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Born: Nov 4/86          Died: June 12/12

My beautiful son, Joshua Alvin Patey was taken from me at our local hospital by incompetence.

This involves three doctors and one nurse.

I am certain they have many good doctors and nurses.

He was an accomplished writer, great cook, could imitate anybody, very compassionate about every living thing, and very passionate about sports.  He made everyone laugh, always the life of the party.

He touched so many people in his short life!

 

 I FIRMLY BELIEVE THEY KILLED HIM!

   This is my belief.  Judge for yourself. 

  Click here for my story of his hospitalization

 

The following is a list of things that I had no idea of until after Josh died and I received his hospital records.  It was supposed to be all of them although there seems two very important ones are missing, even though it was only 6 days after he died.

1. On June 6/12 at 10:45 am the internist discontinued the antidote because the blood work from earlier (about 8:00 am) showed his ammonia and valproic acid levels to be down to almost normal.  At 2:20 pm the psychiatrist tried to interview Josh and could not get any sense out of him.  At 3:15 pm just 35 minutes later the internist "medically cleared" Josh.  At 3:35 pm, twenty minutes later, he was given the blood work results taken at 1:00 pm.  This showed Josh's levels rising significantly again (ammonia 100 - normal is 18 and valproic acid 701 - top of the acceptable level).  When he was shown this he said, "not concerned about ammonia levels - patient still medically clear."  The high levels are very dangerous and very life threatening when you take an overdose so why was he not concerned?  This doctor said in one of his letters that he was more concerned about Josh's mental health.  I say what good is mental health treatment if you are physically dead.  Physical wellness should have been the first priority.  Since he is not a psychiatrist he had no legal right to make this decision.

At this time he did not contact Poison Control for treatment recommendations as is protocol.
Despite his rising levels, the Dr. still medically cleared Josh. This means he was left with no medical treatment for the continuously rising valproic acid and ammonia levels in his system.  Then Josh was accepted to the Mental Health Unit by the same psychiatrist who could not get any sense out of him one hour before even though this psychiatrist knew about the rising ammonia and valproic acid levels.  

At 6:00 pm Poison Control contacted the hospital to inquire as to what was going on with Josh since they had not heard from them for some time. When they found out that his levels had started rising earlier in the day, they were very concerned for his well being. When the doctor that previously cleared Josh was contacted by the psychiatrist about this, he clearly stated that he “stuck by his decision, patient is medically clear” even though it was quite evident that my son was deteriorating quickly and was not medically clear.
He was  deprived of this medication from 10:30 am, when they discontinued the antidote, until almost 11:00 pm (about 12 hours) when he had deteriorated significantly. 

Also Poison Control told them not to give Josh "Haldol" but he was prescribed  it twice that day by two different doctors (psychiatrist and internist).  I believe this may have contributed to his deteriorating condition as it can cause "Neuroleptic Malignant Syndrome" as well as other serious conditions.  According to Poison Control it can cause seizures when given to a patient in Joshua's condition.   The hospital said, yes, Josh was prescribed this twice but since there is conveniently no Pharmacy record for this they maintain that he never received this.  However on the bottom of the doctors orders it shows that it was faxed to the pharmacy. Given the events that led up to him being restrained in ICU, I am certain that he received this and they pulled the record to cover this up.  I asked the college, the coroner, the hospital and HPARB to ask the nurses as to what they administered and all of them totally ignored this request saying there was no need since there are no pharmacy records and they did a medicine cabinet check.  How convenient?  Why would they not ask the nurses if they were so certain Josh did not receive this and for no other reason than to prove me wrong.

2. Violated the “Consent to treatment Act”.
On June 6/12 Josh was unable to speak for himself from 8:00 pm on, and they never called me until after midnight. When someone can not speak for themselves, they are supposed to contact the next of kin to get signed authorization to treat the patient. They treated him without written or verbal authorization from me (next of kin).   Why did it take over 4 hours to contact me?  I live 5 minutes away from the hospital.  In fact  over the next four days when he was sedated and restrained nobody bothered to discuss his treatment with me. 

3. Violation of the “Minimal Restraints Act.”
Only the doctor in charge can order physical restraints and they are supposed to closely monitor this and keep records.  There are very few records of this.  The doctor in charge said in one of her letters "I am not saying Mrs. Patey isn't telling the truth but I do not remember the restraints" even though you can clearly see them in the picture above and I have signed  statements from witnesses regarding this. After I sent her the picture, through the college, she changed her story to say that they have since found some records regarding him being restrained a few times. I was at the hospital almost the whole time and he was restrained the whole time he was sedated.  She also did not get my permission for this.  How could she treat him every day and not notice the restraints? This put him at great risk for the DVT he developed.  I am now aware that the reason for keeping him physically and chemically restrained for over 4 days is because according to the doctor every time they tried to wean him and bring him around he got "a little agitated".  This is not a good enough reason to keep someone dangerously restrained.  Anyone waking up in this situation would naturally be confused and a "little agitated" if they were restrained, especially if they had no idea how they got there.  I told the nurse I would like to be present when they brought him out of it because I know I could have helped to calm him, but this was totally ignored.  Instead they kept him immobilized for over 4 days increasing his risk for blood clot.  The College and the doctor claimed there was no time to contact me and since it was an emergency situation, they had every right to physically restrain him.  He was not restrained until around midnight, so why could they not have contacted me 4 hours earlier when he started deteriorating?

4. He had all the symptoms of the DVT (blood clot) he developed which led to Pulmonary Embolism and caused Cardiac arrest which killed him.
                          Pink sputum, sweating constantly,  fever, high heart rate, trouble getting his breathing regulated.
The doctor claims she was treating him for aspirated pneumonia even though several  X-rays revealed he did not have this. She never even looked at any other reason for his symptoms. I thought when one thing is ruled out you naturally would look at another cause for the symptoms. Why did she not do this?  I believe he had developed the DVT on the evening of June 6/12 when he ended up in ICU since he had the symptoms from that time on until he died (over 4 days).  If this is the case it is likely that only giving him heparin would not help.  It is a preventative measure and does little good after the DVT has developed.  This doctor is supposedly certified in internal medicine so how could she miss this as it is quite common given the circumstances of immobility and Josh being at high risk.  Since his heart rate was between 105 and 130 bpm(normal is 70 - 80) for over 4 days I wonder why a cardiologist was never consulted. 

5. When I found my son in distress on June 12 at 3:40pm, I pushed the call button and got no response from anyone. About 5 minutes later I pushed it again, and about 1 ½ minutes later the nurse finally arrived. The nurse now claims she answered both calls.  Why would I push it twice if she came after the first one?  When my son started turning colour she left the room instead of pushing the code blue as is protocol. It was not until after she returned and Josh passed out that they finally pushed the code. I witnessed this. This nurse wasted over 10 minutes from start to finish of my son’s last minutes of life and we will never know if the call had been answered promptly the first time and the code had been pushed sooner if this would have saved him. By the time the team arrived I know in my heart he was already gone as I seen his eyes roll back and heard him defecate just before the code was pushed.   Interestingly enough, this particular nurse is no longer with the hospital.  I wonder why?

Update on the nurse:  I have since learned that this nurse was arguing with ICU about sending him up to her.  She strongly felt this was risky and she felt he should at least have one to one nursing.  I now believe that she was very distraught about the situation and I can forgive her since she seems to be the only one who was advocating for my son.  This information has also been conveniently left out of the records and I did not find out about this until after I had complained to the nurses' college.  I have since dropped my complaint.

6. The coroner states the cause of death as “suicide”. Although he took an overdose this is not what he died from. He was hospitalized for almost 8 days and the medications he ingested were long gone out of his system. He died due to Deep Vein Thrombosis (pulmonary embolism) which was most certainly caused by the events of the evening June 6 (caused by him being medically cleared too soon) and then being restrained in ICU for over four days.   It is easy to blame the patient.  I requested an inquest from the chief coroner's office and this has been denied as he feels it would not help patient safety or help in any future patient treatment.   If Josh's case does not speak to patient safety I do not know what does.  So many mistakes over 8 days. 

click here to read the coroner's final decision

click here to read my complaint about the coroners to various government agencies

You would think that because they claim Josh died from complications of ingesting his medications that they would have done toxicology (blood work) at the time of autopsy.  However none was done.  I find this very suspicious but when I asked I was told that they don't always do this and it was not necessary in Josh's case because they knew he died from a pulmonary embolism.  How  can they possibly say the pulmonary embolism was caused by the medications he ingested without the toxicology being done.  Again I say it is easy to blame the patient when actually it was most likely caused by being restrained in the ICU for over four days.   

The coroner also makes mention that because Josh's case was sent to the Patient Safety Review Committee that it is unlikely any further recommendations could be brought out at an inquest.  If you read the Safety Review findings you will note that it is obvious they were not given the information regarding the restraints as they make no mention of this in their report.  They also speak of alcohol withdrawal as if Josh was addicted to this.  Let me tell you my son was not addicted alcohol or street drugs.  He was a binge drinker.  He would party for a day or so and then not touch it for weeks.  He also smoked pot occasionally but nothing else.  The good news is that the Patient Safety Review Committee did make recommendations about the blood clot that killed him and because of this Joshua's death has probably saved many others from the same fate. 

read the safety report here

Although the overdose Josh took caused him to end up in the hospital, the negligent and incompetent treatment he received afterwards was not his fault.  I have lost all faith in our medical system. I know there are good doctors out there and I believe they are forced to look the other way or be black listed if they speak out.

If this should happen to you my advice would be to get your medical records as quickly as possible and hire an attorney if you are lucky enough to find one to take on your case.  I do not blame the lawyers as they are well aware of how our system works and the CMPA tactics.  Forget complaining to the college or the coroner.  However, that being said, civil suits are also very difficult to win since the doctors have the CMPA to protect them.  They are largely funded by our tax dollars.  The CMPA has far more money than the average citizen to spend on defending the doctors and if it regards a death our government puts a cap on your head which means it will cost far more than you could hope to recoup. 

Video on CMPA tactics

You must learn to advocate for yourself and your loved ones.  My advice is not to leave them alone, question all procedures and medications and do your own research.  If something does not feel "right" get a second opinion.  It is your right.  I also would advise taking video of conversations and pictures.  If we did not have the one above I would have no proof of the restraints as it is only mentioned occasionally in the records.

I am fully aware that I will never get true accountability or justice for what happened to my son.  I keep this site only to warn others of what they will have to go through when dealing with medical errors.  It is truly devastating to the patients and their families and the frustration and anger never ends.  Is is clear to me how very unfair our system is to the patients in this country when they suffer harm.  I have met several others who have been treated as I have.   I understand about human error, but I believe if those in our medical system, particularly the doctors, were held more accountable for their actions there would be a lot less mistakes made.  

I will always have the what ifs : 1.we took him to a different facility

                                                    2. he was not turned over to Dr N. 

After I received the college's decision I complained to the Health Professionals Appeal and Review Board (HPARB).

Read my submission and their decisions here inculding many hospital records.

Watch this video on Haldol

Former Drug rep speaks out


 

 
for more info follow the links below
 

40,000 DEATHS

Canadian Medical Protective Association

Horror Stories

DYING IN SECRET - A MUST READ

Wrongful Death Act

More Links to Info

Video - Mr Fantasy

Video - Society

Medical Secrets

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