples.  As the expert reviewer stated, such a disruption can and does happen despite proper surgical technique. Though it is uncommon, it does occur in 1 to 5% of all bowel resections.”

Letter dated April 1, 2009 from Dr A. McCallum

“While I realize that you have many remaining questions, I am not in position to respond. You may wish to speak with your daughter’s caregivers regarding these questions.”

“However, I can state that our investigation did not reveal an issue in care that led to your daughter’s tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.”

Letter dated June 25, 2009 from Dr A. McCallum

“The expert consultant who reviewed your daughter’s case had no affiliation with the University Of Toronto Faculty Of Medicine and thus had no conflict of interest. I can assure you that the review was both thorough and independent.

“As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter’s death. The Patient Safety Review Committee’s mandate is to look at systems issues contributing to a death. As there are no systems issues contributing to your daughter’s death identified by our investigation, it would not be appropriate to refer her case to that committee.”

LET US LOOK AT THE OMISSIONS AND COMMISSIONS THEY SAY HAD ABSOLUTELY NO CONTRIBUTING FACTOR IN MY DAUGHTER'S DEATH.  YES THE COLON RESECTION BREAKDOWN CAUSED HER DEATH BUT WHAT CONTRIBUTED TO THIS BREAKDOWN---- THAT’S THE COVERUP.

--NO MENTION OF ALL THE STAPLES BEING REMOVED FROM THE ABDOMINAL INCISION AND THAT TEST RESULTS INDICATED THE PRESENCE OF MANY GRAM NEGATIVE BACILLI (SAME CATEGORY AS C DIFFICILE) No mention of the many Gram Negative Bacilli Seen and how it should be treated? Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This results in reduction of oxygen transported to the tissues thus explaining the necrosis of the tissue surrounding the re-sectioned colon.

--NO MENTION OF MANDATORY ANTIBIOTIC PROPHYLAXIS NOT BEING ADMINISTERED

--NO ANTIBIOTICS GIVEN AT ANY TIME? THIS IS APPROPRIATE?

--NO MENTION OF ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid (Ascites is an accumulation of fluid in the abdominal cavity.), or air

--NO MENTION OF LOW HEMACRIT, LOW RED BLOOD CELL COUNT AND LOW HEMACRIT COUNT Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia. Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding etc Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body. No mention of low hemacrit, red blood cells & hemoglobin indicates anemia (iron deficiency)

--DOES NOT MENTION LOW ABSOLUTE LYMPHOCYTE  (type of white cells to fight infection)?

--NO MENTION OF HIGH PULSE RATE 34/38 readings above 90

--DOES NOT COMMENT ON MANY PMN'S. (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process. The presence of many PMN’s implies an inflammatory process. PMN’s are the hallmark of acute inflammation PMN’s are rapidly recruited to tissues upon injury or infection

--NO MENTION OF THE SERIOUSNESS OF THE OOZING, INFECTED ABDOMINAL INCISION -- ALL STAPLES WERE REMOVED DUE TO INFECTION Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.

THERE WERE FAR TOO MANY ISSUES NOT COMMENTED ON, DELIBERATELY, AND THE COO OFFICE FAILED TO FURTHER INVESTIGATE MY CONCERNS SENT TO THEM!
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 After reading the medical information and the rather inept death investigation, you would agree the COO failed my daughter & all citizens of Ontario.

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"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, in no way did the above!

The College of Physicians and Surgeons of Ontario, and the Chief Coroners Office are guilty of the following:

Confirmation bias = seeking or interpreting information that (one thinks) will support one's favored hypothesis or diagnosis.Ego bias = biasing probability estimates in a self-serving way.

This Office has declined multiple requests:

a. my request for a public inquest

b. MPP Runciman's, now Canadian Senator, request to reconsider the public inquest

c. my request for Terra's death to go before the Patient Safety Death Panel

d. my request for an Eastern Ontario Coroner's Review since Terra passed in Kingston

e. my request to initiate the Chief Coroner's Review Process

f. refused the Ombudsman Office request to meet with me and respond to my concerns

g. refused OPP detective request to meet with me and respond to my concerns

What do all of the above say about transparency and accountability?

WHAT ARE THEY HIDING?  Note: Dr Huyer did meet but the meeting was useless. He was careful to state that there were many patient care issues, (did not use the words patient safety) and they should be dealt with by the CPSO and Hospital--- this was a cop out and he neglected his duty to all of Ontario. When I bought up the other two names (McCallum and Lauwers) he basically said they no longer work here so no comment.

I BELIEVE PAST CORONER, DR ANDREW MCCALLUM, PAST DEPUTY CHIEF CORONER DR BERT LAUWERS AND THE PRESENT CHIEF CORONER SHOULD BE CHARGED WITH "BREACH OF TRUST"

Misleading Justice:  Perjury, Fabricating evidence                        Obstructing justice:

Every official who, in connection with the duties of his office, commits fraud or a breach of trust is guilty of an indictable offence and liable to imprisonment for a term not exceeding five years, whether or not the fraud or breach of trust would be an offence if it were committed in relation to a private person. Too save space I did not outline the entire Act with regard to Breach of Trust by a Public Official but did send it to the Commissioner as well as the legal aspects of:

SHOULD THE PRESENT CHIEF CORONER , DR HUYER, AND PAST CHIEF CORONER, DR. McCALLUM, AND PAST DEPUTY CHIEF CORONER, DR. LAUWERS, LIE TO YOU OR AVOID ANSWERING DIRECTLY TO QUESTIONS POSED, AND/OR REFUSES TO PROVIDE FACTUAL DOCUMENTED EVIDENCE TO SUPPORT HIS OPINION THEN HE CAN BE CHARGED WITH THE ABOVE.    
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Code of Ethics for Coroners July 2005 Dr Lauwers , Dr McCallum and Dr.Huyer have all FAILED THE FOLLOWING:

Coroners shall exercise their duties and responsibilities without fear, favour, prejudice, bias or partiality towards any person.

Coroners shall proceed in the public interest to carry out diligently, and with all due dispatch, their duties and responsibilities as set out in the Coroners Act

Coroners shall have due regard for the fact that they are performing a public duty and that their actions and decisions affect the public interest as well as the interests of private individuals.

Coroners shall not, in the discharge of their duties, make decisions beyond the scope of their personal expertise and knowledge but shall seek guidance from the appropriate source or sources.

Coroners shall not conduct themselves in a manner which might tend to bring their office into disrepute or affect public confidence in that office.

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Complaint About the Police

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City*  This complaint against the OPP is with regard to their policies and procedures which I feel discriminates against a private Ontario citizens who would dare to ask for an OPP investigation into the public office of the Chief Coroner's  Office and in particular to three top officials of said institution. I feel the OPP does not want  to "stir up shit" and/or are influenced by our provincial liberal government.

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Summary of complaint* I sent in a request to the Hdqt of the OPP in Orillia. This was requesting they investigate Dr. Bert Lauwers, past Deputy Chief Coroner of Death Investigations Dr. Andrew McCallum, past Chief Coroner of Ont. and the present Chief Coroner, Dr. Dirk Huyer regarding "Breach of Trust by a Public Official".

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Freedom of Information and Protection of Privacy

The personal information that you have provided on this complaint form is collected by the OIPRD under the Police Services Act. The information will be used to investigate your complaint. As an agency of the government, the OIPRD must adhere to the Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about privacy protection, please contact the Freedom of Information and Privacy Office at the Ministry of the Attorney General at 416-326-4300.

            I sent a request to the Headquarters of the OPP in Orillia.  This was requesting The OPP investigate Dr. Bert Lauwers, past Deputy Chief Coroner of Death Investigations Dr. Andrew McCallum, past Chief Coroner of Ontario and the present Chief Coroner, Dr. Dirk Huyer regarding "Breach of Trust by a Public Official" which is contained within the Criminal Codes of

Canada and Ontario.

I had sent the OPP all the material to prove the CCO conducted a flawed death investigation regarding my daughter's death in 2006.  

The CCO based all of their decision on the report by Dr. Lauwer's unnamed expert whose report

contained numerous omissions.

I maintain they did not want to find fault with regard to the surgical procedure and after

care of my daughter.

The CCO refused to call into question the many omissions by their expert.

Instead of "Speaking for the Dead To Protect the Living", they chose to cover-up the negligence contributing to my daughter’s death in order to protect a fellow member of the CPSO.

THIS IS BREACH OF TRUST.

The previous two mentioned above as an intimidation technique use the Toronto Police Force who then contacted the OPP in Brockville to question me with regard to threatening the two.   Complete bullshit 

--- no charges ever laid not even close.  But the first visit by the OPP was at my home, 

then followed in the months ahead to two video-taped interview at the Brockville OPP detachment.  Again, the CCO was attempting to silence me.

THIS IS A BREACH OF THE POLICE COMPLAINT PROCESS.

If the OPP truly investigated and use the material I supplied they would see that there is

merit to an investigation being conducted.  Their role is to protect the public.  Instead the

OPP stated I should consider complaining to the DIOC.  They obviously did not read the material I sent them.  Twice I have approached the DIOC.  This institution cannot or will not address the medical issues which my complaint is about, so the OPP is the last avenue I thought I would take.

Yes, I know the three men involved are very important, influential people but when they have breach the trust of the public, they should be held accountable.  The Minister of Correction nor his Ministry will do anything.

Briefly, what I have done to find transparency and accountability:

--had a meeting with 5 administrators of the hospital who sat muted and did not address a single question.   Note: HRRH in 2006 had the second highest in-hospital mortality rate in all of Canada.

   It should be noted that another victim of my daughter's surgeon, a twenty seven year old woman died in December of 2012.  Her parents requested a meeting with the hospital.  They hospital asked for the question before hand, and upon receiving them cancelled the meeting with Mr. and Ms. Rose.

--it took two years to finally have the CCO of the hospital admit that the mandatory antibiotic prophylaxis was not administered prior to the open operation to remove a tumor and have a colon resection done.  It also took my doctor almost 5 months to get the hospital records which were to be destroyed or sent back but I managed to obtain them.

   My daughter bled out 12 hours after discharge.

A--put in a complaint to the CPSO

   I went to HPARB to appeal their first decision and HPARB sent it back.

   I appealed the second decision which took well over a year to get from the CPSO and HPARB                        sent it back.

   I appealed the third decision to HPARB but this time they accepted the unbelievable.

   As Alan Shanoff from the Toronto Sun stated in his article, HPARB appeared to simply throw      up their arms and gave up.

B--I presently have the Ombudsman looking into the third decision by HPARB and their denial of my request for reconsideration which was denied by HPARB.  This was regarding to failure to ensure a fair and procedural process for the third decision and their denial of the reconsideration twice.

C—a--I had requested a public inquest into my daughter's death to the CCO which was refused.

   My MPP, now Canadian Senator requested the same as it was denied.  It should be noted that my research back then yielded that no private citizen requesting a public inquest that dealt with a hospital/surgeon/doctor has ever been granted.  It should also be noted that then Conservative Party leader ask the Chief Coroner’s Office to conduct a public inquest into the death of one of his constituents who died in an ambulance after the family’s request was denied.  Mr Hudak did get his request granted by the temporary Chief Coroner who was taking over from Dr. McCallum

b--I requested that my daughter's death go before the Patient Safety Death Panel which was refused.

c--I ask for the Chief Coroner to assemble his own Chief Coroner’s Review Panel to look into Dr. Lauwers’ decision and this was refused.

d--Since Terra passed away in Eastern Ontario, I ask the Eastern Ontario to conduct his/her own review.  Interesting to note that only he/she can deny this.  But I received a letter from Dr. Lauwers that this was being denied.

e--The Ombudsman’s Office requested that Dr. Lauwers and Dr McCallum sit down and answer my concerns.   Their response was “We will not meet with him nor answer his questions.”

f--OPP Detective Sheldon Seeley who saw the two named directly above with regard to their complaint against me asked the very same question as the Ombudsman’s Office and got the exact same response.  Detective Seeley told me this after the second video-taped interview.

g--Finally after numerous request to Chief Coroner Dirk Huyer, he agreed to meet with me.  He would not discuss anything related to Dr. Lauwers or Dr McCallum and basically said “they don’t work here anymore.”  He then proceeded to state there were some patient care issues that should be addressed by the Hospital and the CPSO.   He was careful not to use the words “patient safety”.    What is the difference?   He stated none of the concerns I brought forth had any affect with Terra’s death.   Bullshit.

ONCE THE CCO GOT CAUGHT IN THE COVER-UP OF PROTECTING A FELLOW MEMBER OF THE COLLEGE, THEY THEN HAD TO START PROTECTING THEMSELVES.  THUS FAR, THEY HAVE GOTTEN AWAY WITH THIS BREACH OF TRUST.

D—Numerous attempts to get the past and present Premiers, Ministers of Health and Ministers of Corrections to assist me to no avail.

E—The DIOC waited for more than 2 years to look into my complaint and only did so after both Dr. Lauwers and Dr McCallum left the CCO.   It should be noted that according to legislation any complaint against the Chief Coroner is to be investigated immediately!  And they stated that they don’t deal with the medical aspects of my complaint so they are effectively useless.

F—I tried to obtain information via the Freedom of Information Act.  My request went to the Ministry of Corrections who oversees both the Chief Coroner’s Office and the DIOC.  What a waste of money.   All I had asked for was the number of deaths and dates whereby the CCO had investigated that involved my daughter’s surgeon.  I did not ask for the names of the deceased.

What I got back was 50 photo copied pages of bariatric surgery procedures which my daughter did not have?????   When I mentioned this request to my MPP, Steve Clark, he held up a blank sheet of white paper and said does this look familiar??  Yep, all kinds of whitened out sections.  What a waste of my time and I had to pay for this!

I BELIEVE AN OPP INVESTIGATION INTO BREACH OF TRUST, AT THE VERY LEAST, WOULD MAKE THESE THREE PARTIES TO TELL THE TRUTH.   THEY WOULD NOT WANT TO MAKE MATTERS WORSE BY LYING DURING A POLICE INVESTIGATION, AS FURTHER CHARGES COULD BE PURSUED.

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