Duty of the Ontario Minister of Heath

July 21, 20018

It has been two 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.

-----COMPLETE BULLSHIT OF A RESPONSE

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."

HE FAILED ALL ONTARIO CITIZENS BY NOT ACTING!

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.

IS THE COLLEGE MAINTAINING THE APPROPRIATE STANDARDS?

OR, ARE THEY ACTIVELY COVERING UP SURGEON NEGLIGENCE!

Medical Opinion

NOW WITH RESPECT TO ALL THE MEDICAL FACTS LISTED BELOW, LET US LOOK AT THE EXPERT OPINIONS PROVIDED AND BY OTHER QUALIFIED SURGEONS OUTSIDE OF ONTARIO AND CANADA:

WHY SHOULD AN ONTARIO CITIZEN HAVE TO GO OUTSIDE OF ONTARIO AND THE COUNTRY TO GET THE TRUTH AND WHY SHOULD THE FATHER OF THE DECEASED HAVE TO CONDUCT HIS OWN DEATH INVESTIGATION OF HIS DAUGHTER???


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

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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

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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, 

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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

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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

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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

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H. GET A BETTER LAWYER. RRG SWCVTS

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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

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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

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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

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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 

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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

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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

*******************************************************************

H. GET A BETTER LAWYER. RRG SWCVTS

******************************************************************

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

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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 

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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

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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."

Appearances:

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.

Procedure

(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.

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NOW WITH REGARD TO PROCEDURAL FAIRNESS AND PRINCIPALS OF NATURAL JUSTICE:

THE BASIS FOR RECONSIDERATION IS CLEARLY STATED BELOW:

#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


Notice how the College brings into the discussion my daughter's death from these example below: reason to deflect away from the standards of care to the Terra's death

"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."


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


"He agrees with the IO provider that: The issue of antibiotic administration had no bearing on the outcome of this case,”

“The only benefit of pre-operative prophylactic antibiotics is to prevent a postoperative wound infection, Preoperative antibiotics have no preventative or beneficial effect for an anastomotic leak."

"Further to this clarification, the Committee notes that, as supported by the IO, the lack of antibiotics in this case did not influence the unfortunate outcome, given there was no evidence of sepsis at the time of the discharge from the hospital."

THE STANDARD OF CARE IS THE ADMINISTERING OF THE MANDATORY ANTIBIOTIC PROPHYLAXIS NOT THE OUTCOME!

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

#4 It appears this decision was made in record time: less than two months from the meeting in June my receiving the decision by mail on Aug. 1st.

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

It makes one wonder whether HPARB had already decided well before, especially considering the following:

--HPARB appears to substantiate the College's opinion that Dr. Klein did not know that a colon resection was to take place until after he converted to an open abdominal surgery. The HPARB panel totally disregarded the operation record that clearly stated that the first procedure attempted was: "laprascopic surgery for colon resection." This clearly indicates that he knew that a colon resection was to be performed before he opened her up.

--No antibiotics what so ever, even after an abdominal incision infection and the presence of "many gram negative bacilli". Again, found in the hospital records. Also, they ignored the letter from then Eastern Ontario Coroner which stated reasons for death also included "complicated by an infection

--Totally ignored my expert's opinions.

--Again, common sense. Not an emergency situation, this was elective surgery supposedly well planned. --- A surgeon is going to make an 9 inch incision in the abdomen, move around some internal organs, remove a tumor and perform a colon resection.----- without the mandatory antibiotic prophylaxis.

#5 The Third HPARB appeal panel had my submission on their laptops but they could not locate the sections I was referring to during my oral presentation. They became so frustrated, the Chair, Thomas Kelly interrupted me and stated that I need not continue as they had read the submission. BUT, I had my presentation prepared to highlight and point out the inconsistencies with regard to the College’s opinion and the medical facts contained within the hospital records and supporting documents. This was extremely unfair and the procedural process was definitely affected negatively.

# 6 How could HPARB be sidetracked away from the "Standards Of Care" issues and be concentrating whether these issues to led to my daughter's death? HPARB should have been dealing with whether the Standards of Care were held up to, or not!

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

# 7 And Dr. Klein merely laughs off the College decision: And this was in with the package the CPSO sent to HPARB.


From letter sent to the College by Dr. Klein

July 13, 2011

Ms. Angela Bates Manager,

Committee Support Area Investigations and Resolutions

College of Physicians and Surgeons of Ontario 80 College St. Toronto ON M5G2E2

RE: Ms. Terra Dawn Kilbv - Your File #77429

Antibiotics

The independent assessor is correct that Ms. Kilby did not receive preoperative antibiotics. I agree with the independent assessor's opinion in response to your subsequent letter that preoperative antibiotics would not have been a contributing factor to the anastomotic leak. Antibiotics are used to prevent or treat an infection. They have no preventative or beneficial effect for an

anastomotic leak. Furthermore, it is not my practice to prescribe antibiotics for a planned laparoscopic surgery with possibility of conversion to an open procedure As I have explained in my initial response, Ms. Kilby did develop a superficial wound infection postoperatively that was treated appropriately. I do not feel that the wound infection 'was in any way related to the outcome of this case.

L. Klein

******************************************************

AGAIN, WE ARE TALKING ABOUT STANDARD OF CARE NOT THE OUTCOME.

Oh, my God!!!! Dr. Klein has not learned a thing from Terra's death and is obviously going to continue as he did!

This is detrimental to the safety of patients that are under his care!!!!!!

More Medical Experts

The Medical Community: some answer the specific questions, some provide emotional support, some comment on other issues


Apparently, only in Ontario is it not the standard to administer antibiotic prophylaxis for open abdominal surgery to remove a tumor and perform a colon resection. Take a good look at all the surgeons below who have a conflicting assessment to that of the CPSO? Now seriously, as Ontario's Health Minister, should you not question this in order to maintain the standards and protect Ontario citizens? Of course, you should!

“Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?”

1. Yes Kumar (B. Sivakumar MD)


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2. Dear Mr. Kilby,
I am very sorry for your daughter.
Just one question, how did you get my contact?
By the way you are telling things happened it seems to me that bowel cleansing is not mandatory
although antibiotics are!
Call me if you need any help. Best Dr Schraibman MD

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3. In general, bowel prep or bowel cleansing is somewhat controversial and is not absolutely considered standard-of-care and is clearly not related to bleeding. Now not giving antibiotic prophylaxis is a bit different - I think it is standard to receive antibiotics for a planned colon resection, at least in an adult. Still that would relate to a higher infection rate and is not related to bleeding. Bleeding happens during and after surgery. I hope this helped but I really do not know anything about the details. I have a daughter myself and I hope things worked out.

Douglas Iddings MD

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4. Antibiotic prophylaxis is important and can reduce postoperative infection. Bowel cleansing has not been shown to have a positive or negative effect on outcome.

Dale D Burleson, MD

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5.  Mr. Kilby,
First, I am very sorry for your loss.  
To answer your questions in general. Bowel cleansing is a matter of surgeon's preference prior to colon resection. There is evidence to show that the outcomes are not significantly different with or without a bowel preparation for colon surgery.
Antibiotics are recommended for colon surgery 
just prior to the start of the operation but
should be stopped within 24 hours unless
there are clinical indications to
continue
beyond the 24 hour period.

These are the guidelines in the US and the
goal of perioperative antibiotics is to prevent
wound infections from surgery.
Sincerely,    Daniel H. Hunt  MD

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6.  If the situation played out as you said above, then I would have given her
anti-biotic prophylaxis.
I would like to know the diagnosis before the operation
to be able to say if I would have had your daughter have bowel clean sing.
W Mourad  MD

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7.  Dear Sir/Madam
I am sorry to hear about your daughter's outcome. To answer your question, the 
colon bowel prep has been in debate for few years. Some surgeons do not feel it is
necessary while others still use it.
The antibiotic prophylaxis is
used to prevent infection during and after
surgery.
As I am aware, both practices may not increase or decrease the
incidence of postoperative bleeding
I hope this will answer your question and help you deal with the event. Please feel
free to ask more questions. I hope that your daughter is recovering well.
Sincerely;   Niazy M. Selim, MD, PhD, FACS
Associate Professor of Gastrointestinal/Laparoscopic,
Endoscopic and Robotic Surgery
Medical Director of Bariatric Program. Department of Surgery

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8.  I am sorry for your loss   Usually antibiotic are given iv 
prior to colon surgery

I hope you will find peace in your future
Amelia Grover, MD

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 9.  YES     Willie Melvin  MD

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10. The antibiotic bowel prep the day before surgery has become controversial, but the antibiotic dose within one hour of surgery that can be continued for up to 24hrs after surgery is standard of care.

Your Welcome, Dr. DeNoto MD

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11. yes, one dose at the beginning of operation Victor Tomulescu MD

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12. Yes, that would be the standard of care.

Helen Chan MD

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13. Antibiotic prophylactic cover is essential to colonic resection while bowel prep is controversial Michael LI K.W. MD

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14. Without knowing the details, I believe that most surgeons would perform some type of bowel prep and give preoperative antibiotics for elective colon surgery. Elective colon surgery without a bowel prep has been reported.

Michael H. Wood, MD, FACS

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15. Both are standard practice for whoever undergoing elective colorectal surgery unless your daughter received an emergency surgery without time for formal bowel preparation. Once again the colonic surgery is a clean contaminated operation, routine antibiotics prophylaxis should have been given
Thanks

C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons

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16. Hi Mr. Kirby,

First of all, I am sorry for your tragic loss. The use of antibiotics in colon rectal surgery is currently a very hotly debated topic.
While most surgeons agree that IV antibiotics should be routinely used at the time of surgery, there is a widely emerging body of data that has brought the use of preoperative bowel preparation and oral antibiotics under question. Currently the evidence is supporting the use of no oral antibiotic or mechanical bowel preparation.

Gregory Gallina MD

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17. I am sorry to hear about your daughter. I hope she came through this OK. I do not have the details of the case, and clearly this opinion is not based on the details of this case. The importance of bowel prep is currently being debated. In general IV prophylactic antibiotics given preop is indicated in colon surgery. Despite this, I doubt that the absence of bowel prep or antibiotics contributed to the bleeding episode. I hope this is helpful.

Harold Kennedy MD

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18. Yes I would Michael LI K.W. MD

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19. Hi Mr Kilby-

I am sorry for your loss. Clearly you are describing a difficult situation and it sounds like there are significant legal issues. I will only say that in the US it is considered standard of care to administer IV prophylactic antibiotics within one hour of skin incision for a clean-contaminated surgical case. Colon resection is considered a clean contaminated case. I do not know have any knowledge of the particulars involving your daughters case, nor would it be appropriate for me to be involved so these comments are in no way intended to be related to the case you are describing. I am only making a statement about what you asked with regard to prophylactic antibiotics and colon surgery. Best of luck

Elliot Newman MD

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20. Good Morning,
Yes, antibiotics prophylaxis is in case of open abdominal surgery (colon resection) a routine procedure.

Best Regards Dr.Tvaruzek MD

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21. Yes C N TANG Dr, HKEC CSD(Accreditation & Standard) / PYNSUR Cons

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22. The simple and accepted answer is yes. I am sorry for your loss Charles Anderson MD

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23. I was able to catch Dr. Parra-Davila between cases to see if he could answer your question below. Dr. Parra-Davila said yes to your question below and said it is a US guideline to follow for this procedure. Hope this helps.

Penny Griggs Advanced Minimally Invasive & Bariatric Surgery ConsultantsAdministrative Assistant to Drs. Keith Kim and Eduardo Parra-Davila

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24. Mr. Kilby: The answer is yes. I would recommend an antibiotic that is effective against the common colonic flora. Perhaps for 24-48 hours starting at the time the abdominal incision is made. I wish you good luck with your crusade.

hugo gomez-engler

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25. Mr. Kilby, I I am sorry for your loss and obvious anguish over your daughter’s death. In answer to your question, antibiotics are routinely given prior to colorectal operations, whether open or laparoscopic – but this does not prevent infections from occurring (still occur 10-20% of the time regardless of antibiotic use). There are rare circumstances where they are not advised (allergies, etc.). Best of luck, and thank you for your interest in our program. Hopefully your legal counsel will provide the support you need to get the answers you are seeking.

PW Paul E. Wise, M.D., FACS Assistant Professor of Surgery Director, Vanderbilt Hereditary Colorectal Cancer Registry Vanderbilt University Medical Center

D5248 MCN Nashville, TN 37232-2543 Office: (615) 343-4612 Fax: (615) 343-4615www.vanderbiltcolorectal.com

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26. yes Malcolm Steel MD

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27. I see, well I certainly am very sorry to hear about such a tragedy and nothing could possibly replace her in you heart. I am a cardiac surgeon and thus general surgery is out of my expertise. However all patients having surgery are required to have antibiotic preoperative and if there is a documented infection it is mandatory to treat it with antibiotics. I would retain an attorney and have it investigated and seek damages if your attorney deems it just.
Sincerely Wendel Smith, M.D.

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28. We always used to give a bowel prep including antibiotics, but recent studies suggest a bowel prep is not necessary and results are better without a bowel prep. I doubt she died because she did not receive antibiotics. Something else must have been going on. I cannot understand why the coroner would make that statement without explaining the circumstances to you.

Adrian Greenstein, MD

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29. Mr. Kilby,
I am sorry for your loss.
Yes of course a patient should receive antibiotics prior to colon resection.

Sanjeev Sharma MD FACS

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30. Yes Sent from my iPhone

Cohen, Robbin MD

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31. Arnold.

I am sorry hear about your daughter. What a loss. Regarding the antibiotics; I have not done colon surgery for some time but I used to give antibiotics prior.

Go to the American colorectal website and see if they have an official policy.

Matt Slater, MD

Associate Professor

Clinical Director, Adult Cardiac Surgery OHSU Sent from my iPhone

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32. YES todd grehl MD

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33. Just this one... yes

Anthony P Furnary MD

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34. Yes, he should J.S. Smetana Josef MD

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35. Dear Arnold,

The answer to your question is YES. Usually a broad spectrum antibiotics administered at the time of induction of anaesthesia.

Kind regards,

David Jayne MD Senior Lecturer in Surgery Leeds

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36.
Yes Demeester, Steven MD

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37. The answer is yes. I'm sorry for your loss.

FF. fernando Fleischman M D

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38. Yes, she should have received "preoperative" antibiotics within

One Hour if beginning operation. Whether this would have prevented her death is unclear, but infection rates are known to be significantly reduced with routine antibiotic use. I am sorry to hear about your daughter’s loss.

Luis Castro. MD

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39. Mr Kilby,

I am sorry for your loss. It seems that there's more to it than just the lack of prophylactic antibiotics that was involved. Unfortunately with every procedure, there are potential risks. I don't know the circumstances around the death of your daughter but I can most certainly feel your pain. My condolences

Alex Ky MD,FACS,FASCRS Division of Colon and Rectal Surgery 212-241-3547

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40. Dear Mr. Kilby,

I am sorry for your loss, having children myself of similar age I can only imagine how difficult it has been for you. In answer to your question, bowel preparation and
administration of antibiotics for prophylaxis prior to surgery have been a standard of care in surgery for at least 25 years. In my opinion you have every reason to deserve frank answers about what happened to your daughter. Cases involving perioperative death are always reviewed by hospital morbidity/mortality committees, as well.

Regards, Douglas Boyd Professor of Surgery University of California Davis

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41. Yes the colon should be cleaned and antibiotic started prophilactically

Sent from my iPhone HOMAYOON Ganji

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42. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Definitely yes. Usually the day of surgery, and at least an hour before surgery.

Long, William :LPH Dir. Tra

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43. It is the standard in the United States to give prophylactic antibiotics within one hour of surgery.

Ismael N. Nuno, MD, FACS, FACC, FAHA. Chief, Cardiac Surgery Service LAC+USC Medical Center TEL: (323) 409-8666

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44. Dear Mr. Kilby,

Your anger I share, and your unresolved grief is palpable. I have tangled and lost with a family medical issue in Victoria, which still angers me. That was five years or so ago, and fortunately I have moved on to the point where it is just a bullet point in the list of reasons to keep our own medical system as it now stands. I wish truly that I could be of more help with the resolution of your problem, and also that time will allow you to move on.

Cord Cordell H. Bahn MD

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45. I am very sorry for your loss. It is generally advisable to administer antibiotics just prior to skin incision.
Tara Karamlou MD Sent from my iPhone

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46. Hi - sorry to hear about this sad case....It is tragic and nothing in life is perfect.
God willing and with some luck and fate, we will conquer.
Best to you. Ed Yee MD
PS
: pre-operative antibiotics for "clean contaminated" cases are usually recommended...

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47. The standard of care in the US is for patients undergoing any surgery is antibiotics within 1 hr of surgery, and for 24 hrs after surgery. This applies to clean and dirty procedures. Clean procedures referring to procedures where bacteria are not normally involved other than skin bacteria, and dirty procedures where bacteria are normally in-countered such as bowel surgery (colon surgery), gyn surgery, and oral surgery Your daughter should have had pre-op and peri-operative antibiotics.

Michael Wood MD

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48. Arnold

I am a retired cardiothoracic surgeon who is board certified in general surgery and thoracic surgery. I can't comment on your daughter's case without the record and autopsy report but there is no doubt she should have been given pre-operative and post operative antibiotics. Was this the cause of her death, that I can't say without more information. I am sorry for your loss.

Mike Perelman MD

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49. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes Diethrich, Edward MD

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50. YES, AND YES, GET A BETTER LAWYER. RRG

SWCVTS@aol.com

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51. Mr. Kilby,

My sincere condolences on the loss of your daughter. You are correct that I am not a general surgeon but I know that it is the accepted procedure to use prophylactic antibiotic coverage for colon surgery in the hospital where I work here in Denver, CO. I believe that is true throughout the US. It is disheartening to hear of the lack of transparency on the part of the medical / governmental establishment in the Canadian health care system. Unfortunately, thanks to our socialist president we in the US are probably headed for a similar fate. It sounds like your daughter died of peri-operative sepsis. Prophylactic antibiotics were indicated but that treatment does not prevent this complication in 100% of cases. In all likelihood it would have reduced the probability of such a tragic outcome. Good luck in your struggle to obtain justice for your daughter.

Stanley Carson, MD

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52. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Absolutely.

HP MD

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53. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? My answer is unequivocally YES

I have no pressures from any organization.

BBRoe Benson Roe

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54. Dear Mr. Kilby,

I am a practicing Cardiovascular and Thoracic surgeon in North Dakota. I have not done a colon resection in over 20 years, although I have maintained my general surgery credentials for purposes of covering trauma cases and teaching medical students. For legal purposes, I would not consider myself an expert witness.

I would suggest that you look up the US Medicare SQIP Protocol (Surgical Quality Improvement Project) to review the current recommendations for antibiotic prophylaxis for colon resections in this country
. Generally, it restricts antibiotic prophylaxis to a single pre-op dose, and less than 24 hours of coverage post-op. Antibiotic bowel preps have also fallen out of favor. Antibiotic use beyond 24 hours is only recommended for treatment of infections that are either suspected or known.
I do think it is fair to say that a preoperative antibiotic dose for a colon resection is the standard of care in this country. Whether or not it would have made any difference for your daughter is problematic, absent a proper record review. Even then, it may be difficult to be certain that the omission was causal in her death.
I am sorry for your loss. I help this will eventually help you gain some closure.
Sincerely, A. Michael Booth MD PhD FACS

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55. www.cochrane.org/reviews/en/ab001181.html
I hope you'll find this study helpful. Said Yassin MD

Antibiotics administered to patients prior to colorectal surgery

When people undergo surgical operations of their abdomen they are at risk of infection which will often be cured by an antibiotic. However, it might be better to give this before the operation to prevent the infection (prophylaxis or prophylactic use), rather than wait until an infection occurs before giving it. This review looks at the evidence for giving an antibiotic before surgery takes place.

The review found 260 studies which had recruited