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

THE DEATH INVESTIGATIVE OVERSIGHT COUNCIL--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections

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

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…

2,817

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.

Mr Shanoff, (Toronto Sun Columnist) I don't know if you have done an article on the Ombudsman's Office, but you may wish to take this on as they are not questioning the contradictions. We already know the CPSO is corrupt and HPARB from your article where you 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 appear this week before Tuesday, 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

Tuesday, 12 March 2013

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

 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. 

******************************************************************************
April 11/13  Just an update:  
The DIOC is apparently looking at my complaint against the Chief Coroner's Office right now.   Of course this is two years after I issued the complaint.  Deaths occuring at this hospital may have been prevented if the DIOC had investigated.
I am awaiting HPARB to give me the date and time of the third appeal of the College's inept decision.  I will inform all as to when this will take place as it is open to the public.

Should you wish to express yourself, feel free to contact those below:
KILBY VS THE CHIEF CORONER
The DIOC:      dioc@ontario.ca     fiona.foster@ontario.ca
Minister Meilleur  --oversees the DIOC and the Chief Coroner's Office    mmeilleur.mpp@liberal.ola.org  mmeilleur.mpp.co@liberal.ola.org

Ontario Ombudsman   Andre Marin   amarin@ombudsman.on.ca
                                   Fran Cappe (case worker)  fcappe@ombudsman.on.ca

Premier Wynne   kwynne.mpp@liberal.ola.org  
Andrea Horwath   NDP Leader    ahorwath-qp@ndp.on.ca
Tim Hudak           Conservative Leader   tim.hudakco@pc.ola.org

KILBY VS KLEIN
Minister Matthews  --oversees hospitals and the College of Phys & Surg    dmatthews.mpp@liberal.ola.org 

Brian Taylor (College's Independent Opinion Provider)  brian.taylor@lhsc.on.ca

Angela Bates  College of Physician & Surgeons  abates@cpso.on.ca 
Bob Byrick   President of the College   bbyrick@cpso.on.ca  
**************************************************************************
Unfortunately, my struggles since Terra's death has not resulted in much change with regard to this hospital and this Surgeon!  The cover-up of pre and post operative care continues and so does the harm to patients.  The following from another bereave parent losing their daughter in December of 2012.  Any institution operated by doctors will continue to protect the surgeon and not patient safety.
'Dr Laz Klein did not perform his job as per the outlined procedure and our daughter passed away in December 2012. I can't comment any further as we are in process of legal rights, obligations and other. I say stay away from this doctor and hospital'

Laura H.
on 12/29/12 I do know of someone who  died at HRRH from weight loss surgery in late November or early December.  My daughter works with the ex-girlfriend of the brother of the girl who died.  Don't know the story but she never left the hospital.  It had something to do with a leak.  That is all I know.                                                                                                                                                     

Riley S 
on 12/29/12 When I was getting my surgery on 12/12/12 there was a woman at HRRH who had been done the day before than she had had an emergency surgery on my surgery day same surgeon (Dr. Klein) as me. When I left she was still in critical care. I hope she is not the one Laura is talking about but I had heard it was a leak too.                   

Laura H.
on 12/29/12 Sounds like it could have been.  She was taken back to surgery on the same day she had surgery.  She never recovered and I believe passed away the next day.  Her brother is from Kitchener so I assume she  was too.

Amanda F.
on 12/29/12
Can a patient find out if any other patients of a particular surgeon died as a result of surgery or complications from surgery? I looked on the CPSO website, but didn't see anywhere to see patient losses. I only saw a place for recent disciplinary action.



            AND YOU NEVER WILL!!!!!

       1/11/11
Dr Klein did get all of my mother's cancer BUT she died due to her after care. We visited Dr. K often with our concerns and several ER visits. He finally offered an ultrasound in 10 days; Mom passed away 2 days later. Mom's home care workers were diligent, kind and caring and insisted on us getting Dr.K to do something. I have a coroners report, and nurses’ attendance statements. 
 ***********************
THE DEATH INVESTIGATIVE OVERSITE COMMITTEE
I sent the DIOC my complaint in February of 2011.  It is now March 2013!!
I have heard this before--- last June, sometime in the Fall and then I was told it would start in January,  now when they finish the present case.

I believe they are simply stalling.


From:Arnold Kilby (awkilby@hotmail.com) You moved this message to its current location.
Sent:March-13-13 7:02:11 PM
To: fiona.foster@ontario.ca (fiona.foster@ontario.ca); dioc@ontario.ca (dioc@ontario.ca); Pauline SteveClarkBrockville Office (pauline@steveclarkmpp.com); steve clark (steve.clark@pc.ola.org); meilleur (mmeilleur.mpp.co@liberal.ola.org); a horwath (ahorwath-co@ndp.on.ca); Tim Hudak (tim.hudakco@pc.ola.org); andre marin (amarin@ombudsman.on.ca); fran cappe (fcappe@ombudsman.on.ca)

Dear DIOC, could you please answer the questions below in purple.

FROM THE DIOC WEBSITE:


What will happen to my complaint once it is received?

If your complaint specifically concerns the Chief Coroner or Chief Forensic Pathologist, the DIOC complaints committee will consider it directly.

In addition, the committee reviews complaints directly about the Chief Coroner or Chief Forensic Pathologist.
*******************************************************

I submitted my complaint  in February of 2011, That's two years ago.  Apparently, mine is next in line--I have heard this before. 

1) So, could someone explain to me why the above was not applied?   NOW OVER TWO YEARS!2) Was it delayed so that the Chief Coroner, Dr. Andrew McCallum, had a chance to vacate this position, which he did, to become the CEO of Ornge? 

3) Are you waiting for Dr. Bert Lauwers to vacate his position, as well?4) Do you actually have my submission and all the extras sent to the DIOC over the past two years?
5) I know there is no time limit set when you actually begin to look at my complaint and come up with a final decision BUT can I expect it in less than TWO YEARS?

As an advisory body, the purpose of the complaints committee is to consider complaints with a goal of improving Ontario’s death investigation system. The committee is not an investigative body and it is not within its mandate to review or assess medical conclusions or opinions with respect to a cause or manner of death.
In reviewing a complaint, the committee will consider the procedures undertaken during the course of a death investigation.

If you are unable to find suggestions to improving Ontario's death investigation system after looking through my complaint I would be happy to point them out to.
*******************************************************************************
Dear Mr. Kilby,
Thank you for your email.
I can confirm that your complaint is next to be reviewed by the Complaints Committee.  The Complaints Committee will begin to review your complaint once the review they are currently undertaking is finalized. 


As the amount of time required to review a complaint varies from case to case, we are unable to provide you with a set completion date.  We will, however, provide you with a bi-weekly update on the status of your complaint. We may also contact you if the Complaints Committee requires any further information or clarification.

Please note 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.
Should you have any questions on the complaints process or the role and mandate of the organization, please email us or call 416-212-8443 or toll free 1-855-240-3414.
Thank you,
DIOC Secretariat
*******************************************************************************************************
When the DIOC meets in  2013 to handle my complaint.

            You Have A Moral Dilemma 
 
— the two choices the DIOC have??
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.

                                                          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, 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.”   

Letter dated April 1, 2009 from Dr A. McCallum
“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 deaths 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 90
    How 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.”

            Lishan Aklog, MD FACS Surgeon from outside Canada
"The Surgical Care Improvement Project (SCIP) has established clear guidelines on antibiotic prophylaxis prior to all surgery (timing, type). Here in the US our hospital is literally graded on compliance with the SCIP protocols. As a department chair I am responsible for compliance on my team and have to have appropriate procedures in place to assure compliance."


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

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 CT scan.
“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.”

“Patient discharged without having a bowel movement.  Was this reasonable?   NO   Patient had diarrehea in hospital!!!!!”

 
“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 have received a “third” decision from this College and I am appealing to the Health Professions Appeal and Review Board   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??