Joshua Alvin Patey
DOB: NOV 4, 1986
Death of my Son
Joshua
Born Nov 4/86
Died
June 12/12
Updated "April 8/13 to reflect what the records show:
My son was killed due
to negligence and incompetence at our local hospital (Cambridge Memorial
Hospital)
by three doctors and
one nurse.
I have complained to the
College of Physicians and Surgeons about the doctors in question as well as to
the Ontario Nurse’s College regarding the nurse.
Also the regional coroner
tried to cover up for the doctors , and I have since complained about him to the
college as well as complaining to the chief coroner of Ontario who is currently
investigating my son’s case.
I have also requested an
inquest.
My son, Joshua, was admitted
to Cambridge Memorial Hospital emergency on June 5, 2012 after taking an overdose
of his prescription medications. Joshua had been diagnosed as being bi-polar
by a psychiatrist at the hospital a few years before and was under his care
for medication. I would like to say that one of the drugs he was prescribed
was “ Abilfy” which can cause suicidal tendencies. I had asked
the doctor to put him on Zeldox which was recommended by my brother who also suffers
from mental disorder but he did not. His life at this time was going in a
good direction. He was a fabulous writer and had articles published in a local
newspaper as well as just starting to work for the Velvet Rope Society. There
was no indication of suicide.
However he contacted
both me and his father shortly after he had done this.
It was approximately 2:30 am.
We took him to the local
hospital and arrived by about 4:00 am.
He was admitted at once and
the emerge doctor contacted Poison control for recommendations.
This doctor followed Poison
control recommendations and for the next 24 hours my son seemed to improve.
Apparently when you ingest
this much medication it makes the ammonia levels in your system rise as well as
valproic acid levels are high from the medications themselves.
They were told by Poison
control to start him on L-carnitine which is used to lower the levels in the
blood.
They were doing blood work
every 3 hours and had to send it elsewhere for testing.
His levels for the whole day
were very high.
All day on
June 5 he seemed very groggy.
On the morning of June 6 at
10:30 am his levels showed that they had gone down to about normal.
At 2:40 pm the psychiatrist
tried to assess him but could not get him to follow direction or give a sensible
response.
He said he would come back
later to assess Josh.
Josh’s care
had been turned over to a new
doctor and this doctor had
been assessing him all day on June 6.
At 3:15pm just 35 minutes
after the psychiatrist could not get any sense out of my son, the new doctor
“medically cleared” him.
How could this be?
At 3:35 20 minutes later the
nurse questioned his decision and showed him the most recent blood work results
from 1:00 pm that day which showed Josh’s levels to be rising again.
He still medically cleared
him and sent him off to the Mental Health ward.
They did not contact Poison
Control with this info.
Upon Arriving at the
mental health ward the psychiatrist prescribed Haldol even though Poison Control
told them not to.
Apparently he did not consult
their recommendations.
At approximately 6:00 pm
Poison control contacted the hospital since they had not been contacted since
much earlier that day.
When they learned that my
son’s levels had started to rise again, they became very concerned and advised
them to have the antidote ready and closely monitor Josh.
The psychiatrist contacted
the doctor who had “medically cleared” Josh and his was response was as follows
“I stand by my decision, patient is medically clear.”
Now the psychiatrist brought
in yet another Internist to assess Josh.
By 8:00 pm my son was
deteriorating quickly.
He was incoherent, confused
and trying to leave the hospital.
The new doctor sent him over
to the medical ward.
After being transferred to
this ward they restarted the L-carnitine antidote for his rising ammonia levels.
He
was still not stable and at 10:45 the Internist prescribed Haldol again.
Consequently from 8:00 until
about midnight my son was in a very bad mental state.
During this time he had a
code blue.
At about 12:30 am the
hospital finally called me.
I could hear ungodly
screaming in the background which I was told was my son.
She told me they were
admitting him to the ICU.
My other son and I rushed up
to the hospital and about 2:00 am the doctor finally came in to talk to us.
I asked what had happened and
all she told me was that Josh’s levels started rising and they did not know why.
I had no idea about the
rising levels earlier in the day or that they had given him Haldol in spite of
being told not to by Poison control.
I was also told that it had
taken 7 – 8 people to hold him down when they moved him to ICU and he had to be
physically and chemically restrained to protect him.
I have asked in my complaints
why I was not contacted as soon as my son was unable to speak for himself since
there is an informed consent to treatment act
which states that if a patient is incapable of speaking for themselves than the
next of kin (me) should be contacted.
I live about 5 minutes away
from the hospital and they waited over 4 hours before contacting me.
This is in clear violation of
the act.
From the time he was
in the ICU he had a high fever, he was sweating, had a high heart rate (over 130
the whole time up until his death) and developed pink sputum.
These are all signs of DVT
(blood clot) but nothing was done to check for this.
They gave him heparin which
is only effective in preventing blood clots and is useless after the clot has
developed.
By chemically and physically
restraining him for over 4 days they increased the risk of blood clot.
He should have been given
surgical stockings and physio as well as heparin but he was not.
They never did one test for
the clot.
They assume giving him
heparin would take care of this. Again I stress I believe he had already
developed this by the time they gave him heparin.
I also questioned the
use of physical restraints after he had been chemically restrained as well.
Josh looked like he was in a
coma and could not even move a tiny muscle so why did they leave the physical
restraints on.
There is also a
Minimum physical restraints act in Ontario.
It states that only the
doctor can order this and they have to monitor and keep records of this and
remove them as soon as possible.
There are no records on
monitoring this.
In one of the doctor’s
responses to me, she states “I am not saying Ms. Patey is not telling the truth
but I do not recall the physical restraints and there are no records of this.”
She was not aware of the
picture we have.
I sent her a picture and had
everyone who visited Josh and witnessed the restraints sign an affidavit.
She now miraculously claims
that records have been found that they missed giving her at first and yes, he
was restrained a couple of times.
She claims that this was to
stop him from pulling out any tubes etc.
How in the world can anyone
who is so sedated and physically paralyzed pull anything out?
This is a ridiculous
statement by her.
She knows she violated the
restraints act and has lied and tried to cover this up.
During his intubation
they had trouble getting his breathing stable.
The nurse even asked me if he
had asthma.
This is also a sign of a
blood clot but still no one questioned this.
He was intubated,
physically and chemically restrained from June 7 at 12:30 am until June 11 at
8:00 am.
4 ½ days lying perfectly
still.
On June 11 at about
8:00 am they extubated him and woke him.
At 10:00 he had to go to the
bathroom and they sat him in a commode next to the bed.
He promptly started turning
blue and did a face plant on the bed.
A code blue was called just
as I was arriving in the ICU.
They got him stabilized and I
was told this was probably due to dizziness from laying in the bed for more than
4 days.
According to the
coroner, this was likely a sign of the blood clot.
However again neither of the
doctors involved in the code blue could figure this out.
Who is practicing at this
hospital?
A layman, like me, would
attribute this to dizziness, but a trained doctor should have more sense than
this.
I stayed with him
most of the day and ordered TV for him since he was an LA Kings fan and the
final game was on that night.
Thank goodness he at least
got to see his team win the cup. This was the only good thing that happened to
him.
During the day he had an
oxygen mask on and he kept pulling it away from his face and sucking in.
The nurse assumed he was
trying to remove it and put the restraints back on for a while.
I believe he was doing this
because again he was having trouble breathing and he was trying to suck in more
air.
I had a good talk with him
and told him all about the last 5 days and what had happened.
He had no recollection of
anything from June 6 until June 11.
Many family members visited
with him that day and he seemed to be doing well.
We all thought we were now on
the road to recovery.
Josh was sincerely sorry for
what he tried to do and was looking forward to receiving the counseling he
needed.
I left the hospital after the
game and told him I would see him around noon the next day.
That same day, June
11, the doctor started prescribing Haldol again but I was not aware of this
until after he died.
At about 3:30 am on June 12,
he started hallucinating and pulled out his catheter.
He was getting very paranoid
now.
I called the hospital
at 9:00 am and was told about the incident in the night, but not to worry as he
could void on his own.
They did not tell me about
the paranoia.
When I arrived at
noon the first thing he said to me was “Mom, you have to get me out of this
hospital.
I will go to another one.”
I said “Why?”
He said, “They don’t want me
here.
I heard them say “He doesn’t
belong here”.
I said, “Oh Josh, they would
never say that.”
He was acting very paranoid
and started to tell me the details of his hallucination in the early hours.
I did not believe my son at
the time but now I realize they wanted the bed in ICU and were trying to decide
which patient they would move to free up the bed.
I was concerned about
the paranoia, which I am now convinced was caused by the Haldol.
At the time, however, I
thought it was from being without any meds for so long and it had to do with his
bipolar condition somehow.
I went to the nurse and the
doctor was there with her and I asked that a psychiatrist be brought in to
assess him.
They called the
psychiatrist who was on call and he came to see us.
I found out later after
reading his report that he was clearly concerned about the paranoia and assumed
Josh was still on a Form 1 at the time and said he would continue this.
A Form 1 means that a nurse
must be with Josh 24 hours to watch him closely.
Apparently the other
psychiatrist had discontinued the Form 1 earlier in the week and the doctor did
not consult with the new psychiatrist about this.
Thus my son had no nurse
assigned to him.
Josh and I continued
to watch some TV and at about 3:00 pm a cleaning lady came in and started
cleaning the room.
She said you are moving to
the medical floor.
I was surprised since this
was the first I heard of this.
Apparently
they definitely were in a hurry to get the bed since they had the room cleaned
before we left.
How sanitary is this?
especially since they had no idea if my son had c-diff or any other contagious
disease. I asked the nurse if we were moving and she said yes.
I was still concerned since
Josh had diarrhea, stomach cramps, still a fever and high heart rate (130) and
was very paranoid.
She said they would put a
portable heart monitor on him and keep the antibiotics IV with him.
She plunked him in a
wheelchair.
I noticed his feet were not
on the foot rests and helped him to put them up.
His legs were very stiff and
he could not lift his feet by himself.
Apparently I am the only one
who noticed this.
Again I found out later that
this is another symptom of DVT (blood clot).
Nobody bothered to ask or
check him.
At this time they still did
not know exactly what was causing the high heart rate or fever.
They were so sure it was some
kind of infection although they had no idea what it was.
The doctor was so sure it was
aspirated pneumonia but all x-rays earlier in the week showed his lungs were
clear.
Why did she not even check
for something else.
I thought when you ruled out
one thing you would check for something else as the cause of the symptoms.
We arrived at the
medical ward about 3:30 pm.
The nurse came and helped him
to the bathroom and said she was going to get him into bed.
May I say that they put him
in a semi-private room at the end of the hall.
This room was probably the
farthest away from the nurse’s station that you can get.
Never mind his physical
symptoms what about the paranoia.
They didn’t seem to be
concerned about what might happen because of this.
I left to go and
arrange a phone and TV transfer.
When I came back ten minutes
later, 3:40 pm, Josh was jumping around in the bed.
I asked what was wrong and he
said “I think I’m having an anxiety attack.
I think I am going to die.”
He could not breathe.
I pushed the call button.
At this time I noticed feces
on him and got some paper towels and water and washed him.
I tried to calm him down.
After about 5 minutes I
pushed the button again as no one had answered the call the first time.
After another couple of
minutes I went into the hall to see the nurse coming.
She said they had contacted
her from ICU because he had dislodged one of the leads from the heart monitor
and his heart rate was climbing (160).
I believe this is the only
reason she came and not because I pushed the button.
She was very snarky and
seemed annoyed with Josh.
We both tried to settle him
down and after a few minutes he started turning blue.
At this point she left the
room.
I ran after her and said,
”Where are you going, my son’s turning blue.”
She replied, “I know I am
going to get oxygen.”
She came back a few minutes
later and called another nurse to assist her.
She put the mask on him.
I was with him holding his
hand and the last thing he said to me was, “Mom, don’t let me go.”
After this I watched his eyes
roll back and I heard him defecate.
It was not until then, that
the nurse pushed the code blue and everyone came running.
I was pushed aside and taken
to a quiet room.
They worked on him for almost
an hour but to no avail.
I know in my heart he was
gone before she even pushed the code.
Protocol states that they are
supposed to push the code as soon as a patient starts to change color but she
wasted at least another 5- 10 minutes before pushing the code.
I believe if I had
not been present I would never have known the truth about what happened with
Josh.
I am sure they would have
told me they did everything they could and I probably would have believed them.
Only after I got his records,
did I realize the extent of the harm done to him.
They were truly
incompetent with my son’s care.
If they had kept in contact
with Poison Control and did what they told them to, I am certain my son would
still be here with us today.
They caused him to end up in
ICU by not treating his rising levels and prescribing him Haldol.
This is why I cannot accept
what happened.
They killed him and he
deserves justice.
I pray that we will be
granted an inquest.
By medically clearing
him too soon, prescribing Haldol when they were warned not to by Poison Control
and miss diagnosing the DVT they clearly killed him.
Two of these doctors
are supposed to specialize in internal medicine.
Why was the DVT not even
considered?
These doctors should be
criminally charged with negligence causing bodily harm and death. They have no
idea what this has done to the surviving family and friends.
When they took my son’s life,
they took mine as well.
Life will never be the same.
Sincerely,
Mary-lou Patey
Mother and next of kin
Update on my story:
I have received the coroner's report. Not surprising
he is trying to protect the doctors and hospital. However I have complained
to the College and Physicians about him as well. He claims my son died from
complications brought on by the meds he took. He makes it sound like he died
by suicide. Not true, the meds were all gone by the time he died.
No where in his report does he mention the fact that Josh was physically and chemically
restrained for over four days. This is one of the major causes of blood clots
and I suspect it is the reason he developed this. He also has a statement
as to what happened on June 11 but he has the facts and the date all wrong.
I don't think he even read the hospital records. How could he die from the
overdose when they had him for over 7 days. How many other times has he covered
up for doctors?
New update:
Since I complained to the chief coroner of Ontario and the
College on the regional coroner he has amended the autopsy on two points I made.
We still have one to go. I guess complaining does help. I know he never would
have changed it if I didn't.
My story was in the KW Record
on Saturday Sept 8/12.
To see click here.
In the story the head Dr Lawry said they give blood thinners, surgical stockings
and therapy to help prevent blood clots, however Josh only received blood thinners.
No surgical stockings or therapy was done. Why?
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