Son says oversight at Ottawa Hospital cancer clinic serves as a warning

Lung cancer patient Xuguang Zhao was 80 when he died in April 2010 due to respiratory failure.
OTTAWA — The Ottawa Hospital acknowledges a clerical oversight in 2009 was the reason an elderly man suffering from lung cancer didn’t see a radiation oncologist as soon as he should have.

It was only after his son finally got through to complain to the hospital that an appointment was booked.

Xuguang Zhao was 80 when he died in April 2010 due to respiratory failure caused by the cancer. His son, Donghai Zhao, who took Xuguang to his medical appointments at the Ottawa Cancer Centre, says he doesn’t know if his father would have lived longer had there not been a delay in seeing the radiation oncologist and the subsequent radiation treatments.

Donghai says doctors never told them the cancer, discovered in June 2009, was terminal, or if he could survive longer with treatment. But he says tests and scans that followed determined it hadn’t spread and was confined to Xuguang’s right lung. That, he says, gave him and his father reason for optimism.

Donghai thinks his father’s story should serve as a warning to urgent-care patients and their families not to take anything for granted when dealing with our health-care system. Donghai says he trusted it, but it let his family down.

Following his father’s death, he asked the hospital’s patient advocacy department to investigate. He received a letter a year ago, outlining what it found. For Donghai, it raised more questions than it answered. He says the hospital’s sequence of events — after they were told in late summer 2009 that his father’s cancer, a tumour of six centimetres, was confined to the right lung — doesn’t match his timeline. Out of frustration, he says, he didn’t do any follow up with hospital officials, even though he had been invited to do so.

The February 2011 letter from patient advocacy specialist Renée Blouin says documentation indicating that Xuguang needed to see a radiation oncologist was missed. Paula Doering, Ottawa Hospital vice president of cancer care, says a clerical staff member missed a doctor’s notation at the bottom of an order sheet that Xuguang needed to see a radiation oncologist next. The doctor had ticked off a box above the notation that indicated he didn’t have to see the patient again.

Says Blouin in the letter: “I wish to apologize to you and your family for any delay that may have been experienced as a result.”

What does Blouin mean by “may,” Donghai asks. There’s no doubt in his mind that there was a delay — a significant one. He says three months passed from the time they were told in early September that a treatment plan had to be devised to when his father started receiving radiation in early December.

Doering confirmed the hospital’s position that the clerical oversight occurred following Xuguang’s Oct. 23, 2009 visit with a medical oncologist. The oncologist determined that chemotherapy was not appropriate treatment and asked that an appointment for Xuguang be set up with a radiation oncologist. Doering says surgery had been ruled out, which suggests the cancer is in its late stages or has spread. Donghai says doctors decided his father was too old for surgery.

Donghai says the delay was caused before Oct. 23 as about seven weeks had passed from early September, when they were told that a treatment plan would have to be devised. During that time, his dad started spitting up blood. Alarmed, Donghai says he called the cancer centre several times, leaving messages that went unanswered. He says he finally connected with a social worker and the appointment was scheduled.

The hospital says the Oct. 23 appointment followed a Sept. 4 consultation visit. It says it was with a medical oncologist, not the radiation oncologist that Donghai says his father saw.

Though Donghai recalls that his father met with a medical oncologist at one point, he says the radiation oncologist who examined his father was surprised so much time had passed without treatment. The doctor looked into the matter and told him the delay was the result of “miscommunication.” But before the doctor could order radiation treatments for Xuguang, Donghai says new tests were ordered because the first ones done in the summer were deemed too old. An X-ray that day showed the tumour had grown to 10 centimetres in diameter. New tests and scans took another month, says Donghai, and again doctors concluded the cancer had not spread. Xuguang’s radiation treatment started in early December 2009 and continued into January 2010. Donghai says doctors felt the radiation was working.

But in early February, Xuguang started experiencing lower back pain. He was put on painkillers, but they did little. In early March, Xuguang complained that his legs were numb. He was taken to hospital, where magnetic resonance imaging showed a tumour on his spine. He couldn’t walk and started receiving radiation treatments on the new tumour, but his condition only worsened. He died on April 14.

Despite the differing accounts over the delay, Doering says the administration met with clerical staff to address the error and reinforce the need to check all medical order sheets thoroughly.

“You need to make sure you go through every note on every order and not make any assumptions,” says Doering, who is also regional vice president for the cancer program of the Champlain Local Health Integration Network.“We’re actually doing double checks with nursing on those orders as well.

“It was a human error. It was one of our staff at the desk, and they do many orders in a day. So when I think about it, yes, errors can happen (which) may or may not have a significant impact on the patient. I don’t know whether this did (on Xuguang Zhao) because I’m not an oncologist. But it was an error.”