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
