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Ontario coroner to investigate death of man who suffered cardiac arrest while waiting in ER

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A provincial coroner will be investigating the death of 68-year-old David Lippert, who suffered a cardiac arrest while waiting in a crowded emergency room in Kitchener, Ont.

“I am relieved,” said Lisbeth Lippert, his widow, after learning of the coroner’s investigation. “I want to know why he was left alone for a long period when he was under such duress.”

David Lippert, a local executive, was taken to emergency in Kitchener, Ont., in March of 2023. He was feeling weak and had awoken unable to walk.

Medical records reveal blood tests showed dangerously low hemoglobin levels, with doctors suggesting he was suffering from a gastrointestinal bleed. Lippert told his wife he was afraid to stay in hospital, and initially rejected admission.

But he agreed to be admitted to St. Mary’s General Hospital after blood transfusions failed to boost his blood levels.

However, while waiting for admission overnight, medical notes show Lippert was found unresponsive by hospital staff in the ER, having vomited blood while lying on a stretcher. His heart had stopped.

Medical teams gave him four rounds of CPR. He was taken to the ICU, but doctors there found him non-responsive. He also suffered seizures and had signs of brain damage from an extended lack of oxygen. He was pronounced dead the day after he came to hospital.

His widow says she spent almost a year trying to retrieve his medical records and surprisingly found no notes on what happened between 1 a.m. and 7:30 a.m. the morning after he arrived, when he was discovered in cardiac arrest. "I just wanted him to be in a place where I thought he was safe,” she told CTV News. "It’s just his worst nightmare to die in the ER."

She also told CTV News the ER was chaotic when she stayed with her husband on the first day.

'Running around like crazy'

He was placed near the nurses’ station where she says she heard them taking calls from other staff calling in sick. It was clear, she said, that they were understaffed and overwhelmed with patients who were waiting for care and lining the ER hallways.

"They were running around like crazy. I don't know how you would even maintain that as your career for any length of time," Lisbeth said, adding she saw the nurses and orderlies doing their best.

A report in September 2023 warned that based on projections, Canada could see between 8,000 and 15,000 deaths in the country’s emergency units because of over-crowding.

“I am truly hopeful leaders will finally see and understand the horrible circumstances that patients and staff often endure.,” wrote Dr. Michael Howlett, president of the Canadian Association of Emergency Physicians. “A proper investigation is the right and responsible thing to do.”

"In a functioning health -are system, someone with a GI bleed and a hemoglobin of 40 is admitted promptly... you have an example of a man who should not have been in the ER for at least 22 hours before arresting," according to Dr Blair Bigham, who was permitted to review the medical records. Bigham is also an assistant professor at the University of Toronto's Dalla Lana School of Public Health.

Officials at St. Mary’s General Hospital declined to comment on Lisbeth Lippert’s story telling CTV News they could not comment on the specifics of the case.

'Poster boy for deaths in the ER'

“We offer our condolences to the family and encourage them to reach out directly to our Patient Relations team," said Brandon Douglas, vice president of Clinical Services at St. Mary's General Hospital

Since telling her story, Lisbeth Lippert says she has been approached by dozens of people in her community, with stories of long waits for medical care, and crowding in the local ER. She hopes the investigation probes whether the intense demand for ER care she witnessed, and the shortage of staff on duty, had a role to play.

“I don’t think my husband David would have liked to be the poster boy for deaths in the ER, but yet, here we are,” she said.

“I would like to see ERs get resources they need so lives don’t get missed.”

The investigation is being handled by the Ontario coroner’s office for Hamilton and Waterloo regions.

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