WHAT WE WANTED?

Many people – family, friends, strangers – have asked us why we’ve pursed answers to our mother’s death so vigorously. Why not just let it go, let time heal? Well, to answer this, you had to know our mother. She was a strongly principled individual who believed that if there was a wrong, it needed righting, and that we should never leave it to someone else to promote change if it was within our own power to do so. Here were our requests prior to investigation ... and the follow-up responses:

We believe that the best weapon against bad medicine is public disclosure and awareness. What do we want? Certainly we want the RNABC and the College of Physicians and Surgeons to thoroughly investigate the events of February 20th through March 5th, 2000 and to consider the documented conduct of the named doctors against the accepted standards of professional practice and good medical judgment (See Letter to College)

Follow-up
We are heartened that the RNABC has been extremely proactive in responding to the Coroner's findings, has made a number of visits to Chilliwack General, and have been instrumental in helping to set up a permanent Professional Practice Committee that will look at new protocols and procedures, and encourage education and re-education as needed. See the Medical Response area for a copy of their final response to the Judgment Inquiry.

We also want to encourage the Administration of Chilliwack General Hospital, and the Management and Board of Directors of Fraser Valley Health Region (See Letter to Chairman of the Board) to consider some of the recommendations arising out of our personal experience with this particular hospital, as well as responding, of course, to the recommendations of the Coroner’s Office in its official Judgment of Inquiry.

Follow-up
Again, we were very pleased to receive in writing (June 26th, 2002) the assurances of the new Chair of the Board of Fraser Health Authority, Barry Forbes, that a "multidisciplinary team has been established to address all the recommendations of the coroner's report and develop an action plan. This team consists of the medical director, chief of staff, anesthetist, site administrator, and nurse representatives from OR, surgery and medicine and the Quality Advisor. A plan outlining a process to ensue (sp) quality of care and accountability for the improvements is expected to be completed by mid-July and will then be brought back to the medical and nursing staff to be used as a learning tool."

See the Medical Response area for a copy of their final response to the Judgment Inquiry.

We are not asking for the impossible. We understand the severe pressures on today’s medical system in terms of personnel and funding shortages. But we feel our recommendations are not about spending money: they are about exercising better judgment, demonstrating good sense in expediting changes to the system, and most important, having the intention to make things better.

Our Recommendations:

1. That the College of Physicians and Surgeons thoroughly review the actions of Drs. A.A. Suleman, D.M. Wickham, and A.R. Richmond to ascertain whether care was in conformity with standard practice.
2. That the Registered Nurses Association’s Professional Conduct Committee thoroughly reviews the actions of the nurses involved in the care of Esther Winckler to ascertain whether care was in conformity with standard practice.
3. That the role of Patient Advocate be clearly defined by the Health Region and their presence made known to families prior to a patient’s death.
4. That hospital charts have a clear area dedicated exclusively to the tracking of bowel movements of the patient.
5. That restraint policies of the Hospital be revisited and that the Hospital consider looking to the Ontario experience and the Report written by John Hurdis of the University of Waterloo for Health Canada. As well, that the Hospital look to the experience of Burnaby General Hospital who hired Clinical Nurse Specialist, Marsha Carr five years ago to examine hospital policy on restraints. The result is an innovative program and the existence of a ‘Least Restraint Committee’ that meets monthly and that comprises all hospitals in the Simon Fraser Health Region.
6. That medical personnel at Chilliwack General Hospital get further training in geriatric medicine – specifically the effects of certain drugs on seniors (i.e. Atavan) and also the signs to look for to differentiate post-op confusion in seniors from clinical distress. Given the demographic of Chilliwack General Hospital, it would seem sensible to pay more attention to the needs of this aging population.
7. That the Hospital re-look at the availability of medical personnel (on-site and on call) on weekends. (Note: It was impossible for family to get a doctor to come to Esther Winckler’s room through the critical last day of her life, despite her acute distress.)
8. That the Hospital Administration take a hard look at a culture that has developed internally which has nurses telling a family who is insisting on seeing a doctor that they aren’t encouraged to call the doctors on a weekend UNLESS there’s a good reason.
9. That families be given a brochure or some written explanation that clearly outlines what a DNR order means and what the ramifications will be once the family signs this form. Different medical personnel explain it differently to each family and this should be a standard.
10. That all hospital staff should be re-educated as to the importance of note-taking. Our mother’s chart had significant holes in levels of information. If not for the patient’s benefit, one would surely be moved by articles such as that in the Medical Post (Volume 37, No.07, February 20, 2001, “Not taking notes constitutes negligence”) whereby a recent Ontario ruling found that the failure to take notes was the central and not the side issue in a lawsuit.
11. That there be a system of checks and balances in place so that transfer from one ward to another does not result in complete absence of continuity of care. Bells should go off when it shows that in an entire 15 day hospital stay, the operating surgeon has only made one chart notation post-surgery, despite a later decline in the patient’s condition. As well, nurses mistaking a decline in health for senility should not be acceptable, one floor to the next.
12. That family members be brought into the process more effectively. That if there are shortages in staffing, the family is alerted so that they can make arrangements to sit by the patient as opposed to having long periods of restraints and an ‘out of sight, out of mind’ treatment mentality. As well, if the patient IS to have restraints, or has fallen, the family should be immediately notified.
13. That liquid and food intake be charted. The family noted that food workers came in and out taking the food without lifting the lid to see if anything had been ingested. No one appeared to be monitoring dehydration or nutrition levels.
    
14. That if an anesthetist or anyone attending the patient changes the gameplan regarding the surgery at the last minute (flying in the face of the pre-op consult, the understanding of the GP, and the family and patient), that at least one member of the care team is notified. This should not be an arbitrary decision by one person. Note: In Esther Winckler’s case, her GP, family and surgeon were not made aware of the change of plan re the general anesthetic vs. the epidural.