Why would my daughter’s operation go ahead without the mandatory anti-biotic prophylaxis? Why did my daughter not receive the colon cleansing required for colon surgery? Why did my daughter remain on a liquid diet for eight days and be only receiving 687 calories per day, with no nutritional supplement?–this is a starvation diet! Should below standard test results for red blood cell count, hemoglobin count and hemocrit count is addressed before releasing the patient? (sign of Anemia) Should her abdomen going from flat to rounded and finally to enlarged be addressed prior to releasing her? (sign of internal problem) Should the many gram-negative bacilli present not be addressed before releasing her? Should the fact that MANY PMN’S ) Polymorphonuclear Neutophils greater than 15/LPF– a sign of infection) being present not be addressed before releasing her? Every staple had been removed from her abdominal incision and she was released with it being infected and still oozing purulent fluid and odour. No doctor or her surgeon saw her on the day of her release.
Should these not have been addressed by the hospital?
“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 has been examined by specialists in the field, we are not prepared to accept the fact that Terra’s death has no explanation.”
Her colon resection broke down and she bled out.
I should note that further concerns developed after I had more time to research and look into my daughter’s hospital records. Also, it took me almost five months to get the records from the hospital. As well, I wrote a letter dated Oct 22, 2008, to Ms Collins, COO of this hospital asking for a copy of the internal investigation which I had asked for before. No reply.
Assessment by my sister-in-law of my presentation before HPARB
It was evident that the panel of three was very impressed by the detailed, well-organized and professional submission by A. Kilby. I suspect that very few appellants come as well prepared. The submission proceeded smoothly, as there were very few queries, questions, requests for clarification.
A Kilby progressed from the details of Terra’s post-operative care to generic considerations, the implementation of which that would be of enormous public service. His humanity and concern for others was always in evidence.
It is difficult to believe that Dr. Klein could not have been aware how ill-prepared his lawyer was. The lawyer claimed to have met with Dr. Klein on numerous occasions; he could easily have gone over a list of points with her and how to refute at least some of the claims made by the appellant. After more than three years, Dr. Klein must realize how well-informed Mr. Kilby is and how he feels compelled to find a resolution in Terra’s death. This leads me to conclude that either:
· Dr. Klein is so confident that HPARB will rule in his favour (it rules in favour of the medical professional 90% of the time) that it matters absolutely nothing how good or bad the lawyer is
· Dr. Klein is aware of the gravity of the complaints, can do little to refute them and is just hoping that eventually A. Kilby will give up and go away.
Dr. Klein could of course have represented himself. Although meeting A. Kilby again would have been very difficult for him, it would have allowed him to present his own case and presumably, refute A. Kilby’s points and thus convince the panel that he had not been negligent.
The lawyer for Dr. Klein is employed by one of the big five or six Bay St. law firms, a world-renowned firm. Her profile on the firm’s website indicates that after only three years in practice she is, among other areas, a specialist in medico-legal matters. This is far from what I observed. If the law firm considers all HPARB cases as fait accompli, then they must be complacent enough to send anyone at all to represent clients and not care how their lawyers appear to others at the hearing.
The participation by teleconferencing, rather than in person, by the CPSO (on College St) administrator is puzzling. Why would she not attend in person? Teleconferencing is designed to connect people separated by distance. The administrator sounded detached and uninterested in the proceedings. It certainly appeared that the lawyer and the CPSO administrator were negligent in underestimating the strength and conviction of A. Kilby’s submission; this should not have been the case. I suspect they just didn’t bother to study the situation carefully.
Reference was made to the three physicians for CPSO who studied the hospital records and cleared Dr. Klein of negligence. One of these was a paediatrician. Is there a possibility that CPSO was so careless in its assessment of the case that it assumed Terra was a child, as it is the father who is seeking answers? If this is case, it is a shocking oversight.
While A Kilby awaits HPARB’s decision, it would be very useful for him to study past decisions, but these appear inaccessible. We are attempting to locate these. If they are not made public, there must be a reason. There is absolutely nothing public about the name HPARB. If HPARB rules in favour of the defendant (medical professional) nine times out of ten, there is something amiss. On the law of averages, that should not happen.
An American Surgeon’s opinion
Lastly, I am Board Certified in adult surgery and happy to help.”
“I apologize for taking so long to get back in touch with you. I hope you and your family were able to enjoy the Holidays. Unfortunately, I tried to open the file that you sent to me a few weeks ago but was unable to. I even tried to save it onto my computer and then open it but that didn’t work either. If you resend it and I am able to open it I promise to respond within a week. In regards to the questions that you posed recently, the distended abdomen could have been from bleeding but more likely from a disrupted anastomosis. This would also explain the stool coming from her wound and her being so sick (septic). She may have had some bleeding at the anastomosis shortly after her surgery that led to the anastomosis breakdown. Let me know if you are sending that file again.”
“I have read the report and agree that it doesn’t address several issues. It doesn’t sound as though she was tolerating her meals well and was very distended – this should have prompted some investigation, i.e. plain x-rays or a CT scan, particularly if she was tender. Also, I have not heard of someone having life-threatening hemorrhage a week after having a bowel anastomosis. Lastly, does the actual autopsy report state that there was blood in the abdomen or not and also was the anastomosis intact? They should have pictures of these findings. I am suspicious of a leak from her anastomosis that was not picked up before her discharge from the hospital. I am sure that this entire process has been frustrating and painful beyond words. I hope that something good does eventually come out of this”.
“While complications can happen with any operation, I think the key thing with your daughter’s care is that it appears to me that there was evidence that there was a problem before she left the hospital that was not picked up by the doctors, either because they ignored the evidence or didn’t see / examine her. How long was she at home after her discharge from the hospital before she returned to hospital / ED?”
“I am sorry to ask you these details but I think that it is very doubtful that she would have a massive bleed after she left the hospital and die in less than 12 hours when she was over a week out from her operation. I suspect that she had a disruption of her anastomosis that was not picked up prior to her discharge from the hospital”
“I think that you should request a formal inquiry and hope that you get some answers to these questions. I am happy to help you as much as I can. Happy New Year to you, and your family as well!”
“Arnold, I am sorry to hear about the lack of support from the Coroner as well as the difficulty with Dr. Hebert. In regards to your questions:
She was not seen by her surgeon, or any doctor on the day of her release. Would this not be wrong? Ideally, she should have been seen by a surgeon or physician or at least a physician’s assistant every day, especially on the day of discharge.”
“She should have been given wound care instructions, possibly after her wound was opened, and antibiotics. Also, if her abdomen was more distended, tender and she had not had a return of bowel function, no, she shouldn’t have been sent home in my opinion.”
From MPP Mr Runciman now Senator to Chief Coroner of Ontario
Dear Dr. McCallum:
I was recently visited by a constituent, Mr. Arnold Kilby, to discuss his concerns surrounding the circumstances of his daughter’s death in July of 2006.
I understand that you are personally familiar with Mr. Kilby and his concerns and that your office rejected the need for an inquest into his daughter’s death.
Mr. Kilby, understandably, is quite passionate about determining the real cause(s) of his daughter’s death and insuring that, if mistakes were made, that they not be repeated and jeopardize other lives..
During his visit, Mr. Kilby laid out a very persuasive case, raising legitimate questions that, apparently, have never been answered. As a layman I can’t speak to many of the issues he raised, but two jumped out at me as very legitimate causes for concern in the way his daughter was dealt with.
The first was the decision to operate without purging the colon for fear of infection; and the second was the nursing charts indicating a persistent “foul odour” at his daughter’s incision, an odour that was still present upon her release from hospital and should indicate, to the least trained eye, that infection is present.
After reviewing Mr. Kilby’s extensive file, I believe his daughter’s death merits reconsideration from your office with respect to the death meriting an inquest. There remains far too many unanswered questions surrounding Terra Kilby’s untimely passing, questions that only your office can secure answers to.
I urge you to give every possible consideration to calling an inquest into Terra’s death.
Kind regards. Sincerely, Robert W. Runciman, MPP Leeds- Grenville