Over the last few months we have been invited to participate in different meetings with some of the stakeholders in health care and as you know, we have been seeking ways of building and maintaining momentum for positive change. More than six months have passed since the release of the Health Quality Council of Alberta’s report (and recommendations) on Greg’s tragic death. While we have been told and we believe that this has led to talk among health care professionals, there has been little that we have felt we could report in terms of meaningful change achieved or specific dates for the implementation plans that have been discussed. We are continuing to work on this and will happily report on significant developments when we can.
Today we are posting some history written at the time we were waiting for and dealing with the report from the Medical Examiner, and our request for a Judge led Public Fatality Review Board investigation into the circumstances and multiple failures leading to Greg’s premature death.
Within the next week, we will post a recent letter from a College of Physicians and Surgeons of Alberta responding to Minister Horne’s request for their response to the HQCA report and recommendations. Along with that we will post our own comments on that letter.
Thank you for following Health Arrows and our efforts for significant improvements in patient care in Alberta, and for any efforts you are making to have other members of the public learn from all of this and push for change. We all have a unique opportunity to help initiate a public discussion on Alberta’s health care system during the run up to new political leaders being chosen, and following that the provincial election. Let’s make the most of it.
Our experience investigating what happened and how the “system” responds
It was and continues to be difficult to dig more deeply into what happened but we know that it is critically important to the future, and to ensure that something positive can be made to come out of such a tragedy. Our family has met often on our own, and we have found mixed reaction from those we have sought answers from, either in person, or by other means. Outlined below are the different steps we have been taking and what we have learned up to date, as well as some other events that we feel also are factors in how some of the players within the system act. We have organized this according to the different areas of focus, rather than a simple chronology of our experience. In this way, you will see a more complete picture of those parts.
You will know from reading Greg’s Journey, that on the way home from the hospital where Greg was pronounced dead, we had a call from the Medical Examiner’s Office indicating that it had been recommended that they investigate Greg’s death. We learned from that call, that the Medical Examiner’s office was under the Department of Justice and therefore we felt that it would be a way to learn the truth, without being exposed to the challenge of the system investigating itself. We learned that most reports take 4 months to complete and we understood from the initial conversation and others later, that the individual investigator did a lot of work, starting right from Greg’s visits to Doctor #1.
When the Medical Examiner’s report was not produced within the time frame projected, we began to be concerned that other factors were entering into the mix. Time continued to pass without the report being signed off, even though we believed that the investigative work had been completed. Finally, on December 12, 2012 the report was released to us (we have attached the report for your reference). We were surprised and disappointed that it was only a couple of pages long and only focused on the last few days of Greg’s life. It did not report on much of what had happened to Greg putting him in a very compromised health condition.
What It did say was that Greg died of “natural causes”, a blot clot in his lungs! Even more disturbing, it was not reported that Greg had lower abdominal swelling prior to surgery. This we felt was a critical oversight as we thought it was an indication of Greg’s compromised circulation system and reasoned that the restriction of blood flow would have been a significant contributor to the creation of the blood clot.
I wrote a letter providing our concerns and noting the missing and incorrect information. The response came from the Chief Medical Examiner for the province. We have attached the exchange that followed (January 7, 2013 – Letter to the Medical Examiner, January 16, 2013 – Letter from Medical Examiner, June 19, 2013 – Letter to Medical Examiner , July 4, 2013 – Letter from Medical Examiner). You will see that I was asked to provide the Medical Examiner written proof of this pre-surgery swelling! This also was incredible for me. The Department of Justice asked for proof when they should have interviewed and had the authority to get the whole truth from the surgeon involved. I had heard that surgeon speak about the swelling when Greg and I were in his office two days before his surgery. Much later, we learned from another doctor that there were notes of this swelling and indeed, once we got the FOIP information we requested, we saw that notation ourselves. (we have attached a portion of this information we obtained, showing the notation) Today, we can only speculate on the potential reasons that the full and correct information was not included in the Medical Examiner’s Report.
Fatality Review Board
Early in the time after Greg’s death, we asked about what the Fatality Review Board did, and who could request to have them to look into cases. We learned that as a family, we could do that. We also learned that the Health Quality Council of Alberta, through their investigation of what led up to Greg’s death, also felt that there should be a Judge led, Fatality Review Board hearing and they would be recommending that.
We wrote a letter to the Fatality Review Board on June 15, 2012 Shortly after sending it, we were requested by the Medical Examiner to provide them a copy and we also provided a copy to the HQCA for their reference.
Months passed without any response. Finally on March 15, 2013 Greg’s file was reviewed and on April 5, 2013 a letter addressed to the family was sent. Our request was denied without explanation.
We checked and were told that we could appeal this decision but did not know whether there was a time limit on that appeal. We decided that given the way the Medical Examiner’s report had been handled, and the character of the FRB response, that this would be a fruitless and frustrating exercise. Later we were provided some potential excuses by others that follow this kind of process. We were told that the FRB generally only becomes involved in cases where there is potential criminal activity, or where there has been a fatality while someone is in the custody of the legal system. The report on Greg’s death by the Medical Examiner’s office being of “natural causes” perhaps conveniently, put it outside the more common FRB hearings. We did know that cases likes Greg’s do get investigated because coincident in time with all of this, was a FRB hearing in Calgary into the death of a patient with appendicitis where it was learned the surgeon used the wrong instrument, damaging an artery which resulted in the patient bleeding to death.
Our obvious conclusion out of the world of the Justice Department was that it was not prepared, nor willing to investigate areas which could potentially expose errors or gaps in the health system in Alberta, even when it clearly resulted in a tragic death.
It also raised some questions about the interaction of provincial politics and overall system accountability.