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…

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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

Saturday, 11 October 2014

No Accountability or Transparency in Ontario--Dr. Laz Klein/Dr. Bert Lauwers/Dr. Andrew McCallum/Dr. Kirk Huyer/--Part Thirty-Two

           RE:  

CPSO 's Phase two transparency Discussion is not an open, transparent procedure‏

My attempted comments have been prohibited from the CPSO's Discussion blog.  This is happening to several others who have had issues with the CPSO.  They don't want the public to see all the responses that others may have attempted to post. They sure have a lot of Physician comments!

THEY HAVE DISAPPEARED FOR THE SIXTH TIME!
 

This shows you to what lengths the CPSO will go to, in order to eliminate public input while claiming to being transparent!  If they can not have an open, transparent comment discussion, do you really think they will operate in a manner that puts the public first and ensures patient safety?? 

Bill 29 must be passed.

                     

 

                                

REFLECTIONS IN THE MIRROR
As I gaze upon the mirror,
A tearful, old man does appear.
Over eight years exposing the truth;
Those in authority rejecting the proof.

            Nothing have I done has made a change!    Why?

As I peer upon the mirror,
A heart-broken man existing here.
Worn-out, exhausted and aspiring an end;
Those in power who fraudulently defend.

           Surgical negligence contributing to Terra’s death!    Why?

As I stare into the mirror,
A wounded heart beyond repair.
Those who ignored, you know who you are;
Failing the citizens; keeping justice afar.

             Nothing have I done has made a difference!    Why?

As I glance into the mirror,
My precious daughter does appear.
No positive changes have taken place,
By the very men/women who are a disgrace.

           Nothing have I done to enhance patient care!    Why?

As I look upon the mirror,
Faces of the guilty show up there.
Ontario Chief Coroner's Office;
Dishonest, devious; merely depraved scum!

            Salaried by us but committed to CPSO colleagues.    Why?

As my reflection weeps from within the mirror,
The failure of Bill 29 would make it abundantly clear.
My time on earth must come to an end,
               Transparency and accountability I could not defend.    Why?
*******************************************************
Why? –Our elected MPps feel Surgeons/Doctors’ reputations ARE more important than peoples’ lives!
                                    So let’s allow more preventable deaths.
******************************************************************************

 UPDATE:  January, 2015


HPARB refused my request for a reconsideration of the third HPARB decision!

The Ontario Ombudman's Office has stated they can do nothing with respect to my complaint regarding the Chief Coroner's Office's inept death investigation

And the Death Investigative Oversight Council stated they can do nothing with respect to the Chief Coroner not sending Terra's death to the Patient Safety Death Panel.

All of the above are completely useless and a total waste of tax payers' dollars!

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

ATTENTION:  ALL CITIZENS OF ONTARIO, CANADA.

RE: ACCOUNTABILITY AND TRANSPARENCY OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO

PLEASE DOWNLOAD THE PETITION AS MANY TIMES AS YOU WISH AND PERSUADE YOUR RELATIVES, FRIENDS AND NEIGHBOURS TO SIGN.  WE NEED TO GET AS MANY SIGNATURES AS POSSIBLE!   SPREAD THE NEWS OF OUR FAMILY TRAGEDIES.


https://onedrive.live.com/view.aspx?cid=2745897169AE6990&resid=2745897169AE6990%21336&app=WordPdf


ONLY THE ORIGINAL CAN BE MAILED DIRECTLY TO STEVE'S OFFICE WHICH IS ON THE BOTTOM OF THE PETITION.

*********************************************************************
Today is the last day of the fall session, Mr. Kilby.
 The legislature will return on Feb. 17, so if we could have them returned by early February that would be great.  LET'S TRY FOR FEBRUARY 8TH.

YOU MAY WISH TO DOWN LOAD A COPY OF BILL 29 SO THE PEOPLE WILL KNOW EXACTLY WHAT IT IS ABOUT

Look further down for Bill 29
**************************************************************

  Arnold Kilby

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

https://onedrive.live.com/view.aspx?cid=2745897169AE6990&resid=2745897169AE6990%21336&app=WordPdf



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

IMPORTANT NEWS
Over the years I have contacted each and every single MPP in Ontario with very little response.  Steve Clark’s Bill 29 is crucial if we want to see the CPSO accountable and more transparent to the citizens of Ontario who have allowed this institution to be self-regulatory.  They have not truly investigated citizen’s complaints for the past two decades and have masked negligence and hidden away the many errors that surgeons and doctors have committed.  How do we truly know that these surgeons have learned from their mistakes?  We can’t without Bill 29 becoming law.  (Keep in mind, open abdominal surgery to remove a tumor and have colon resection without the mandatory antibiotic prophylaxis being administered, no antibiotics for infected abdominal incision whereby all staples were removed and no antibiotics for the presence of “many gram negative bacilli”)




            The MPPs of Ontario do not really know how a death of a loved one affects the family but worse the contempt shown by the CPSO in their failure to truly investigate.  Perhaps, if there is indeed a heart within each of you, reading the following may help to persuade you to do the right thing.  Support Bill 29!   Terra bled to death!


Re: Dr Laz Klein

CPSO COMMENT  “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by [the Respondent] in this case. The Committee would suggest that [the Respondent] 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.” PURE  BULLSHIT!


My MPP, Steve Clark put forth his private members bill and it passed first reading:

Bill 29, Medicine Amendment Act, 2014

Bill 29                                                          2014   OCTOBER 20

An Act to amend the Medicine Act, 1991

Her Majesty, by and with the advice and consent of the Legislative Assembly of the Province of Ontario, enacts as follows:

   1.  The Medicine Act, 1991 is amended by adding the following section:

Register

   8.  (1)  The register maintained by the Registrar shall contain the following information about each member, in addition to the information that is required under the Health Professions Procedural Code:

    1.  A notation of every complaint filed with the Registrar regarding the conduct or actions of the member.

    2.  A notation of every caution of a member by a panel of the Inquiries, Complaints and Reports Committee.

    3.  With respect to every civil action or proceeding alleging the member’s professional negligence or malpractice, the prescribed information.

    4.  A notation of every death of a patient who was under the member’s care, as determined in accordance with the regulations.

    5.  If a member practised medicine in another jurisdiction, all available information from the other jurisdiction that is comparable, as determined in accordance with the regulations, to the information described in paragraphs 1 to 4.

Same

   (2)  The Registrar shall make best efforts to obtain the information described in paragraphs 1 to 5 of subsection (1).

Publication ban

   (3)  No action shall be taken under this section which violates a publication ban, and nothing in this section requires or authorizes the violation of a publication ban.

   2.  Section 12 of the Act is amended by adding the following clause:

  (d)  for the purposes of paragraphs 1 to 5 of subsection 8 (1), prescribing anything referred to as prescribed and governing any matter referred to as being determined in accordance with the regulations.

Commencement

   3.  This Act comes into force on a day to be named by proclamation of the Lieutenant Governor.

Short title

   4.  The short title of this Act is the Medicine Amendment Act, 2014.



EXPLANATORY NOTE

Currently, the Health Professions Procedural Code requires the College of Physicians and Surgeons of Ontario to maintain a public register of its members containing certain information. The Bill amends the Medicine Act, 1991, to provide that the register must also include information about complaints, cautions and civil actions or proceedings against a member, as well as information about deaths occurring in patients under the member’s care. The register would also include comparable information from other jurisdictions in which a member practised.
***************************************************************************

Subject: Steve's question to Health Minister
Date: Thu, 20 Nov 2014 14:42:58 +0000


Good morning, Mr. Kilby.

I wanted to send you a link to the video clip of Steve's exchange yesterday in Question Period with Minister Hoskins over CPSO transparency.

You can view it here: 

 
  *************************

The following was sent to Ontario Ombudsman, Andre Marin: and to every MPP in Ontario

ATT: The Ontario Ombudsman’s Office 
Re: Ombudsman’s Decision dated December 20, 2013 

I am sending this to all parties who have in the past looked and dealt (inadequately) with my concerns, as well, to my MPP and numerous others who are concerned. 

Image 
Mr. Marin 
Ms Boucher 
And the numerous other Ombudsman officials I have dealt with over the past 8 years or so: 
Kelly Mark Foote Early Resolution Officer/July 2008 
Julian Meynell Early Resolution OfficerSept 2008    
Jennie Santiago   March 2009 
Angela Alibertis 
Dominique Pierre 
Fran Cappe 

I know you are well aware of my many concerns that I have brought to you. 
I am extremely frustrated with the entire lack of transparency and accountability within Ontario’s Institutions.  I also realize that I have had to resort to actions that I sincerely wished I didn’t have to use, but how to you wake up a person/institution to the real world they are afraid to acknowledge is abusing honest people. 

I don’t feel you have gone into investigating my many concerns with a completely open and unbiased mind. 

Page One of your letter: 
Image



I believe you also have jurisdiction with regard to the Ontario Chief Coroner’s Office and both Ministries of Health and that of Corrections. 
It appears you never addressed my complaints verses the three above except to fully believe Dr. McCallum and Dr. Lauwers’ opinions with no basis of fact.  They were allowed to allege complaints to the Toronto Metro Police, which were followed up by the OPP from Brockville, whereby there was a visit to my home and two video taped interviews at the OPP station.  No charges were ever laid.  These were merely attempts to intimidate me, and try to prevent me from further investigating their failures. 

The DIOC 
When they rendered their decision, they said that they could not investigate the medical aspects of my complaint.  Yes, I know I am unable to do anything with regard to the denial of my request for a public inquest.  However, my other requests were quite reasonable such as referring my daughter’s death to the Patient Safety Death Panel. 

Now, it would be obvious to all that a complaint against the Chief Coroner regarding a death investigation would, of course, pertain to medical aspects of the investigation.  So, how can the DIOC simply disregard this?   And of course, the Ombudsman’s Office simply disregards this, as well! 

Page Five of your letter 

Image 

The College merely expresses the above without factual documentation to support the statement.   It is not a common and reasonable procedure when involving the colon! 

But of course, the Ombudsman’s Office and HPARB merely trust that this is the truth! 

Page Six of your letter 

Image 

Image

Now, I want you to pay careful attention to the word “neglected” above. This was found within the second and third decisions by the College.  They use of this word was in its verb form.  The noun version is “negligence”.   During my second appeal at HPARB, I had pointed this out.  It is very difficult for the College to retract this, so what they did was try to mask it in their 3rd decision by stating that Terra’s surgeon was unaware that a colon resection was to be done until after he had converted to open abdominal surgery. 

Now, the Ombudsman’s Office and HPARB appear to pay no attention to this very important statement by the College and their IO provider! 
Please note the following letter sent to Terra’s General Practitioner dated April 4, 2006, approximately 4 months prior to Terra’s surgery.  It clearly states that a bowel resection may be required.  Therefore, if the surgeon felt this was indeed a possibility then why did he not properly prepare her as the Standards require. I have enlarged it so that the Ombudsman’s Office can clearly see it. 
So, if HPARB was following procedures, why was this not a clear indication that the College’s assertion that Dr. Klein was completely unaware of the possibility of a colon resection occurring was conflicting the College’s IOP and itself. 

This along with the Surgery document stating under Procedure One are two positive pieces of FACT that have been totally ignored.  I ask why, except to place the surgeon first and Ontario citizens well behind.  Which is clearly what our Ontario Ombudsman’s Office has done. 

TELEPHONE (416)782-2616960 LAWRENCE AVE WEST 
FAX (416) 7*2-5899 
SUITE 504 
TORONTO, ONTARIO M6A 3B5  
LAZ V. KLEIN, M.D., M.Sc., F.R.C.S.(C)  
GENERAL AND LAPAROSCOPIC SURGEON 
April 4,2006  
 Dr. Sandra Best 
80 King St. East  
Brockville, ON  
K6V 1B5 
 RE: Terra Kilby Dear Dr. Best, 
Ms. Kilby has returned to my office today. I have had a chance to review her CAT scan. She likely has a mesenteric cyst or possibly a duplication cyst. It looks amenable to laparoscopic excision and appears to be separate from the bowel, kidney and ureter. 
She continues to have symptoms and has a palpable mass in her right abdomen. 
1 have therefore recommended a laparoscopic excision of the cystic mass. We discuss potential risks which include infection, bleeding, bowel injury, bladder injury. There is a risk of injury to any nearby organs such as her ureter or major blood vessels.  
There is also small risk that she may require a bowel  
resection.  

Certainly, there is a risk that this will need to be done through an open approach. 
She would like to go ahead. I answer any question she had. Consent for surgery was obtained. I will take her to the operating room at the next available opportunity. 
Sincerely, 
Laz V. Klein, MD, MSc, FRCS(C) LVK 
TRANSCRIBED BY VOICE RECOGNITION TECHNOLOGY. DICTATED BUT NOT READ 


This is the first time that I have seen this letter that was sent as part of the package from the College to HPARB for the third review.  I wonder what else I have not seen?   

Page Eight of your letter 

Image 

THE MAJOR “BOO BOO”! 

Here is where the College tries to cover up their use of the word “neglected” by incorrectly stating the surgeon was unaware that he would be dealing with the bowel. 

And let us not forget the letter sent to Terra’s physician previously shown in this letter. 

How can HPARB and the Ombudsman’s Office not place any importance on the conflicting facts?  And appear to overlook this major injustice! 

If either of the above looked at the operation procedure report, you would have notice that Procedure One clearly indicates the laparoscopic attempt for a colon resection.  It is clearly stated.  Please look under “Surgical Procedure” in the chart below: 

Procedure One:   "laparoscopic colon resection attempted for mesenteric mass"
Procedure Two:   "hemi-colectomy (right colon resection) and excision"

For some reason the chart keeps disappearing:


But you can find it by copying the following and pasting it in a new window:
https://onedrive.live.com/view.aspx?cid=2745897169AE6990&resid=2745897169AE6990!327&app=Word

This was before the surgeon converted to open abdominal surgery.  This clearly indicated the surgeon knew the colon was go be a part of the operation and apparently attempted a colon resection in the minimal evasive procedure.   He then went ahead with open abdominal surgery without the mandatory antibiotic prophylaxis being administered.   The second procedure clearly indicated the open abdominal surgery.  So, my daughter’s life was at risk because it was more cost and time efficient to proceed.   Therefore when the IOP states “the standard would not require the administration of prophylactic antibiotics” is a deliberate attempt to confuse and mislead all.   I have maintained all along that I was in total agreement that laparoscopic surgery may not require this antibiotics but this was open abdominal surgery that does.  The expert agreed with this in the second decision but then had to somehow hide it in the third decision. 


And HPARB and the Ombudsman’s Office accepts that my daughter did not require any antibiotics whatsoever during her entire stay, even after the abdominal incision became infected and test results show “many gram negative bacilli present”.   Now, the College cleverly masks the truth with regard to these two issues.  Yes, they are absolutely correct that there is no need for antibiotics in these circumstances.  But, that is only if the mandatory antibiotic prophylaxis had been administered.  The College cleverly presents their view without mention that this important detail was overlooked.  When have you ever heard of someone going through major surgery with no antibiotics prior, during or after the operation during their stay in a hospital?  Come on, Mr.Ombudsman, think about this.  No, let’s not research this and merely accept that the College is a trustworthy organization! 

Please note this additional fact regarding the seriousness of Terra’s infections as see in this letter from the Eastern Ontario Coroner, Dr. David McCallum who later became the Chief Coroner of Ontario.  This was sent to the College: 

This is the first time that I have seen this letter that was sent as part of the package from the College to HPARB for the third review.  I wonder what else I have not seen?  AWK 

This is now the THIRD FACT totally ignored by the College, HPARB and the Ombudsman’s Office.

TAKE SPECIAL NOTE OF THE PORTION IN BOLD PRINT     
Community Safety and Correctional Services 
Office of the Regional Supervising Coroner - Eastern Region 
366 King Street East, Suite 440 
Kingston. ON   K7K6Y3 Telephone:613-544-1596 
Facsimile:613-544-3473 

Mlnistere de la Securite communautaire et des Services correctionnels 
Bureau du Coroner Superviseur Regional - Region de 1'Est 
366, rue King Est, Bureau 440 Kingston, ON  K7K6Y3 Telephone:613-544-1596 
Telecopieun613-544-3473 

September 14,2007 
Ms. Sandra Keough 
Investigator 
Investigations and Resolutions 
The College of Physicians & Surgeons of Ontario 
80 College Street 
Toronto, ON M5G2E2 
Dear Ms. Keough: 
Re: Kilby, Terra Dawn 
Death Pronounced: 21 July 2006 
Our File No.: 2006-11425 
The investigation into this death has now been completed. In response to your original request to the Office of the Chief Coroner, which was forwarded to my office, please find enclosed the following documents: 
  1. Coroner's Investigation Statement 
  1. Report of Postmortem Examination 
1 trust this information will be of some assistance to you. Yours sincerely, 
Image 


Andrew McCallum, MD, FRCPC 
Regional Supervising Coroner for Eastern Ontario 
AM/lr 
cc       Dr. James T. Cairns, Deputy Chief Coroner for Ontario 

I have now only copied the pertinent information from this letter to the College from Dr. McCallum, Eastern Ontario Coroner, at that time. 

Contributing Factors: 
Narrative 
This 28 year old woman underwent abdominal surgery on the bowel 10 days ago and  
was discharged homo on July 19th to her parent's home to recover. She had had a  
bowel tumor removed and the operation was complicated by a post op wound  
infection.  At discharge, her vitals and bloodwork were normal, though there was some  
foul smelling discharge from the incision She was feeling well upon arrival to her  
parents' home but suddenly felt unwell in the bathroom that evening and collapsed. She  
was rushed to hospital by ambulance but died in emergency respite resuscitation. 

Regional Supervising Coroner's Note: the cause of death as determined at autopsy was intra-abdorninal hemorrhage on a background of coagulopathy  
A 2cm defect was noted at the line of anastomosis (the point of joining) of the  
terminal ileum and transverse colon. This defect was oozing blood, but (he pathologist  
could not determine if this was the point where hemorrhage occurred The Regional  
Supervising Coroner for Toronto West has reviewed this case with the hospital. A meeting has been held with Ms. Kilby's parents 

AWK-- note -- according to the records her blood work was not normal.
Page Eight of your letter 
Image 
Image 
Image 

Please note the expert statement above which clearly indicates it is a Standard of Care.  This is why is use the term “neglected” in the second College decision. 

So again, how can HPARB and the Ombudsman’s Office not see this! 

Now notice the following: 
Image 
So, they first state that the surgeon didn’t know that the bowel would be affected and now they are attempting once again to confuse the situation by their statement above trying to absolve the surgeon’s neglect!!   Again, it should be noted that the College has never provide factual documentation to support their opinions.  They must have access to numerous medical journals, books, ect.,to do so.  Why don’t they??????  It seems to be a simple request to do so!    Remember, the patient got no antibiotics at all. 


Page Nine of your letter; 
Image 
The Board does indeed have the authority to conduct an investigation and/or engage in further fact finding.  The Chair of the third HPARB appeal stated so when I brought it up, and he said at the time that it is rarely used, if at all! 
I believe all my concerns should be readdressed beside what I have brought forth in this letter.  The College has covered up numerous “Care Issues”.  They seem to dwell on the death and relating my concerns leading to her death.   My complaint was not on the death but the  “Standards of Care” and this is where the College’s responses suck in HPARB and the Ombudsman’s Office.  Take the death out of the picture, just concentrated on the issues of Patient Care! 

Also, with respect to HPARB’s statement in the second paragraph.  So, the member that is the subject of the complaint only needs one, I repeat one, expert opinion that supports the actions taken by the health professional.   Do you realize how absurd this is?  This may be true if the College did indeed put patient safety first, but they don’t.  And secondly, I have shown already the discrepancies in the College’s and the IOP’s statements.  My over 100 qualified surgeons’ opinions supported by my research should have made HPARB conduct a further investigation and further fact-finding. 
Of course the Ombudsman’s Office swallows the above HPARB response to my request for them to review all decisions made my HPARB appeal and review panels. 


There is no way the College or even HPARB conducted a reasonable and adequate review” 
Image 
They may have followed the practices and acted within its legislative mandate, BUT is it not required to base their decisions of factual truths?  It appears when an institution or party get caught, they do what they can to make the issue go away even if it means accountability and transparency is abused so that the public is indeed not protected. 
What a shame! 
Respectfully yours,   A W Kilby   888 County Rd 2,  Lansdowne, Ontario,  K0E 1L0 

So, how do you explain the Ombudsman’s role in this farce? 

REPLIES FROM MPPS:   
THE ONLY MPPS TO REPLY!  SHAME!
LIBERAL---Thanks for taking the time to inform the office as to what is occurring. Your time is greatly appreciated.

Office of MPP Joe Cimino  

Sudbury, Ontario
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NDP---Thank you for your email.  I am certain you can appreciate, it has long been a custom and a courtesy to allow each MPP to address the concerns of their constituents.  As you reside in Southern Ontario we feel it is best to continue to deal with your local MPP.

 Sincerely,
 Karen O'Connor
Special Assistant
Bill Mauro, MPP Thunder Bay-Atikokan

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Conservative---Steve Clark Leeds/Grenville
My MPP, Steve Clark called me this evening to tell me that the Conservative Caucus supported the bill which he is introducing this Monday in the afternoon.
He explained that it is not the be all to end all, but it is a beginning. Basically it refers back to the article written by Alan Shanoff a year ago. ---- making Cautions public so that it becomes a little more transparent.
He agreed that there are many other concerns that the government should address and he is hoping that the media will pick up on his bill and pursue it further.
I mentioned that we will probably find the College issuing very few cautions from now on, thus hiding their action behind closed doors once again.
He said that at approximately 10:15 on Monday, he will try and pop out to meet me for five minutes.
The protest begins at the CPSO at 8:30 am and then we walk to Queens Park for 10:00am
 
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Additional e-mail sent to the Chief Coroner Dirk Huyer, Ontario's Ombudsman, Andre Marin.

Mr  Huyer,  Chief Coroner

At our meeting in June,2014, you mentioned that there were several "patient care " issues you could not deal with as it was not in your authority to do so according to the Coroner's Act.  I guess that was an outright lie!  The stench is not coming from the morgue but from your own office!
I believe you are responsible to "facilitating patient safety improvement" but choose not to do so because it would involve a fellow member of the CPSO.
Taken from the CCO website:


"Another modality available to the Office of the Chief Coroner to facilitate patient safety improvement is a Regional Supervising Coroner’s Review. Regional Supervising Coroner’s Reviews have been conducted for a number of years as an alternative to an Inquest where there appear to be specific areas that may be the focus of recommendations and in matters where the medical issues may be complex. This is especially true when issues identified are confined to one hospital department."    NOTE:  HRRH's department was shut down temporarily in 2010 by the Coroner's Office due to 5 to 6 deaths in 2009 to Feb of 2010.  My daughter had been operated in July of 2006 in this same department.  My many request to the Chief Coroner's Office was denied--- perhaps the deaths after my daughter's may have been prevented!  ---including the death of a 27 year old woman by the same surgeon in Dec of 2012-- same department and same team.


"These meetings allow opportunity for clarification of any issues identified by the investigating coroner and allow reflective learning through discussion. The Regional Supervising Coroner chairs the meeting summarizing the details of the case as understood from the review of the medical record and the coroner’s investigation. PDRC expert report(s) will assist with case discussion illustrating any issues identified. An expert may attend to assist the Regional Supervising Coroner in the discussion."


"These meetings provide an opportunity for those present to receive suggested recommendations and consider approaches for implementation. By involving those who participated in the child’s care, recommendations that are insightful, reasonable and practical, and enhance medical organizational effectiveness will hopefully result from the discussion."
*****************************
"One way to prevent such deaths is to study fatal adverse events and to ensure that the lessons learned are understood by everyone in the health care system so that continuous improvements can be made in the way care is delivered. In this way, the processes of care are improved, and care becomes progressively safer. It is this philosophy upon which the mandate of the Patient Safety Review Committee (PSRC) of the Office of the Chief Coroner is based."

"To help expedite the review of coroners’ cases with actual or perceived systemic patient safety implications, and where possible to make recommendations to prevent future similar deaths through more immediate actions, the Office of the Chief Coroner established the Patient Safety Review Committee in 2005."

 


    1 To provide expert opinion about the cause and manner of death in health care-related cases where systems-based errors appear to be a major factor. 
    2 To assist coroners to improve the investigation of deaths within, or arising from, the health care system in which systems-based errors appear to have occurred. 
  1. To stimulate educational activities for professionals through identification of systemic problems, referral to appropriate agencies for action, collaboration with professional regulatory bodies and the dissemination of an annual report. Emphasis will be placed on speedy dissemination of information.
  2. To provide expert evidence at inquest on request.
  3. To do, or promote research, where appropriate.
  4. To undertake random or directed reviews when requested by the Chairperson.
  5. To help identify the presence or absence of systemic issues, problems, gaps, or shortcomings of each case to facilitate appropriate recommendations for prevention.
A patient safety review of my daughter's death would have definitely helped the committee with several of their aims and objectives listed above, but they never got the chance due to the corrupt actions of past and present Chief Coroner's of Ontario.

"The Patient Safety Review Committee reviews coroners’ cases that are referred by a Regional Supervising Coroner. These cases, and the issues arising from them, may be brought to the attention of the Regional Supervising Coroner through the investigating coroner, family of the deceased, or other organizations, agencies or individuals."
I definitely brought my daughter's case to the Chief Coroner's Office and tried to bring it to the Eastern Ontario Coroner but the CCO blocked my efforts repeatedly.

The motto of the Chief Coroner's Office is a complete fallacy.  The only speak when they want to and definitely not if a surgeon or hospital is implicated.  They are controlled by the CPSO!



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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. 

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BEWARE OF ALL THE INSTITUTIONS AND PEOPLE NAMED BELOW

FEEL FREE TO SEND THE FOLLOWING AN E-MAIL EXPRESSING YOUR CONCERNS:
--Dr. Bert Lauwers CCO
blauwers@rmh.org
--Dr. Andrew McCallum CCO
amccallum@ornge.ca
--Dirk Huyer Acting Chief Coroner of Ontario 2014
dirk.huyer@ontario.ca
--Fiona Foster Manager-Death Investigative Oversight Council fiona.foster@ontario.ca 

--Linda Lamoureux Health Professions Appeal/Review Board since left to go to Parole Board
--Janice Vauthier    janice.vauthier@ontario.ca Chair Of HPARB
--Anna Dunscombe
Anna.Dunscombe@ontario.ca
--Thomas Joseph Kelly Vice-Chair, Presiding
tomkelly@forestcitylawyers.com
Panel Member for third decision HPARB
--Stephen Jovanovic Vice-Chair
djovanovic@bartlet.com Panel Member for third decision HPARB
--Brenda Petryna
bpetryna@sudburylaw.com
Panel
Member for third decision HPARB
--Angela Bates CPSO abates@cpso.on.ca

--Brian M Taylor  brian.taylor@lhsc.on.ca   CPSO's Independent Opinion Provider
--Dr. Rueben Devlin CEO of Humber River Regional Hospital

rdevlin@hrrh.on.ca
--Barb Collins COO of Humber River Regional Hospital
bcollins@hrrh.on.ca
--Kathleen Wynne Premier of Ontario

kwynne.mpp@liberal.ola.org
--Eric Hoskins Minister of Health

ehoskins.mpp@liberal.ola.org
ehoskins.mpp.co@liberal.ola.org

--Madeline Meilleur Past Minister of Corrections

mmeilleur.mpp.co@liberal.ola.org
--Yasir Naqvi Present Minister of Corrections

ynaqvi.mpp.co@liberal.ola.org
--Andre Marin Ontario's Ombudsman amarin@ombudsman.on.ca
--Lorraine Boucher Ontario Ombudsman's Office

lboucher@ombudsman.on.ca
--Fran Cappe Ontario Ombudsman's Office
fcappe@ombudsman.on.ca
--Angela Alibertis Ontario Ombudsman's Office
aalibertis@ombudsman.on.ca
--Domonie Pierre Ontario Ombudsman's Office
dpierre@ombudsman.on.ca
--And let's not forget the surgeon
Dr. Laz Klein --Humber River Regional Hospital

lklein@hrrh.on.ca l.klein@utoronto.ca surgery@misgroup.ca

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Most Interesting Man in the World

I don't always ........................but when I do I ...........................



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Has competition from these Ontario Men below:
Current Chief Coroner of Ontario, Dirk Huyer
"I don't always answer truthfully,
But when I do, I mask it with complete BS!"

 
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Past Deputy Chief Coroner of Death Investigations,

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Past Chief Coroner of Ontario, Andrew McCallum  --currently the Head of Ornge
"I don't ever cover up a faulty death investigation,
But when I do, it is to support my colleagues!"

 
I couldn't send this to Dr. McCallum as he has blocked me but perhaps one of you could do it for me at:  amccallum@ornge.ca
**************************************************************
Ontario Ombudsman, Andre Marin
"I don't personally get involved with a citizen's complaints,
But when I do, it is so I can be publicly recognized for doing so!"