The fight for medical information after patients die
Published Saturday, October 9, 2010 6:58PM EDT
When faced with a trip to the emergency room, Canadians believe the quality of care they will receive will be second to none.
But if the unthinkable happens and a critical mistake is made, there is also the belief that the medical system will provide answers to what went wrong. But as W5 has discovered, in Newfoundland, some families are left fighting for years to get the information they want and believe they deserve.
In 2002, Trudy Meaney's sister, Paula Browne, was rushed to hospital in St. John's, N.L. with a pain in her leg. Once in the emergency room it quickly escalated to a life-threatening situation. Just over an hour after arriving at hospital, Paula Browne was dead.
"We knew from day one something wasn't right. It just didn't make sense," Trudy Meaney told W5's Victor Malarek.
It was a tragedy. But Paula Browne's family was unable to shake the feeling that something had gone horribly wrong in the emergency room. But with nothing but a hunch there was little they could do.
Then, in 2008, they got a call that confirmed their worst suspicions. A man who called himself "Tom" had come forward and said that Paula had died as a result of a mistake made by the doctor who attended her in the ER.
Tom, a healthcare professional who worked in the ER where Paula died, agreed to an interview with W5. However, fearing a backlash from the medical community, he only agreed on the condition of anonymity.
"There is a serious question of medical judgment and decision-making," said Tom.
Emergency room records obtained by W5 show that when Paula was admitted to St Clare's Hospital, run by Eastern Health, she was complaining of dizziness and weakness. Her heart was racing and ER staff couldn't obtain her blood pressure. Tom says these were classic symptoms that Paula had a blood clot in her lung which resulted in a faster heart rate. But the ER doctor treated her for an irregular heartbeat instead and gave her a shot of Verapamil, a drug designed to slow down her heartbeat. Within minutes Paula's heart had stopped.
Tom believes the dose of Verapamil was the equivalent of giving Paula a lethal injection and he also provided another piece of disturbing news. The same doctor who had treated Paula had been suspended by the hospital and sent for additional training following the deaths of several patients he was treating in the ER.
"It's a big thing for the hospital to do," said Tom.
With new information about the death of Paula, the family went back to the hospital seeking answers. They requested the records of her treatment in the ER and were given a few documents. But when they asked about the internal investigation, the Browne family was told they weren't entitled to that information.
Trudy Meaney couldn't believe it. "It's ridiculous. Whatever happened with my sister, we should be entitled to everything."
The hospital then insisted that the family must file a request for the documentation under Newfoundland and Labrador's access-to-information law, which they did. But once again, Eastern Health refused to give them the internal report. Finally, the family appealed to the province's Information Commissioner, who ordered Eastern Health to hand over the records.
Even then, it took over a year for the hospital to hand over the results of the internal investigation. But other ER records were still missing. The first 12 minutes of an EKG (electro cardio gram) -- the critical minutes that might prove whether an error had been made.
"They're covering up. They're not going to release this information because they know they're wrong keeping this information from the family," complained Meaney.
Tom, the whistleblower, also believes families have a right to all the information concerning their health care and that of loved ones. He claims that "fear of bad press, fear of lawsuits, fear of reputation" on the part of the medical system is why families keep getting the silent treatment.
Eastern Health is no stranger to controversy surrounding the withholding of information critical to patients and their families. Scandal surrounded the hospital and soon embroiled the Newfoundland and Labrador provincial government in 2005, when it was revealed that Eastern Health had neglected to inform 400 patients that their breast cancer screening tests had been botched.
The scandal led to a public inquiry. In her 495-page report, Judge Margaret Cameron was scathing in her comments about the healthcare system in Newfoundland saying, "The whole of the health system, to varying degrees, can be said to have failed the ER/PR patients," Cameron wrote.
She singled out Eastern Health, writing that the province's largest health board had not been forthcoming to the public at large.
"The communications to the public minimized and obfuscated both the scope of the problem and the potential seriousness of its consequences for the patients affected," she wrote.
As a result of the scandal Eastern Health promised to be more open in the future. A new CEO, Vickie Kaminski, was brought in promising a new era of transparency. She told W5 that under her tenure, the hospital gives families "as much information as we can."
"Certainly we sit down and we all go through the medical record with them, have the physician participate. We'll talk to them about what happened, show them test results. If that's what they require then that's certainly what they get."
But Paula Browne's family complains that's certainly not what they experienced. And they weren't the only ones who feel their requests for information have not been fully answered.
Eight weeks after the death of Paula Browne, another family suffered a tragic loss at the same Eastern Health hospital with the same emergency room doctor attending.
Ellen Callahan had been in for surgery and suddenly, a few weeks later, her daughter says she began to vomit blood. Rushed to emergency, Callahan's condition continued to get worse through the night. She died two days later.
Callahan's daughter, Donna White, told W5 that she felt something had gone wrong with her mother's treatment. Vowing to "do right by Mom," for eight years White tried to get to the bottom of what happened in the ER the night her mother died.
Tom, the whistleblower who provided crucial information to Paula Browne's family, told W5 that Callahan's death was another case of physician error.
According to emergency room records, when Ellen Callahan arrived at the hospital, she was showing signs of internal bleeding. Without conducting a CAT scan, the emergency room doctor decided she had a blood clot in the lung. Emergency room nurses disagreed with the diagnosis, but the doctor disregarded their advice and gave Callahan a powerful blood-thinner, called Lovenox, a drug for which there is no antidote.
"A lot of people would agree that a bleeding patient should never be put on blood thinners or anti-coagulants," said Tom.
Armed with her mother's medical records, Donna White went looking for justice. Her first stop was at the office of the province's Chief Medical Examiner, Dr. Simon Avis. He conducted an investigation and found that a mistake had been made -- "a wrong diagnosis was made (and that) … the treatment contributed to her death," he told W5.
But Avis refused to recommend an inquiry be held into Callahan's death and White didn't feel the Medical Examiner's investigation was enough.
According to Avis, disciplining doctors is not the Medical Examiner's job and recommended that White approach the College of Physicians and Surgeons of Newfoundland and Labrador, the governing body that regulates the behavior and licensing of doctors.
In her complaint to the College, White expected action, as the alleged mistake by the ER doctor in question had resulted in the death of her mother. All she got in return was a letter, in which the College advised White that they had found her mother's treatment to be fair and that their mandate did not include "the investigation of allegations of negligence."
When W5 sought an interview with the College of Physicians and Surgeons they refused the request, pointing to the Newfoundland and Labrador Medical Act which sets out the College's jurisdiction for dealing with complaints.
The jurisdiction of the College of Physicians and Surgeons to deal with complaints is found in the Newfoundland and Labrador Medical Act.
A review of the Medical Act by W5 shows that the College may investigate "conduct deserving of sanction" including "professional incompetence," however, what constitutes incompetence is not defined.
W5 sought an interview with the Registrar of the College of Physicians and Surgeons, to understand their mandate and whether negligence would form a part of an investigation into professional incompetence. The interview request was denied.
Approached by W5, Dr. Robert Young, the Registrar stated: "We investigate conduct deserving of sanction" but referred to the Medical Act for a definition.
According to the Medical Act "conduct deserving of sanction includes: professional misconduct, professional incompetence, conduct unbecoming a medical practitioner, (and) incapacity or unfitness to engage in the practice of medicine." But the decision of what constitutes such conduct is left to the Registrar of the College of Physicians and Surgeons.
All of which has left Donna White still seeking information and accountability for what happened to her mother, who died eight years ago after mistaken treatment in the ER. White complains she is frustrated, angry and has no hope of closure. "My mom is just another statistic and she's buried and she's gone and that's not how I want her remembered."