GRH chief of staff cautioned for misleading family of man who died in hospital

Dr. Ashok Sharma, chief of staff at Grand River Hospital, speaks with CTV News on Tuesday, May 26, 2015.

The chief of staff at Grand River Hospital has received a verbal caution from the College of Physicians and Surgeons of Ontario for how he dealt with the family of a patient who was given the wrong dose of narcotics.

Dr. Ashok Sharma said that he did not intentionally mislead the family, although he did not contest the committee’s finding that the family was misled.

In June 2010, an 85-year-old man was admitted to the hospital with what was believed to be a bowel obstruction.

The man was prescribed a narcotic for pain relief.

The drug was supposed to be injected into his skin.

According to hospital president Malcolm Maxwell, the nurse instead injected the drug into his IV line.

“As a result, the patient got more of the drug quicker,” Maxwell told CTV News.

“That could have depressed the respiratory system. It could have contributed to the patient’s death.”

One day after the drug was administered, the man died.

An initial coroner’s report stated that he had pneumonia and small bowel obstruction.

“The hospital immediately made the family aware that the medication error had occurred,” Maxwell said.

“The difficulty is in trying to sort out what were really the consequences of the medication error.”

That summer, the man’s family members met with hospital employees including Sharma.

Documents show that Sharma said the medication mix-up posed “likely no consequences to the patient.”

After family members provided more information, the coroner’s report was amended to say that a drug overdose likely played a role in the 85-year-old’s death.

In 2011, the family filed a complaint with the college, stating a belief that they had been “deliberately misled” by Sharma.

The college found that Sharma did mislead the family about the medication error, and “(downplayed) the damage that such a dose may have caused to the patient’s respiratory system.”

That decision was then taken to an appeal board, which determined that the college was right to verbally caution Sharma.

Maxwell says that he thinks Sharma was working “with the information that he had at the time” when he first said the medication error played no role in the man’s death.

“I think that after the reviews and discussions that have gone on … he should have been more cautious in that statement,” he said.

In an interview with CTV News, Sharma denied deliberately misleading the family.

“I think it was a good process we went through,” he said.

“Definitely we learn from every event and … we have already made some improvements.”

Hospital officials say they have made a number of changes since the man’s death, including adding more checks and computerized systems around medication.

Sharma and others from the hospital have apologized to the family.