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

*****************************************************************************
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)

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

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

Thursday, 6 December 2012

No Accountability or Transparency in Ontario--Dr. Bert Lauwers/Dr. Andrew McCallum/Dr. Laz Klein--Part Twelve

 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. 

****************************************************************************** 
Finally a response from the DIOC

Dear Mr Kilby,

Thank you for your recent correspondence to the Death Investigation Oversight Council (DIOC). A copy of the attached letter has been sent to you in the mail. The letter acknowledges receipt of your email correspondence and provides an update on the status of your file. As noted in the letter, I can confirm that the initial review of your file by the Complaints Committee will commence early in the new year.

I would like to reinforce the mandate of the DIOC. The purpose of the Complaints Committee is to review complaints with a goal of providing advice in order to help improve Ontario’s death investigation system. As an advisory body, it is generally not within the committee’s mandate to review or otherwise assess substantive medical conclusions or opinions with respect to the cause or manner of death. Consequently, and to the extent that your complaint before the DIOC may raise such issues, these aspects of your complaint may be outside the authority of the committee to consider.

Thank you,

Fiona Foster
Manager
Death Investigation Oversight Council

**************
I would like to thank you for finally responding to my many e-mails that were previously ignored.

Please keep in mind of all the denials of the requests I had made. It does not take a medical expert to clearly see that Dr. Lauwer's independent expert delivered a very inadequate report. Keeping in mind that all decisions by the Chief Coroner's Office quotes this expert, there is no doubt that this Office failed all Ontario citizens. Keep in mind that this office shut down the very same hospital department due to many more deaths----- after my daughter's.
I made the Chief Coroner's Office fully aware of my concerns and they ignored them--- didn't even bother to try to find the answers to my concerns----- this is a failure to the death investigation process. They should have went back to this expert and have him respond to my concerns!!!


One could take the easy way out by saying: "is generally not within the committee’s mandate to review or otherwise assess substantive medical conclusions or opinions with respect to the cause or manner of death. Consequently, and to the extent that your complaint before the DIOC may raise such issues, these aspects of your complaint may be outside the authority of the committee to consider."

My complaint clearly indicates a failure of this department. I can certainly come up with many positive recommendations to improve this Office's death investigation.
I am not questioning the cause or manner of death but the many denials by this office that could have saved lives

ie-- not letting my daughter's death be reviewed by the Patient Safety Death Panel

ie-- explaining why they feel there were no systemic issues related to my daughter's death when they failed to address my concerns---no antibiotic prophylaxis, no antibiotics whatsoever, not addressing the fact that test results indicated many gram negative bacilli, just to name a few. Their expert didn't see this???? The Coroner's Office did not address these concerns and they do have some medical expertise, don't they????

If the DIOC can not, then I would suggest that the DIOC contact the government to indicate that the DIOC can not truly investigate concerns by Ontario citizens when it comes to a complaint against this office and the Chief Coroner (which according to the changes in the Coroner's Act they are supposed to be able to) and that the government must come up with some other avenue to ensure accountability and transparency.
Arnold Kilby

***********************************
Dear Ontario Reader;
(for entire story, start reading from the beginning Part One)

I desperately need your assistance. Under the new Coroner's Act, I submitted a complaint with the Death Investigative Oversight Committee with respect to the inept death investigation of my daughter's death back in July of 2006.
This complaint is against the Chief Coroner's Office of Ontario. ( two years after her death they closed the hospital department, brought in an expert to see why this department had quite a few deaths-- this should have been done after my daughter's death---lives may have been saved.
As you can see from the following they are not answering me!

This is now the eleventh e-mail sent to the DIOC with no response from you.


Mr. Ali Veshkini

I submitted my complaint to the DIOC in February of 2011. This is now November 2012, soon to be 2013!

I would really appreciate a response from you ASAP
Could you please update me ASAP with respect to my complaint against Dr. Lauwers and Dr. McCallum. (The Chief Coroner's Office of Ontario)

Mr. Veshkini, A response???? Is there a particular reason why you are not responding to my e-mails?? I notice your website does not have a telephone number???

There has been no response to all of these e-mails below????

Date: Wed, 28 Nov 2012 14:13:31 -0500
Date: Wed, 21 Nov 2012 10:19:31 -0500
Date: Wed, 14 Nov 2012 14:32:38 -0500
Date: Sun, 4 Nov 2012 19:30:14 -0500
Date: Mon, 29 Oct 2012 20:45:36 -0400
Date: Mon, 15 Oct 2012 18:39:14 -0400
Date: Tue, 9 Oct 2012 12:21:52 -0400
Date: Mon, 1 Oct 2012 12:25:21 -0400
Date: Thu, 27 Sep 2012 11:58:56 -0400
Date: Mon, 24 Sep 2012 16:29:28 -0400

Arnold Kilby

I found out today, Dec 6, 2012 from my MPP's office that the DIOC is to put it bluntly---- pissed off at me.  That is probably why they are not answering me.  This is ridiculous as they are funded by the Ontario taxpayers and should understand my frustrations with the delays--- Remember, I lost a daughter!!
*********************************************
If readers of this blog could send an e-mail to the following demanding
1. they respond to me
2. they initiate the investigation into my complaint

ali.veshkini@ontario.ca  
Apparently, he is no longer in charge so the new person can be contacted at:
fiona.foster@ontario
dioc@ontario.ca
mmeilleur.mpp.co@liberal.ola.org
*****************************************
Also, dear friends
I have had two decisions by the Ontario College of Physicians and Surgeons' returned to them by the Health Professions Appeal and Review Board. They, as well, don't appear to willingly want to respond with respect to the third decision that have to make.

Ms Bates from the College has failed to acknowledge and reply to the following e-mails sent:

Would you please let me know when I will be receiving the College's third decision? ASAP
Sent: December-05-12 11:45:58 AM
Sent: November-29-12 8:12:57 AM
Sent: November-21-12 1:16:31 PM
Sent: November-14-12 2:45:05 PM
Sent: November-06-12 5:04:20 PM
Sent: October-30-12 12:42:13 PM
Sent: October-23-12 12:38:12 PM
Sent: October-21-12 4:21:03 PM
Sent: October-16-12 10:11:03 AM
Sent: October-01-12 12:22:42 PM
Sent: September-25-12 6:11:01 PM

***********************************
Again, If you can send an e-mail off to the following:

1. demanding that the College answers me
2. that they already stated that the surgeon was negligent with respect to conducting open abdominal surgery without administering the mandatory antibiotic prophylaxis and to render an immdediate decision.

abates@cpso.on.ca
bbyrick@cpso.on.ca
dmatthews.mpp.co@liberal.ola.org

***************************
Thank you, Arnold W Kilby   
awkilby@hotmail.com
Terra Dawn Kilby
"An Angel In Our Lives"
April 22/78 to July 21/06

***************************************************************************
The Following was sent to the DIOC on Dec 14, 2012

When the DIOC meets in January 2013 to handle my complaint. 
You Have A Moral Dilemma

— the two choices the DIOC has??
1. Perform your duty to the citizens of Ontario
The DIOC is an independent oversight council committed to serving Ontario by ensuring that death investigation services are provided in a manner that is effective and accountable.   All evidence points that Terra's death investigation was severely flawed.  Question -- on purpose or negligent error?

OR

2. Maintain the "Curtain of Concealment"
Have your names associated with the continued cover-up of an inadequate death investigation which quite likely led to further deaths at the same hospital; and by failing to act with my complaint, thus encouraging the continuation of future inadequate death investigations which will, in turn, lead to even more hospital deaths.I’m sure there were those within the Chief Coroner’s Office who suspected Dr. Smith but remained silent. People were wrongly accused, convicted and sent to prison. In this case, we are talking about "more DEATHS"
*****************************************************************************A Short Recap:

The Office of the Chief Coroner did the death investigation of Terra Dawn Kilby.

In the case of my daughter, the Office of the Chief Coroner of Ontario (Dr. Lauwers and supported by Dr. McCallum) did not conduct a high quality death investigation and has, in fact, appeared to concealed and ignored relevant information which does factor into her death.
This office as denied all of the following requests made to them:
 

1. Declined my request for a public inquest.
2. Declined my request for my daughter’s death to go before the Patient Safety Death Panel.
3. Declined my request for an Eastern Ontario Coroner’s Review
4. Declined MPP, now Senator, Robert Runciman’s request to reconsider the public inquest.
5. Declined my request for the Chief Coroner to assemble a Chief Coroner’s Panel to look into Dr. Lauwer’s decision and death investigation
6. Declined the Ombudsman’s Office of Ontario’s request to meet with me.
7. Declined an OPP Detective’s request to meet with me.



What are they afraid of?

Letter dated March 4, 2009 from Dr. A Lauwers
 
"The last issue that the coroner must consider when making a determination about whether or not an inquest is necessay, is the likelihood that the jury on an inquest might make useful recommendations directed to the avoidance of death in similar circumstances."
…. How could HRRH have known that Terra would bleed to death hours following discharge from a site along the line of anastomosis?"

Dr A McCallum, Chief Coroner of Ontario's comment, letter dated March 13, 2009
"Given that the care was appropriate
, it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance."  "While I realize that you have many remaining questions, I am not in position to respond. You may wish to speak with your daughter’s caregivers regarding these questions."
"However, I can state that our investigation did not reveal an issue in care that led to your daughter’s tragic death.
This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture."
NOTE: This same hospital department that my daughter had her operation was shut down by the Coroner’s Office due to more death which occurred in the year 2009 to February of 2010.

"Useful recommendations directed to the avoidance of deaths in similar circumstance"certainly could have been made!!!

There certainly was a "realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance"

"Our investigation did not reveal an issue in care that led to your daughter’s tragic death." Oh really?
I know the new Coroner’s Act and the DIOC can’t deal with a request for a public inquest, but certainly you agree that one should have been done and more importantly why were my other requests denied??

*****************************************************************************
Why will they not answer the following concerns?? Why will they not seek out the answers if they do know?

They keep saying they completed a thorough death investigation. Answering the five questions is not the only issue they should deal with!

"We Speak For The Dead To Protect The Living" Those that died after my daughter certainly would agree that this office failed them, their families and all Ontario Citizens!


How about the enlarged abdomen?
How about the foul, purulent oozing incision?
How about the fact she had no colon cleansing?
How about the fact that she did not have the anti-biotic prophylaxis given at the time of induction?
How about the fact she received no anti-biotics what so ever?
How about the fact the she remained on a liquid diet for 8 days consisting of jello, juice, tea and both without any nutritional supplement? How can a wound heal without proper nutrition?How about the fact her resting pulse rate was over 90How about the fact that she was only receiving 687 calories per day for 8 days?How about the many gram negative bacilli seen? And not treated.How about the low Absolute Lymphocyte (type of white cells)?
How about the many PMN’s (polymorphonuclear Neutrophils) –? hallmark of acute inflammatory process
How about the above normal temperatures?How about the low hemacrit, red blood cell count and haemoglobin?
I wonder how many of the deaths following my daughter’s death had the same concerns found within their hospital records as the above?

PLEASE RE-READ THE REPORT BY DR. LAUWER’S EXPERT. YOU WILL NOTICE THAT HE DOES NOT COMMENT ON MOST OF THE ABOVE CONCERNS WHICH ONE WOULD DISCOVER LOOKING AT TERRA’S HOSPITAL RECORDS. JUST THE FACT THAT DR. LAUWER’S EXPERT FAILED TO NOTE THE NEGLECTING OF ADMINISTRATING THE MANDATORY ANTIBIOTIC PROPHYLAXIS CALLS INTO QUESTION THE OVERALL VALIDITY OF THIS EXPERT’S REPORT! 

Letter dated November 17, 2008 from Dr A. Lauwers
"You have requested that I review the quality of care that this patient received and I have done so.""The operative procedure was carried out according to the appropriate standard of care and good decision making is evident." "There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no need for supplements of things like Vitamin K and Calcium."
"While the patient suffered the most devastating complications of an operation, and specifically one of the common complications of bowel resection,
at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care she received."

"The operative procedure was carried out according to the appropriate standard of care and good decision making is evident." "... at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care she received."
I would ask the council to consider the follow second decision from the College.
Appropriate Standard of Care???? Notice the word "neglected" and "oversight".


INQUIRIES, COMPLAINTS and REPORTS COMMITTEE (the "Committee" or "ICRC")

DECISION AND REASONS
COMPLAINANT: Mr. Arnold Kilby
PATIENT: Ms. Terra Dawn Kilby
RESPONDENT: Dr. Lazar Victor Klein (CPSO # 70489)

"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."

There are indeed systemic failures but the Chief Coroner’s Office failed to notice!

From the College’s own opinion provider: Dr. Taylor from London.


"Dr. noted that the patient's serum albumin was only 10 at Kingston General, something that "does not happen overnight", but indicates profound protein loss and poor protein intake."

"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."

"He noted that he would have expected a more thorough analysis of the situation in the surgeon's notes."

 "We do not know her actual condition on the morning of discharge. Perhaps a reassessment of Ms. T.D.K. on the morning of discharge would have been more appropriate."

 "At one point, he was actually concerned there might be an intraabdominal infection but decided there was not enough evidence to order a CTscan."


"The failure to increase the diet was driven by T.D.K.'s diarrhea problem and only in retrospect is it possible to understand that she may have had intraabdominal sepsis as the cause of the diarrhea."

 "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."

 "Dr. stated that he found no evidence in the record that 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."  

"Having said that, the Committee is troubled by the five month delay of the documentation of the discharge summary. The Committee is satisfied that this concern about Dr. Klein's delayed documentation in this case warrants a counsel. A counsel is issued in circumstances where the Committee is generally satisfied with the care or conduct of the physician under review, but has identified an area of the member's practice which might be improved upon. It is an educative disposition, designed to guide the physician in his or her future practice. "
"For the reasons set out above, the Committee counsels Dr. Klein on timely documentation of discharge summaries, and suggests that the member may wish to consider the use of preoperative antibiotics for bowel surgery in future."


Note: I am still waiting a "third" decision from this College. Has any of the Council members read the Toronto Stars’ report a few years back on the College or viewed W5's report on the College???

My case proves that their ineptness continues even to the present.
So what will it be?

Choice Number One
 or choice
Number Two??


   Arnold Kilby   
      
Terra Dawn Kilby
"An Angel In Our Lives"        
 April 22/78 to July 21/06
http://anangelinourlives-awk.blogspot.ca/