SHOULD AN ADVERSE EVENT OCCUR IN ANY ONTARIO HOSPITAL, THE CITIZENS OF ONTARIO WILL BE ENSURED IT WILL BE COVERED UP BY ALL OF THOSE SEEN BELOW:

THE HOSPITAL --under jurisdiction of Liberal Minister of Health

THE CHIEF CORONER'S OFFICE--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections and is a member of the CPSO and CMPA!

THE DEATH INVESTIGATIVE OVERSIGHT COUNCIL--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections --has Chief Coroner or Deputy sitting on this council!

THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO

THE HEALTH PROFESSIONS APPEAL AND REVIEW BOARD--appointed by Liberal majority government --under jurisdiction of Liberal Minister of Health

THE ONTARIO OMBUDSMAN--appointed by Liberal majority government

THE ONTARIO PATIENT OMBUDSMAN--appointed by Liberal majority government

THE ONTARIO PROVINCIAL POLICE--under jurisdiction of Liberal Minister of Corrections

THE INDEPENDENT POLICE REVIEW DIRECTOR--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections

THE LIBERAL MINISTER OF HEALTH and is a member of the CPSO and CMPA!

THE LIBERAL MINISTER OF CORRECTIONS

THE LIBERAL PROVINCIAL PREMIER

WHEN IT COMES RIGHT DOWN TO IT, THE PRESENT LIBERAL GOVERNMENT SHOULD HAVE COME CLEAN TO PROTECT THE CITIZENS OF ONTARIO.

ALL OF THE ABOVE ARE IN "BREACH OF TRUST" AS THEY COVER EACH OTHERS' ASSES

A FATHER’S FAILURE

Without a doubt; a Conspiracy exists,
Self-protecting Officials; such hypocrites!

If you were a MPP’s daughter; it would cause a fit,
Because you’re mine; they don’t give a shit!

For years we have yearned for justice,
The lack of moral integrity merely disgusts us!

Government institutions that won’t expose,
The Medical negligence concealed by those!

Medical Immunity granted; regardless of guilt,
Preserving Ontario Health Care’s patchwork quilt!

So many individuals paid through our taxes,
Failing us all; what a bunch of asses:

Premier of Ontario --Premier Wynne, Premier McGuinty,

Ontario Minsters of Health --Dr. E. Hoskins, D. Matthews, Rick Bartolucci

Ontario Ministers of Corrections --Yasir Naqvi, Madeleine Meilleur

Ontario Members of Provincial Parliament --majority of them from 2006 to the present

CPSO -- Angela Bates Manager Committee Support Area Investigations and Resolutions, Sandra Keough Investigator

HPARB --Chair Janice Vauthier, Past Chair Linda Lamoureux, Lori Coleman Registrar, Third Appeal Chair Tom Kelly, Members Stephen Jovanoviorc and Brenda Petryna

Ontario Ombudsman --Paul Dube Ombudsman, A Marin-Ombudsman, Investigator Lorraine Boucher- Investigator, Fran Cappe-Investigator,

Humber River Hospital --CEO B. Collins, past CEO Rueben Devlin,

Ontario Chief Coroner’s Office --Dr. D. Huyer, Dr. A. McCallum, Dr. A. Lauwers

DIOC --Joseph C.M. James (Chair), Emily Musing (Vice-Chair), John Pearson (Vice-Chair), William (Bill) McLean, David Williams, Dorothy Cynthia (Cindy) Prince, Denise St-Jean, Fiona Smaill, Lidia Narozniak, Lori Marshall, Lucille Perreault, William (Bill) J Shearing, Michael Pollanen, Fiona Foster Manager of DIOC

Ontario Patient Ombudsman --Christine Elliott, Investigator Marie Claire Muamba

Ontario Provincial Police --Commissioner J.V.N. (Vince) Hawkes, Inspector Bradley McCallum

OIPRD -- Director Gerry McNeilly

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Terra Dawn Kilby
"An Angel In Our Lives"
April 22/78 to July 21/06

Linked 2612 Connections/Followers
https://www.linkedin.com/…/humber-river-hospital-still-cove…

2,884

http://thepatientfactor.com/…/the-unholy-alliance-between-…/

DO YOU SMELL SOMETHING ROTTING WITHIN ONTARIO?
https://1drv.ms/w/s!ApBprmlxiUUnhHumD25kXQnNQ4f_

http://www.torontosun.com/…/why-did-woman-die-after-routine…

http://www.torontosun.com/2013/10/18/secret-medical-cautions

https://www.linkedin.com/…/ontario-patient-ombudsmans-offic…

https://www.linkedin.com/pulse/another-failure-arnold-kilby…

https://www.linkedin.com/…/death-investigation-oversight-co…

https://www.linkedin.com/…/terra-dawn-conspiracy-arnold-kil…

https://www.linkedin.com/…/help-bring-true-transparency-acc…

https://www.linkedin.com/…/breach-trust-chief-coroners-offi…

https://www.linkedin.com/…/hparb-merely-mirage-valid-avenue…

https://www.linkedin.com/…/p-dube-ontario-ombudsman-arnold-…

https://www.linkedin.com/…/att-ontario-provincial-police-co…

https://www.linkedin.com/…/truth-kept-hidden-abusing-legisl…

READ ALL OF MY POSTS AS I ATTEMPTED TO BRING TRANSPARENCY AND ACCOUNTABILITY TO ONTARIO.

SCROLL DOWN FOR POSTS
--Look on right side under "Blog Archive" (oldest to newest)

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College of Physicians and Surgeons - Stories of Failure

What is especially interesting in this recent Star (last week Feb/2016)article is the following:

“We are not a public organization. . . Our accountability is to our members,” said the College’s executive director, Dr. Francine Lemire" CPSO

ONTARIO OMBUDSMAN'S OFFICE FAILS TO PROTECT CITIZENS FROM HPARB'S LACK OF PROCEDURAL FAIRNESS AND ADHERING TO THE PRINCIPALS OF NATURAL JUSTICE.

We already know the CPSO is corrupt and HPARB from the article where it stated "it looks like HPARB just threw up their hands and said we give up"

http://www.torontosun.com/2013/10/11/why-did-woman-die-after-routine-surgery

http://www.torontosun.com/2013/10/18/secret-medical-cautions

But for the Ombudsman's Office to swallow such garbage leaves the citizens of Ontario with no where to go.

Coalition For Physician and Surgeon Oversight is a group who has been harmed or had a loved one taken through negligence by a doctor/surgeon.

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

https://www.youtube.com/watch?v=_LFqWujTEVA&feature=youtu.be

Terra Dawn Kilby --- A Father's Memories
An Angel In Our Lives, Terra Dawn Kilby November 2014

A tribute to the life of my daughter who died due to the negligence of a surgeon at Humber River Regional Hospital, Toronto, Ontario, Canada. Covered up by Humber River Regional Hospital, the CPSO, HPARB, Chief Coroner's Office of Ontario, the DIOC, Ontario's Ombudsman and the entire Provincial Liberal Party!


TERRA DAWN KILBY April 22, 1978 - July 21, 2006. College’s Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. Klein in this case.”…
00:35:48

https://www.youtube.com/watch?v=lMof3T--zUY&feature=youtu.be
******************************************************
THE PATIENT FACTOR

http://thepatientfactor.com/canadian-health-care-stories/the-unholy-alliance-between-organized-medicine-and-government-a-fathers-quest-for-truth-and-justice-in-public-health-care/

HPARB's Decisions Kilby vs Laz Klein.
First Decision:
http://www.canlii.org/en/on/onhparb/doc/2010/2010canlii44390/2010canlii44390.html
Second Decision:

http://www.canlii.org/en/on/onhparb/doc/2012/2012canlii39837/2012canlii39837.html
Third Decision:
http://www.canlii.org/en/on/onhparb/doc/2013/2013canlii46625/2013canlii46625.html

The Letter I Sent to the Chief Coroner's Office Outlining My Numerous Concerns
Coroner's Comments.doc

Death Investigative Oversight Council's Decision

2 years after my initial request and after both Chief Coroner and Deputy Chief Coroner left the OCC.
DIOC Decision Aug 2013.doc
*********************************************************
The Chief Coroner's Office, the College of Physicians and Surgeons of Ontario, the Health Professions Appeal and Review Board, the Death Investigative Oversight Council, the Liberal government and Ms Deb Matthews and Premier Wynne apparently agree that it is perfectly within the accepted Standard of Care to:
--have open abdominal surgery without the mandatory antibiotic prophylaxis

--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed

--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics

ONTARIO CITIZENS----
And the College/HPARB totally ignored Dr. Andrew McCallum's letter to the College when he was Eastern Ontario Coroner. In it he states that infection was a contributing factor in Terra's death.
One must also wonder how on earth the Chief Coroner's death investigation failed to note the lack of antibiotics plus other issues contained within the hospital records and yet I have numerous pieces of correspondence from both Dr. Lauwers and Dr. McCallum stating they saw no issues with respect to the Standard of Care???
HOW DO YOU SPELL COVER-UP???



************************************
THE OMBUDSMAN'S OFFICE has allowed the College and HPARB to establish the above as precedence for future complaints/appeals made to both of them.
VERY DANGEROUS TO ALLOW THIS TO HAPPEN WITH REGARD TO PATIENT SAFETY AND CARE WITHIN OUR HOSPITALS.


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





http://thepatientfactor.com/canadian-health-care-stories/the-unholy-alliance-between-organized-medicine-and-government-a-fathers-quest-for-truth-and-justice-in-public-health-care/

https://plus.google.com/100940639342885447409/posts/YwvYaMn7eTw

http://www.yelp.ca/user_details?userid=BslEQAF9s6rUav3VSPqcWQ

**************************************************
Gan Reporter to appeared July 21, 2015
Terra Dawn Kilby
“An Angel In Our Lives”
April 22, 1978 – July 21, 2006


Tears still appear when we think of you.
Visits to your grave site we often do.
Loving memories convey serenity too!

Our precious daughter, Terra Dawn;
It’s been nine years since you’ve been gone.
Within our hearts you still belong!

July Twenty-first is a time of sorrow.
Additional years, I wish we could borrow.
Maybe then, we’d not feel hollow!

Today, messages guided to heaven above.
Channeled to you on the wings of a dove.
Expressing our heartfelt, everlasting love!


LOVE MOM, DAD AND BRANDY

Monday, 19 September 2011

No Accountability or Transparency in Ontario--Dr. Bert Lauwers/Dr. Andrew McCallum/Dr. Laz Klein--- Part Two Please see June and July Blogs Entry First

 A PRIMER ON THE LAW OF DEFAMATION IN ONTARIO
"Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words)

Proving a Claim in Libel and/or Slander
"the statement must be false!"

Defences to Actions in Libel and Slander
TRUTH--
"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefore there was nothing false about the statement, meaning therefore, that the statement was not defamatory."


FAIR COMMENT--

"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."

QUALIFIED PRIVILEGE--
"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate. 

******************************************************************************  
I received the inept decision by the College of Physicians and Surgeons of Ontario as to my first and second complaint.
From: ABates@cpso.on.ca                                                         
To: awkilby@hotmail.com
Dear Mr. Kilby:
To confirm - you matter is currently being reviewed by an independent opinion provider. I will be following up with that individual this week to determine how close to completion the opinion is. I apologize for the length of time this has taken, but it can take some time to locate a suitable opinion provider who is willing to do the work; and these are physicians who invariably have full-time practices.
I would anticipate that we will receive the opinion by January and back to the Committee byFebruary or March.
*********************************************************************************************************************
 Ms Angela Bates  ---Investigations Manager
 
Note:  The above bold face statement is enough to question 
the validity of anything the College supposedly investigates.
 
How many other complainants have gotten the “shaft” from this College?

Page 6 of College’s Decision
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.”
1.  Notice the College's use of "neglected"                                                                                          
2.  Notice the College’s use of the word “oversight”.  Does this mean“OOOOPS”?  
3.  The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances.”  

   “Suggest”?????? As opposed to “MUST”                                    

From first page of “Memorandum” to the College’s expert dated June 10, 2011
“The second question related to whether perioperative antibiotics should have been prescribed.  Dr. XXXX stated that he found no evidence in the record of any antibiotics had been prescribed perioperatively.  He stated that it is the standard of practice with bowel surgery to administer antibiotics, either orally or intravenously, approximately 2 hours prior to surgery so that the drugs are circulating before the incision is made.
Page 8 of College’s Decision
“….  and suggests that the member may wish to consider the use of preoperative antibiotics for bowel surgery in the future.”
“suggests”   & “may wish to consider”  
----- Watered-down disciplinary measure by the College.
 
Note: The College appears to take lightly the fact that anti-biotic prophylaxis was not delivered at the time of induction and that my daughter did not received any anti-biotics at all.   They also seem to be covering themselves by always qualifying that my concerns they looked into did not factor into Terra’s death.  But the death is not the question-----It is whether or not my daughter received the appropriate standard of care pre and post operative.

From page four of letter sent to College by their own expert dated May 8, 2011
“The progress notes, although written daily, are very brief.  The notes do cover the pertinent aspects of her surgical recovery.”
Do we see any comments with regard to:
Oozing and infected incision?    NO
Increasing size of abdominal girth?   NO
And of course the many concerns indicated within the nursing records.  ie—temperature, pulse rate, insufficient diet etc    NO
 Page 4 of College’s Decision
“Although the odour and the oozing could represent an anaerobic infection, if there was more than a superficial infection, one might expect an increased systemic toxicity within 24 hours from the time this was first noticed. In addition, there was no information to suggest that Ms. Kilby was developing severe sepsis before her discharge.”

I love these words  “could”  “might expect”  “suggest” Not a decisive response
From 5 page of letter sent to College by expert dated May 8, 2011
“In retrospect, she obviously was released too soon, but at the time she showed no apparent signs of intraabdominal sepsis. Dr. Klein documented this well in his notes, and felt in his best judgment that she was suitable for discharge home the following day.”
His notes do not document the above!
From second page of “Memorandum” to the College’s expert dated June 10,
He stated that it is best for a surgeon to see a patient the morning of discharge; or at least, for nursing staff to document the patient's status. As well, Dr clarified that if there were signs of sepsis or hypovolemia on the morning of discharge, these may have shown themselves if the surgeon or nursing staff had assessed the patient that morning.”
Hypovolemia can be recognized by elevated pulse (See Terra’s Pulse Scores)      --I don’t believe Dr. Klein looked at the nursing records until after her death.
“He noted that he would have expected a more thorough analysis of the situation in the surgeon's notes.”
This contradicts his statement above from page 5 of letter dated May 8, 2011 and from page four of letter sent to College by expert dated May 8, 2011
   ie-  “The progress notes, although written daily, are very brief.  The notes do cover the pertinent aspects of her surgical recovery.”
         “…she showed no apparent signs of intraabdominal sepsis. Dr. Klein documented this well in his notes,…”
        “…expected a more thorough analysis of the situation in the surgeon's notes.”
Am I the only one that sees contradictions in expert’s statements with regard to the notes by the surgeon???
From 5 page of letter sent to College by expert dated May 8, 2011
We do not know her actual condition on the morning of discharge. UPerhaps a reassessment of Ms. T.D.K. on the morning of discharge would have been more appropriate”.
I love these words  “don’t know”  “perhaps”  “more appropriate”  Not a decisive response
Page 3 of College’s Decision
“It is apparent only in retrospect that Ms. Kilby was released too soon. At the time of
release she showed no apparent signs of intra-abdominal sepsis. Her clinical condition on the morning of her discharge is not known because she was not seen by Dr. Klein. 
Perhaps a reassessment on the morning of discharge would have been more appropriate.”
Well, I guess so; seeing that it would have been over 24 hours since his last visit on Wednesday when she was sleeping.
From Page 2 of letter sent to College by expert dated May 8, 2011
“On the day of the wound infection, on July 15th, the possibility of a CT scan was raised by Dr. Klein, and he had told T.D.K.'s father that the CT scan might be done on Monday July 17th. However, the CT scan was never done and I presume that at that point in time Dr. Klein felt that the wound infection alone accounted for her symptoms. T.D.K. was having severe diarrhea at this point, and clearly T.D.K.'s father was concerned about this.

I love these words  “presume”   Not a decisive response
From first page of “Memorandum” to the College’s expert dated June 10, 2011
The first question posed related to whether the surgeon properly addressed the foul odour in the wound and the nurses' notes regarding abdominal symptoms. Dr. indicated that this is impossible to know. He indicated that the foul odour could have indicated an anaerobic infection, with the possibility of a flesh-eating infection, bacteraemia and sepsis. The foul odour was noted half-way through the hospitalization; if it had been flesh-eating bacteria, the patient would have gone downhill very quickly from the onset of symptoms, i.e., within 24 hours, which did not happen here.”

I love these words  “impossible to know” “ could have been”  Not a decisive response
From Page 2 of letter sent to College by expert dated May 8, 2011
“Looking back at the situation, perhaps a judicious CT scan done when the diarrhea was causing problems might have led the physicians to the realization that she had an anastomotic leak.”

I love these words  “looking back”  ‘perhaps”  “might have led”  Not a decisive response.
 NOTE: I don’t believe Dr. Klein was being judicious at all, with respect to my daughter’s care.

“Her diarrhea may have been a warning sign of a contained anastomotic leak.”
“… perhaps a judicious CT scan done when the diarrhea was causing problems might have led the physicians to the realization that she had an anastomotic leak.”

I love these words  “may have been”  “perhaps”  “might have”  Not a decisive response
Page 6 of College’s Decision
“In relation to the concerns regarding Ms. Kilby's discharge from hospital, the Committee
agrees with the IOP, namely that there were no clinical signs at that that time that would
have suggested a  delayed discharge (as confirmed by the nursing notes)…. there were no symptoms or signs to suggest tests were indicated, and they were unlikely to have been abnormal.”

I love these words  “would have suggested”  “unlikely”  Not a decisive response
Page 2 of College’s Decision
“It is apparent only in retrospect that Ms. Kilby was released too soon. At the time of release she showed no apparent signs of intra-abdominal sepsis. Her clinical condition on the morning of her discharge is not known because she was not seen by Dr. Klein.
Perhaps a reassessment on the morning of discharge would have been more appropriate.”
Gee, you think so????
“Ms. Kilby did in fact have a bowel movement in that she experienced diarrhea before shewas discharged from hospital.”
Very misleading statement, -- of course she had diarrhea before she was discharged---days before but not a single bowel movement from after consuming dinner on the 19 up to her discharge.  Your statement makes it appear that she did have a bowel movement just prior to her discharge!!!
“Although the odour and the oozing could (as opposed to would) represent an anaerobic infection, if there was more than a superficial infection, one might (as opposed to would) expect an increased systemic toxicity within 24 hours from the time this was first noticed. In addition, there was no information (see hospital records) to suggest that Ms. Kilby was developing severe sepsis before her discharge. The Committee notes that her vital signs were stable, her heart rate (see hospital records), blood pressure, oxygen saturation and temperature (see hospital records)  were never an issue, her abdomen was soft throughout the time in question and bowel sounds were present.”
 
Not a decisive response
“The Committee agrees with the IOP in this regard, namely that antibiotics were not indicated for treatment of a superficial wound infection. We note that standard treatment for a superficial wound infection was given with drainage, packing and culture taken (negative for Clostridium difficile)”.
Misleading response.   
But she had no anti-biotic given to her at any time.  They seem to be ignoring the lack of the mandatory anti-biotic prophylaxis.   Considering this was not administered as it should have been; then Terra’s infection should have been treated with antibiotics.   What about the many gram-negative bacilli seen?  Is it a standard of care for a patient who has undergone major abdominal surgery to receive absolutely no anti-biotics what so ever.  NO it is not!

This College’s investigation is so flawed, I believe it is an Insult to the HPARB Panel, the memory of my daughter, Terra Dawn Kilby, her family and friends, as well as to all Citizens of Ontario.

Participating in Self-Regulation   from College’s Own Website


Physicians have been granted the privilege of self-regulation. Society allows physicians to regulate themselves in return for the covenant that this regulation will occur in the public interest. The social contract between the public and the profession places certain responsibilities on the physician as an individual, with respect to his or her colleagues and with respect to collective involvement for the best interests of patients and the community. Meeting these responsibilities requires efficient and appropriate governance and a reliable system of accountability. It is not enough for physicians to accept regulation. To ensure the continuity of self-regulation, each physician should, along with the College, participate in the self-regulatory process.

The College has not investigated my complaint efficiently, they have not governed this investigation appropriately and they definitely do not demonstrate a reliable system of accountability.  

The goal of regulation is to serve the public by ensuring the best quality care for patients in Ontario. Both the College and individual physicians have a responsibility to ensure quality care by continually improving skills and behaviour as well as responding to concerns around practice/behaviour.
 
The College has not responded to concerns pertaining to Dr. Klein’s practice of performing elective open abdominal surgery without the mandatory anti-biotic prophylaxis and not providing any anti-biotics at all, as well as numerous issues of neglect.

I strongly suggest to HPARB that the Minister of Health, and the Premier should be contacted with regard to the obvious failure of the College keeping the covenant that this regulation (the social contract between the public and the profession) will occur in the public interest, not the individual surgeon’s interest!  Their right to self-regulation requires an investigation by the Minister and the government of the day.  It will also not be unusual for the College Representative and Dr.
Klein not being physically present.  Io appear in person would allow the Board to see their facial and body movements if asked questions by the panel and when I make my statements.
The Health Professions Appeal and Review Board should quite easily find that “the standards of care were not met, that there was indeed negligence with my daughter’s pre and post operative care.”    
The College will never admit to this and if it is within your mandate,  HPARB should take over this investigation.  The College has had two opportunities to investigate truthfully and have failed twice.  Three strikes are OK in Baseball, but not when it comes to protecting patient safety and ensuring transparency and accountability. 

Information I received from within HRRH.

There were 6 more deaths by the bariatric department (staff of four surgeons, Dr. Klein, Dr. Hagen, Dr. Star & Dr Quoc Huynh) of this hospital during 2009 and up to Feb. 2010 under similar circumstances— And this past year, a woman who had a hysterectomy bled out before they could get her to the OR.   It is almost impossible for me to obtain the details but the Chief Coroner’s Office and the hospital would have them-----these deaths may have been prevented if my daughter’s death was thoroughly investigated the first time.  Now one must wonder of the seven deaths, did any of them involve surgery by Dr. Klein?


 "In 2010 the Chief Coroner's Office shut down this department due to 5 or 6 death and brought in an expert from a university hospital to investigate the OR and procedures for Bariatric surgeries, of course after people died of hemorrhages and they did not know what was happening in OR.”
Now dear reader of my blogs.
If this situation repulses you:

Please contact the Health Professions Appeal and Review Board as they will be hearing my second appeal of the College's Decision.  Merely quote "Kilby vs Klein"  This meeting took place Nov. 25, 2010 and I am awaiting their decision.

And contact your own MPP, Premier McGuinty--Now Premier Wynne, and Health Minister Ms Matthews.  They won't give you a response but your MPP will.

And send a letter of disgust to the Ontario College of Physicians and Surgeons.

And invite others to read my blogs and respond as they wish.
 awkilby@hotmail.com