Duty of the Ontario Minister of Heath

July 21, 2018
In Ontario, Canada.covering up medical negligence is the number one rule for our Politicians, the CPSO, the Chief Coroner's Office, the Death Investigative Council, the Health Professions Appeal and Review Board, the Ontario Patient Ombudsmen, the Ontario Ombudsman, the Hospitals, the Minister and Ministry of Health. Quite a list, and except for the CPSO, our tax dollars pay for the rest.😥
The past Ontario Liberal Government did nothing. THE PRESENT CONSERVATIVE ONE DOES THE SAME! They will do nothing in Health Care that would piss off the CPSO and CMPA. There will always be adverse events, but the number could be greatly reduced if those in authority would act. I would imagine that all provinces are infected by the same corrupt, immoral institutions that are taxpayer funded to promote and protect patient safety but in actuality do the opposite.

So, apparently the Chief Coroner's Office goes completely unchecked and can continue to cover up medical negligence contributing to deaths.
We now have no one to oversee not only this office but also the CPSO, HPARB, the DIOC and Hospitals. So Sad.

I do not believe the response. They have political authority to investigate the initial coroner's investigation if they can not order a re-investigation.

From: MCSCS Feedback
Sent: January 16, 2019 2:33 PM
To: awkilby@hotmail.com
Subject: Letter from the Honourable Sylvia Jones, Minister of Community Safety and Correctional Services

Please see attached response from the Honourable Sylvia Jones, Minister of Community Safety and Correctional Services. The text of the response also appears below.


By e-mail

January 15, 2019

Mr. Arnold Kilby


Dear Mr. Kilby:

Thank you for your e-mail of December 10th regarding the death of your daughter. Please accept my condolences on your loss.

As the Minister of Community Safety and Correctional Services, I have no legal authority to direct the Chief Coroner to reopen an investigation. I also cannot provide direction or advice on how an investigation should be conducted.

Death investigations and decisions regarding the investigations come under the purview of the Office of the Chief Coroner. As such, I have shared your message with Dr. Dirk Huyer, Chief Coroner for Ontario.

Best wishes,

Sylvia Jones


c: Dr. Dirk Huyer

Chief Coroner for Ontario

News: This is not Terra's case but another case whereby a patient died. It appears Dr. Laz Klein has been given cautions before according to the following take from an HPARB Review held on July 12, 2017 at Toronto, Ontario

It is the further decision of the Health Professions Appeal and Review Board to return the matter to the Inquiries, Complaints and Reports Committee of the College of Physicians and Surgeons of Ontario and to require it to reconsider its decision to issue advice to the Respondent regarding following up on abnormal laboratory test results and appropriate dosing and monitoring of narcotics administered to a critically ill unmonitored patient.

By Committee, HPARB is referring to the College.
The Committee also concluded that the Respondent’s oversight of the Resident’s care of the patient was inadequate. Those concerns gave rise to the advice issued to the Respondent by the Committee.

At the Review, the Applicant re-iterated these issues and submitted that the Committee’s failure to deal with all of her concerns renders the decision unreasonable. The Applicant also submitted that the Committee’s decision to issue advice to the Respondent was, given the significant and numerous care deficiencies involved in this matter, not strong enough and for that reason, unreasonable.

The Committee identified the need to provide advice to the Respondent concerning documentation deficiencies. Neither party suggested that the Committee’s decision to provide this advice was not reasonable. The Board finds that this aspect of the Committee’s decision is reasonable and is supported by the information in the Record, particularly the additional information provided to the Committee by the Respondent in which he details the nature of his interactions with residents, and his insight into and the proposed changes to his practice as they relate to this issue. As the Committee specifically noted, it is this insight and the Respondent’s stated intention to make changes to his practice which allowed the Committee to conclude that it was appropriate, despite the Respondent’s conduct history with the College, to issue advice on this issue

However, the Board finds that the Committee’s conclusion that it “saw no reason to conclude that [the Respondent’s] care was inappropriate” is inconsistent with its own previously identified concerns about patient care. Specifically, in considering the care provided to the patient the Committee identified two specific issues of concern.

The Committee noted the absence of information in the medical record that appropriate action was taken in response to this information. The Board notes that the patient’s white blood cell count (“not an insignificant finding” according to the Committee) was not followed up on. The Board also notes that the medical record indicates that several issues, including the white blood cell count, were communicated to the Respondent during the day of December 4, 2014 and follow-up appears to have been requested but it is unclear if it occurred. The Committee’s view that the general surgery team “should have followed up on [the patient’s] abnormal test results, particularly those that raised the suspicion of sepsis” is supported by the information in the Record.

The Committee decided to issue advice to the Respondent on these care related issues. The Board finds that this disposition is not supported by the Record and is unreasonable.

As noted above, the Committee specifically considered the Respondent’s conduct history with the College. The Committee indicated that the Respondent’s “history with the College, which includes several complaints on a number of aspects of [the Respondent’s] care, raised some concern for the Committee”. The Board has reviewed the Respondent’s history with the College and finds that the Committee’s concern is reasonable.

The Board notes that in respect of the care related issues identified by the Committee, (and in contrast to the issues related to the Respondent’s record keeping previously described) the Committee does not note, and there is no information in the Record to indicate, that the Respondent had demonstrated the insight that might alleviate the concerns of the Committee arising from the Respondent’s conduct history with the College.

The Board notes that the Respondent’s conduct history with the College includes prior complaints involving the care of patients, including medication issues, that have previously been identified as concerns by the panels of Committee assigned to assess them and have resulted in advice being provided to the Respondent. The repetition of similar concerns highlighted in this case would appear to indicate that previous remediation attempts by the Committee have failed to yield the desired result. There is nothing within the Committee’s decision to indicate how the issuance of another advice in this matter will protect the public interest in light of the Respondent’s conduct history.

Given, in this matter, the differences described above between the information in the Record touching upon those issues related to the documentation of patient care and those related to the actual care provided, the Board concludes that the Committee’s disposition, as it relates to the two care issues it identified, is unreasonable. The Board finds that with respect to the two concerns identified by the Committee which relate to the care provided to the patient, the issuance of advice does not fall within the range of outcomes that can reasonably be supported by the information before the Committee and cannot withstand a somewhat probing examination. The Board finds that this particular aspect of the Committee’s decision is not defensible in respect of the facts and the law.

The Board concludes that this matter be returned to the Committee requiring it to reconsider its decision to issue advice to the Respondent regarding following up on abnormal laboratory test results...

It is the further decision of the Board to return the matter to the Committee and to require it to reconsider its decision to issue advice to the Respondent regarding following up on abnormal laboratory test results

and the following take from a CPSO decision Active Date: March 16, 2018
Note: This matter has been appealed to the Health Professions Appeal and Review Board.

On March 16, 2018, the Inquiries, Complaints and Reports Committee (the Committee) ordered general surgeon Dr. Klein to complete a specified continuing education and remediation program (SCERP). The SCERP requires Dr. Klein to:

 Practice under the guidance of a Clinical Supervisor acceptable to the College for six months

 Undergo a reassessment of his practice by an assessor selected by the College approximately six months following completion of the SCERP

 Review relevant Clinical Practice Guidelines, including literature for guidelines on early identification and management of sepsis, as well as College policies on Medical Records and Test Results Management, and provide a written summary of the documents with reference to current standards of practice, how it is applicable to Dr. Klein’s situation, as well as how Dr. Klein has made, or plans to make, changes to his practice.

The Committee was of the view that the urinalysis results, along with the patient’s history of self-catheterization and prior urinary tract infections (UTIs), the significant increase in her white blood cell (WBC) count (from a normal level of 9,000 at admission to 22,000 by 9:00 am on December 4), and her falling oxygen saturation should have alerted Dr. Klein and hospital staff to the strong possibility of sepsis.
The Committee noted that in his response to this complaint, Dr. Klein indicated that he did not consider the possibility of a sepsis diagnosis. Furthermore, although he claimed to have first seen the patient at approximately 9:00 am on December 4, he failed to document the increased WBC, both at this time and at his subsequent 6:00 pm reassessment.

The Committee was concerned about the significant failure to treat a highly likely UTI with appropriate antibiotics within 12-24 hours of admission, which should have occurred with or without the associated diagnosis of a small bowel obstruction. Furthermore, even if the patient’s abdominal examination did not suggest a strangulated small bowel obstruction or other acute intra-abdominal condition, the Committee noted that there was no indication that Dr. Klein considered the reason for the patient’s seriously elevated WBC count, which he continued to claim was non-specific.

Given Dr. Klein’s failure to offer any explanation for this concerning information in his various responses to this complaint, the Committee felt he demonstrated a lack of insight regarding his failure to properly manage the patient’s care. The Committee noted that a prudent physician should have recognized the above mentioned results as highly indicative of an inflammatory response, such as septic shock, and initiated appropriate antibiotics.

With respect to medical record-keeping, the Committee was concerned that Dr. Klein did not write any notes at any time during the patient’s admission, which does not meet the standard of care and does not comply with the College’s policy on Medical Records. Furthermore, this lack of documentation made it difficult for the Committee to assess the true extent and quality of care that Dr. Klein provided to the patient. The Committee noted that the involvement of residents or students does not absolve physicians from their own documentation responsibilities.

The Committee noted that Dr. Klein has a significant history with the College, which include cases raising both clinical and record-keeping issues, for which he has received advice and been cautioned. The Committee agreed with the Board that the repetition of similar concerns in this case appears to indicate that the previous remediation attempts have not been successful. This, along with the Committee’s concern about Dr. Klein’s persistent lack of insight into his shortcomings in this case, suggested that a more significant disposition was required to adequately protect the public, as outlined above.

The Board notes that the Respondent’s conduct history with the College includes prior complaints involving the care of patients, including medication issues, that have previously been identified as concerns by the panels of Committee assigned to assess them and have resulted in advice being provided to the Respondent. The repetition of similar concerns highlighted in this case would appear to indicate that previous remediation attempts by the Committee have failed to yield the desired result. There is nothing within the Committee’s decision to indicate how the issuance of another advice in this matter will protect the public interest in light of the Respondent’s conduct history.

It has been THREE months since I contacted the Minister and not one single response to date. Aug 30/18

Subject: Minister of Health

I am formally requesting a meeting with you ASAP. Please speak with MPP Steve Clark with regard to my concerns.

*** NOTE: B. Bybrick was the head of the CPSO at the time involved in the third decision, which clearly indicates the top priority of bringing my complaint to a final conclusion regardless of the medical facts and contradictory statements by the College and I suspect HPARB colluded with the CPSO as proven by HPARB's third decision and denial of my two requests to review it's decisions.

The Ontario Health Minister MUST investigate or risk losing all credibility as an elected member of the Legislature, as a member of the Conservative Cabinet and as Ontario's Minister of Health!

Over the past numerous years, I have asked the Minister of Health to address my concerns with regard to the CPSO and HPARB

Mr Hoskin's response was basically to say he had no authority to intervene or question the process and decisions by both the CPSO and HPARB.


This was and is a lie as you will see. but I will shorten it

The following excerpt comes from Mr Hoskins' letter to the College Presidents and Registrars/Executive Directors as seen below:

What a lovely motherhood statement with no authoritative action taken!

"My hope is that we can work collaboratively to implement these steps as we work together to maintain the public’s trust in our health care system. However, as Ontario's Minister of Health and Long-Term Care, my ultimate responsibility is to the people of Ontario. I reserve the right to take any and all necessary measures to ensure that the public interest remains paramount, including exercising the powers reserved to me under subsection 5(1) of the RHA including the ability to require Councils to do anything that, in my opinion, is necessary or advisable to carry out the intent of the RHPA and the health profession Acts."


You, as our new Conservative Health Minister, do have the authority to investigate holding both the CPSO and HPARB accountable for an inept, dishonest investigation into my complaints and enacting appropriate legislation in the Legislature to ensure this never happens again. You should also involve the Minister of Correction to do the same with regard to the Chief Coroner's Office and the DIOC, as both institutions are complicit in the cover up of medical negligence and covering up their own role in such.

According to Regulated Health Professions Act you do have the authority to look into the CPSO either personally or through the Advisory Council. You may erroneously consider this as possible interference but it is your responsibility to do so, and you are mandated to do so!

--matters concerning the quality assurance programs undertaken by Colleges;

-- each College’s patient relations program and its effectiveness;

-- require the Council to do anything that, in the opinion of the Minister, is necessary or advisable to carry out the intent of this Act, the health profession Act

AND question

--whether regulated professions should no longer be regulated;

Duty of Minister

3. It is the duty of the Minister to ensure that the health professions are regulated and coordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board. 1991, c. 18, s. 3.

Powers of Minister --“Council” means the Council of a College;

5. (1) The Minister may:

(a) inquire into or require a Council to inquire into the state of practice of a health profession in a locality or institution

(b) review a Council’s activities and require the Council to provide reports and information;

(c) require a Council to make, amend or revoke a regulation under a health profession Act, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act;

(d) require a Council to do anything that, in the opinion of the Minister, is necessary or advisable to carry out the intent of this Act, the health profession Acts, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act. 1991, c. 18, s. 5 (1); 2009, c. 26, s. 24 (1)

A great injustice has taken place. This case exemplifies the very reason why Bill 29 should have been passed but was not, and the importance of the Minister of Health acting on my concerns. Just imagine if this happened to me, what other citizens have gone through??

--They are not placing patients and patient safety first therefor they are completely ineffective when it comes to investigating complaints

My daughter went through a colon resection and a tumor removed without the mandatory antibiotic prophylaxis, she also did not receive any antibiotics for the abdominal infection of the incision whereby all staples were removed. As well, she did not receive any antibiotics for the presence of "many gram negative bacilli". NO ANTIBIOTICS WHATSOEVER DURING HER TIME IN THE HOSPITAL. SHE BLED TO DEATH 12 HOURS AFTER DISCHARGE.



Medical Opinion



A. Dear Mr Kilby: I have read the sad account of your daughter's illness and the medical society's review and find the review flawed and inadequate. I cannot be an expert witness since I am no longer a practicing surgeon. However, I formerly served on our San Francisco Medical Society's Review Panel. Your daughter's surgeon was wrong and failed to observe your daughter's presenting laboratory and physical findings of intra-abdominal sepsis and wound infection. The surgeon's "slap on the wrist" and review submitted by the Society must have been upsetting to him as a caring surgeon. This may be the only consolation you can ever see for your daughter's death. Hopefully he will have learned from this experience and it will help him provide better care for future patients.

James P. Geiger, MD, FACS COL. MC US ARMY, Retired


B. Mr. Kilby,  Again, I am sorry about the delay in my response and, more importantly, very sorry about your daughter's death and the difficulty that you are having in trying to get the system to recognize the errors that seem to have been made in her tragic death. To preface my comments, as you know, I am a pediatric surgeon and do not operate on adults. That being said, I did complete an adult general surgery residency prior to my peds surgery fellowship and am Boarded in adult general surgery in addition to pediatric surgery by the American Board of Surgery. 

As I review the file that you attached, there are several concerns that come to mind. You indicated that she did not receive appropriate bowel preparation prior to surgery. Even though there is some controversy re: bowel preps and performing surgery on the right colon, I think most surgeons would proceed with a mechanical bowel prep prior to an operation where possible right hemicolectomy was possible. However, there is very good evidence that mandates that patients receive broad spectrum IV antibiotics prior to having colon surgery, especially if they haven't received a bowel prep. If this wasn't done this is not in line with the standard of care in the US. 

Also, I have concerns that the nurses documented for Terra's abdominal exam that her abdomen was "large" for the last several days of her stay in the hospital. More importantly, they document for a number of days prior to her discharge that there was a foul smelling odor and that the wound was "oozing copious amount of purulent discharge" during this entire time as well is very concerning. This doesn't happen with a superficial wound infection. These things happen when there is an anastomotic breakdown and leakage through the wound and possibly into the peritoneal cavity. If I recall, you indicated that a physician didn't even see Terra or examine her for the last couple of days while she was in the hospital? I would be very curious to read their last few notes in the chart and if they didn't document anything b/c they didn't see her, that is inexcusable. 

In regards to colon anastomoses breaking down and causing an acute hemorrhagic event to where someone would bleed out within 12 hours, I have a hard time believing that and have never heard of this happening before, especially over a week out from surgery. She clearly should have been tolerating a diet fairly well before she was released. Again, all of my comments have to be considered in light of the fact that I don't practice on adults and may not be absolutely up to date on everything re: colon surgery in adults.

However, I doubt that any of my above concerns are too far off base, if at all. Ideally, you would be able to find a surgeon that practices on adults, is credentialed by the ABS if in the US or one in Canada that co- corroborate my concerns. I hope my comments help and wish you the best in your efforts to correct the system that appears to be failing you and your family.

All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015 


Mr. Kilby, I have reviewed the document and stand by the comments and concerns that I have sent to you through various emails. In addition to those, my only other comments are:

1. It is very concerning that the nurses repeatedly documented in the chart that her abdomen was large and there was foul odor coming from the wound. Since there was no documentation from the surgeon re: an exam on multiple days, then one can only infer that no surgeon examined her on those days. 

2. Gram-negative bacteria on the cultures from a wound with foul drainage suggest an intestinal injury or anastomotic leak. 

3. Preoperative antibiotic prophylaxis is the standard of care in the US and, I would imagine, the same in Canada. 

4. I can't believe that any physician or surgeon would release a patient from the hospital without seeing the patient or, at least, speaking with the nurses caring for the patient by phone. 

Hope these comments, as well as those that I have made in the past, help your cause. All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015

While complications can happen with any operation, I think the key thing with your daughter's care is that it appears to me that there was evidence that there was a problem before she left the hospital that was not picked up by the doctors, either because they ignored the evidence or didn't see / examine her. How long was she at home after her discharge from the hospital before she returned to hospital

/ ED D. Lanning MD

“It is also concerning that she had not passed stool and was quite distended.” D. Lanning


C. I have reviewed the data you supplied and the data from the colorectal surgeon (acting as an independent peer review). I am at a loss to understand the opinion he offered given the abdominal incision was leaking foul discharge which would mandate re-exploration, or at the very least, a CT scan of the abdomen which would likely have shown significant intra-abdominal fluid, suspicious for anastamotic issues. I have four children and my only prayer is to be in the ground before any of them……Short of not agreeing with the expert opinion offered by the independent physician I don’t know how I can help. Your daughter’s loss was tragic and it would appear to me preventable.

Good luck with your appeal if that is the direction you chose….Moe Lyons MD FACS

I am very sorry for your loss. I am sure the wounds are still very painful 4 years later. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). 

The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. Having said all of that it the lawyers for the doctors are correct; medicine is an art (sometimes performed very poorly) not a science. See the SCIP initiatives available online (Google SCIP initiatives) to better understand when, and what type of antibiotics are recommended prior to colon surgery. Good luck with your inquiry and again I'm sorry for your loss......................

Moe Lyons,

Maurice Lyons, 


D. Dear Mr. Kilby, I just read through the attachment, and I recall reading your prior email.

My personal opinion is that your daughter died of septic shock related to dehiscence of her bowel anastomosis complicated by acute hemorrhage.

Apparent lapses in care are:

1) Lack of peri-operative antibiotics (I am not a general surgeon and do not know if this fails to meet standard care for right colon surgery).

2) Discharging your daughter with ongoing diarrhea of unexplained etiology,

3) Prolonged period of inadequate nutrition,

4) Nursing records that appear to be at odds with the physician record of the abdominal exam,

5) Failure to distinguish the intra-abdominal catastrophe from the wound infection.

It is self-evident that she was discharged prematurely or she would not have died outside the hospital of a devastating post-operative complication.

The big questions are: would a reasonable general surgeon have acted differently, and did her surgeon practice according to the standard of care – I seriously doubt that he did and I think a good surgeon would have done a more thorough investigation prior to discharge.

Things to consider:

1. The low hematocrit prior to discharge is not evidence of malpractice as this is common with acute illness such as what your daughter exhibited.

2. It would be interesting to see if there was a platelet count prior to discharge.

3. The temperature curves and the reported abdominal fullness are concerns that seem discounted by the College assessment.

As I told you previously, I am a father of an almost 3 year old girl and I now have a 6 month old son and a 4 year old son. I cannot imagine losing any of them particularly in such circumstances. Only you can decide if your quest for justice is worth further fight. I do not understand the Canadian system, so I cannot judge. Your case would be helped if you could find a Colorectal surgeon to review it. Unfortunately, most surgeons would not take interest and I do not personally know anyone who can help you. I do wish you the best and I hope that at some phase you can find peace.

Max Mitchell MD FACS


E. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. “It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.” I'm sorry to hear about the death of your daughter. A parent should never lose a child.

Allan Stewart MD


F. Dear Mr. Kirby: From what I remember and my review of the information you sent me my opinion is that your daughter received suboptimal care approaching malpractice-at least by US standards. I would have to assume that Canadian standards are equivalent to US standards but from the response I read perhaps they are not.

Best wishes, Steven J. Phillips, MD FACS




I. Hello Mr. Kilby, It is very difficult to comment sufficiently on your question. There are just so many issues that I may not be aware of and questions that would need to be answered to give you an adequate answer to your question. I can say that for many years I have encouraged patients to build themselves up prior to surgery and to begin using amino acids as soon as possible after surgery. And I have given amino acids to patients so they can begin using them as soon as possible since I do not agree with the often followed practice of near fasting for patients after surgery - the body needs the amino acids to begin the healing process.

I am really sorry to hear of your daughter's case and I am so sorry for your loss. I do hope that someday physicians will be more proactive about improving their patient's nutritional status before and after surgery. I am not optimistic given the general disregard for nutrition that exists anyway.

God bless you, Roger Roger Trubey Dr PH, MPH, ND

You are welcome, Arnold. All I can say is that here in the States you would have a solid case for litigation. I don't encourage frivolous lawsuits or ambulance chasing but some cases can be so egregious that the only way hospitals and physicians will learn is to pay for their mistakes with the hope that the pain is such that it will save others from your daughter's fate.

God bless you, Roger


J. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered.

Matthew M. Cooper, MD FACs

Mr. Kilby: I looked over the materials you sent. I am once again sincerely sorry for your loss and trust that your daughter will live on in your hearts and thoughts. There are several items here that in combination raise concern. Individually, they may have been overlooked as insignificant. Further, hindsight may allow piecing together a potential pattern that may not have been detected as they occurred. 

Were peri-operative prophylactic antibiotics administered? There is a suggestion that they may not have been.

1. It is standard of care to do so for a limited time around the time of operation. 

2. I am concerned about the description of the abdominal examination progressing from "rounded" to "large" in the context of no clear normalization of bowel function. Is that to be interpreted as a distended abdomen? Were there normal bowel sounds? Was flatus present indicative of returning function? Or was there a postoperative ileus? If function was not returning normally in the presence of a progressively distending abdomen, that should raise concerns that might require imaging of the abdomen but certainly resolution prior to discharge. 

3. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered. 

4. Such a bleeding complication after such surgery is certainly a possibility but should be exceedingly rare. If, as you suggest, your daughter's complications were part of a series of such problems then, indeed, a system or operator issue is suggested which satisfies the stated requirement for a complete investigation. 

If I were in your place, I would do the following: 

1. Contact the American Board of Surgery to see if they have an Expert Review Panel to which you could send this case for review. 

2. Canada must have a physician licensing board to whom the above questions could be raised - particular to your daughter's care as well as the potential system issues. 

3. If you have not already, you may address these questions to your daughter's surgeon. Keep a paper trail of the questions, and the response. 

Matthew M. Cooper, MD FACs 


K. “The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge.”

Paul Kirshbom, MD Emory University School of Medicine


L. “If there is a documented infection it is mandatory to treat it with antibiotics” Wendel Smith, M.D


M. “Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case”

Ron Hill, MD, FACS


N. What troubles me from the material you sent is the expert's/ coroner's opinions as to the cause of death. Patients do not die from bleeding at the staple line of an intestinal anastomosis. When such bleeding occurs, it is manifested by significant BLEEDING PER RECTUM, which to my knowledge your daughter did NOT demonstrate. If she died of "intraperitoneal bleeding", that could have come from either a disrupted anastomosis or from larger blood vessels ligated during the resection of the mesenteric cyst and her right colon.

If indeed her abdomen was distending, and her pulse rate rising over an observable period of time, then the really important issue was why was she not rushed back into the operating room when it was clear that an intra-abdominal catastrophe was occurring? I would agree that CAT scans are not necessary to establish an emergency situation, so what was the time delay between what her condition was upon discharge until she was brought back to the hospital? I think it more likely you would get more useful information from the dictated operative report from her original surgery, from personal review of her medical records to see what her condition was when leading up to her discharge, and from the coroner's report of the autopsy findings. 

Anastomotic disruption following a RIGHT colon resection is quite rare actually, and the range stated in the expert's report probably reflects the overall leakage rate from ALL colon anastomoses. Such leakage/disruption is much more common in lower (or "distal") anastomoses, closer to the rectum. If her anastomosis did "disrupt", as alluded to, then it is usually a TECHNICAL ERROR on the part of the operating surgeon, especially because of the young age and apparently excellent former health of the patient. If there is sufficient proof of the above, then an investigation of the surgeon's performance both in this case and others might lead to "systemic" issues which deserve correction. 

The main thrust of such investigations should be prevention of similar outcomes, with a willingness to confront all the causative factors, including surgeons' performances. I hope the above clarifies your thinking, from an insider's perspective. Please let me know your thoughts.

yours sincerely, Mark Helbraun, MD, FASCRS 

Hello again Mr. Kilby: Now you are getting to the important issues in this case! If indeed she died 12 hours after discharge, then the emphasis in your investigation should focus on what was happening to your daughter in the 24 hours prior to discharge from the hospital.It is inconceivable to me that the autopsy report would not contain more detail than what you have given me regarding the status of her ileal-to-colonic anastomosis, since that would be the area that would demonstrate what (if any) disruption of the bowel occurred. 

Since there was "no rectal bleeding" prior to discharge, what bleeding she was having would have been intra-abdominal, and if those counts were falling in the hours prior to discharge, that also should have sent up red flags of warning to anyone who was paying attention. The time plot becomes critical to reconstructing events in a fair and honest way. Again, look carefully at the autopsy results, the operative note, and the version of events leading up to discharge that you have been given. I suspect you would agree that there is a more fitting memorial to your daughter than a garden, and that memorial would be a living, breathing accountability system which would ensure that events like what occurred to Terra would never happen again. These are sometimes called "never events" in our system here, and they are investigated to the maximum. Keep me posted.....

Mark Helbraun MD, FASCRS Mark Helbraun, MD, FASCRS Member of the 2010-2011 International Council of Coloproctology 35 years experience Academic Colon & Rectal Spec Hackensack, NJ Hackensack University Medical Holy Name Hospital Holy Name Hospital, Teaneck, NJ Hackensack University Medical Center, Hackensack 


O. Dear Mr. Kilby, Based only on the information you have provided I find it difficult to justify what appears to be a "whitewash" of the patient's cause of death. The points you have raised are--in my opinion--legitimate reasons to question the validity of classifying her death as "natural" and would support your complaint of inadequate investigation. She unmistakably died of surgical complications that were arguably survivable with less flawed management. Under ordinary circumstances I would be willing to consider testifying on your behalf after undertaking an appropriate first-hand examination of the records. Please accept my regrets and best wishes. 

Benson B.Roe, MD,FACS, Professor Emeritus. Department of Surgery, University of California at San Francisco Medical Center


The following was sent first to HPARB requesting a reconsideration of the Third HPARB decision in which they denied my request. I then contacted the Ombudsman’s Office asking them to get involved. This was pointless waste of my time as well. The Current Health Minister duty must delve into the CPSO and HPARB, as it is quite evident that both have abused their position to cover up negligence by a surgeon resulting in the death of my daughter and have thus failed all citizens in Ontario.

Ms Boucher,

RE: my complaint submitted to the Ombudsman's Office with regard to HPARB:

"was not carried out in accordance with the principals of natural justice and lacked procedural fairness."


The Applicant: Arnold Kilby

Support for the Applicant: Murray Kilby

Support for the Applicant: Hilda LeBlanc

Support for the Applicant: Maie Liiv

For the Respondent: Katherine Booth, Counsel

For the College of Physicians and Surgeons of Ontario: Angela Bates (by teleconference) for the the consecutive time

The selection below also indicates how the procedure during my third appeal was not fair as I was cut short and not allowed the opportunity to complete my oral presentation, so I could comment on the matters related to (a) and (b) below:

And since this was third time I have appealed the College's decision, the Board should have 2(b) required the College to send a representative instead of allowing them for the third time to take part via telephone conference call-- it is a fifteen minute walk from the CPSO to HPARB

Regulated Health Professions Act, 1991

S.O. 1991, CHAPTER 18

Consolidation Period: From December 3, 2015 to the e-Laws currency date.

Last amendment: 2015, c. 30, s. 28.

Conduct of review

33. (1) In a review, the Board shall consider either or both of,

(a) the adequacy of the investigation conducted; or

(b) the reasonableness of the decision.


(2) In conducting a review, the Board,

(a) shall give the party requesting the review an opportunity to comment on the matters set out in clauses (1) (a) and (b) and the other party an opportunity to respond to those comments;

(b) may require the College to send a representative;

(c) may question the parties and the representative of the College;

(d) may permit the parties to make representations with respect to issues raised by any questions asked under clause (c); and

(e) shall not allow the parties or the representative of the College to question each other. 1991, c. 18, Sched. 2, s. 33.




#1 Having the Chair for the third appeal, who pretty much control the entire proceedings from London, Ontario (Forest City Lawyers - London) as is the College's Independent Opinion Provider, Dr. Brian Taylor.

No problem perhaps, but it certainly explains how this HPARB panel completely came up with their incredible decision and prevented me from giving my oral presentation. Both are highly notable men in London and I am confident they may have met many times at public, political and social events.
I would have thought the Chair would have excused himself from this panel!

This was extremely unfair and the procedural process was definitely affected negatively.

#2 The contradictory CPSO's opinion with their own expert as well as the factual documentation within Terra's medical records!

This was extremely unfair and the procedural process was definitely affected negatively.

In response to a request for further information from the College, the IO provider also set out the following information:

The standard of practice for open bowel resections is to provide antibiotic prophylaxis.
However, such administration would not reduce the risk of anastomotic leak.

The standard of practice would be to administer prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only and not opening the bowel, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.

AWKILBY’s Response: The above is pure BS. He knew before he converted to a laparotomy!!

Note the following: This proves that Dr. Klein was going to attempt laparoscopically a colon resection for a mesenteric mass. This was before he converted to a laparotomy!!!

Note the Procedure Desc. In the chart I submitted for the third appeal.

Note the Procedure Desc. In the following chart:

“Laparoscopic Colon Resection Attempted For Mesenteric Mass”

The second Procedure Desc. indicates the laparotomy.

And from Dr. Taylors’ (the College’s I.O) letter to Angela Bates May 8th, 2011,

During the surgery on July 11 2006, Dr. Klein realized that the mass was not separable from the colon or retroperitoneum and obtained consultation with a colleague and went ahead with an open right colectomy. This is well documented in the operative note on page 48.”

From Dr Klein’s own notes:

At the time of laparoscopy, a large cyst could be seen in the mesentery of the right colon. It was densely adherent to the bowel as well as densely adherent to the lateral abdominal wall. It felt very solid and not at all in keeping with a simple mesenteric cyst. We therefore made the decision to convert to an open procedure.

The fascia was divided. The peritoneal cavity was entered under direct vision. A 10 mm trocar was inserted. Pneumoperitoneum was obtained. A 5 mm subxiphoid and 5 mm suprapubic port were placed under direct vision. We immediately could see the large mass in the right upper quadrant and the findings were as above. We did not feel that this was at all easily accessible laparoscopically and could not separate the plane from the lateral abdominal wall as well as from the colon. At this point, we made a decision to convert to a laparotomy

Issue before the Committee

HPARB directed the Committee to reconsider this matter in light of the question of whether Dr. Klein met the standard of practice concerning the use of preoperative antibiotics.

Addendum Report from the IO Provider

The IO provider set out the following information in an addendum to the IO report:

The issue of antibiotic administration at the time of conversion to an open procedure is really not relevant to the outcome for this patient.

AWKILBY’s Response: The outcome is not part of the complaint!

Most general and colorectal surgeons administer antibiotics preoperatively prior to laparoscopic or open colorectal surgery, as they have been shown to reduce the incidence of wound infection. Antibiotics, however, have not been shown to decrease the incidence of anastomotic leak.

AWKILBY’s Response: Temporarily forget the anastomotic leak which was not in my complaint.. The above statement indicates the Standard of Care that was not followed by Dr. Klein.

#3 The complaint was about the Standard of Care not my daughter’s death. Interesting to note the College always mentions the tragic outcome. Stick to the Standards of Care not the Death. HPARB got sidetracked away from Standard of Care and somehow interpreted the Standard of Care not resulting in the death. This was not the complaint.

How can HPARB not focus on the actual wording from the Independent Opinion Provider and the College with respect to their statement contained within the Second and Third Decisions?

· "The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case."

Neglected equals Negligence