No Accountability or Transparency in Ontario-Drs: BertLauwers/AndrewMcCallum/DirkHuyer/LazKlein

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.” Humber River Hospital, the CPSO, the CCO's Office(Drs A McCALLUM, B LAUWERS, D HUYER), HPARB, the DIOC, Ombudsman's Office, the Ontario Patient Ombudsman, most MPPs the Provincial Liberal Party have all failed Ontario citizens. What will the new Conservative Government do? So far NOTHING

CPSO updated decision

Update as of end of July 2020

The most relevant portion of Mr Clark’s e-mail response:

“I recognize that you want to see more done and I extend the same offer to you today that I did on the day we first met. That is to work with you and the government to improve accountability and transparency in our health-care system.”

“But what I can’t do, Arnold is retroactively change the system that was in place when you were seeking answers about Terra’s tragic death.” Steve Clark

SO, MR CLARK IS SAYING TERRA‘S LIFE IS IRRELEVANT because she died due to medical negligence 14 years ago and covered up since then. Who cares— MPP Clark does not.

He has been fully aware since he was Mr Runciman’s Administrative Assistant.

My Response: MPP Clark, you have washed your hands of me. But, you certainly could get the Health Minister using Terra’s case to enact changes to the institutions that failed me and many others. She has considerable authority over HPARB and The CPSO and Hospitals. And the Minister of Corrections can do the same with regard to the CCO and the DIOC

I am sorry but you were far more outspoken before. Since then you have failed Terra and other victims of medical negligence.

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

So sad to see my own Member of the Provincial Parliament, Steve Clark throw away his moral and ethical integrity, when the party he belongs to regained power at Queen’s Park, in order to obtain a Ministerial position within this government. He appeared to be far more vocal during the Liberal government than now. WHY? The old standard still exists— a politician in opposition or campaigning for re-election will say and do anything but this all changes once being elected!

In the morning of October 31^st, 2019 Mr. Jiggens, the administrative assistant to MPP Steve Clark returned my phone call. He informed me MPP Steve Clark and Health Minister Christine Elliott could not do anything with regard to my case with both the CPSO and HPARB as it deals with an individual case--- I pointed out that there are numerous cases involving this surgeon. I told him how disappointed I was and that I do not feel this was true as the Minister does indeed have oversight over both of these institutions. This was merely another “Bull shit” response

Ministry of Health and Long-Term Care

Office of the Deputy Premier and Minister of Health and Long-Term Care

777 Bay Street, 5th Floor

Toronto ON M7A IN3 Telephone: 416-327-4300 www.ontario.ca/health

MAY 02 2019

Mr. Arnold Kilby awkilby@hotmail.com

Dear Mr. Kilby:

Ministere de la Santé et des Soins de longue durée

Bureau du vice-premier ministre et ministre de la Santé et des

Soins de longue durée Ontario

777, rue Bay, 5e étage

Toronto ON M7A IN3 Téléphone : 416 327-4300 www.ontario.ca/sante

361-2018-4087

Thank you for your email regarding your concerns about the investigations into your late daughter's care at the former Humber River Regional Hospital. You and your family have my deepest sympathies.

I would like to assure you that accountability and transparency are important to me and the Ministry of Health and Long-Term Care.

I remember your daughter's case well from my time as Ontario's Patient Ombudsman, and I regret to hear that you continue to feel that your concerns regarding the investigations have not been appropriately addressed.

While I understand that you are not satisfied with the outcomes of these independent investigations; unfortunately, neither I, nor ministry staff, can intervene or become involved in individual cases.

Please accept my condolences for your loss.

Sincerely,

Christine Elliott

Deputy Premier and Minister of Health and Long-Term Care

Duty of Minister

3. "It is the duty of the Minister to ensure that the health professions are regulated and co-ordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board."

Besides the Health Minister, Christine Elliott and her Ministry failing to uphold her own responsibilities expressed in the Act, she and the Conservative government have also failed to ensure the College of Physicians and Surgeons of Ontario uphold the “Objects of the College” which is expressed within the Act.

The Regulated Health Professions Act, Schedule 2, Section 3, sets out the objects of the College of Physicians and Surgeons of Ontario (CPSO):

Objects of College

3. (1) The College has the following objects (emphasis added):

1. To regulate the practice of the profession and to govern the members in accordance with the health profession Act, this Code and the Regulated Health Professions Act, 1991 and the regulations and bylaws.

2. To develop, establish and maintain standards of qualification for
persons to be issued certificates of registration.

3. To develop, establish and maintain programs and standards of practice to assure the quality of the practice of the profession.

4. To develop, establish and maintain standards of knowledge and skill and programs to promote continuing competence among the members.

5. To develop, establish and maintain standards of professional ethics for
the members.

6. To develop, establish and maintain programs to assist individuals to
exercise their rights under this Code and the Regulated Health
Professions Act, 1991.

7. To administer the health profession Act, this Code and the Regulated Health Professions Act, 1991 as it relates to the profession and to perform the other duties and exercise the other powers that are imposed or conferred on the College.

They have, in fact become accomplices in the cover-up of medical negligence and have therefore put patient safety at severe risk. Once again, there is absolutely “no transparency and accountability within Ontario’s Health Care System.

Further adverse events and possible deaths by this surgeon lay completely at the foot of both Steve Clark and Christine Elliott.

Just one of many “Standards of Care” which was not adhered to by this surgeon and hospital:

–open abdominal surgery to remove a tumor and perform a colon resection without the mandatory antibiotic prophylaxis, no anti-biotics for infected abdominal incision whereby all the staples had been removed and not anti-biotics when test results indicated the “presence of many gram-negative bacilli” (in same category as C Dificille) No antibiotics given during entire hospital stay! How have the Health Minister, Christine Elliott, my MPP, Steve Clark and the Conservative Government ensured that the standards of care are indeed upheld???

Terra Dawn Kilby, age 28, bled to death less than 12 hours after being discharged from Humber River Hospital in Toronto.

One can only hope Karma comes to those MPPs and other parties who failed to act!

PUBLIC SERVICE OF ONTARIO ACT, 2006
Made: June 27, 2007
Filed: July 25, 2007
Published on e-Laws: July 27, 2007

Oath of Office

I, Steve Clark (Christine Elliott) swear (or solemnly affirm) that I will faithfully discharge my duties as a public servant and will observe and comply with the laws of Canada and Ontario and, except as I may be legally authorized or required, I will not disclose or give to any person any information or document that comes to my knowledge or possession by reason of my being a public servant. So help me God. (Omit this phrase in an affirmation.)”

An MPP brings the riding’s concerns and needs to the table, and will have a stronger voice if he or she holds a high spot in the government. Cabinet ministers hailing from specific region will be able to shine more light on the area.

NOT IN MY CASE.
As a representative for a particular riding, a MPP is responsible for voicing the concerns of a specific region within Ontario on behalf of the citizens who live within this riding.

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

This is not Terra's case but regarding another death.

This reappeared on the CPSO website re: Dr. Klein

https://doctors.cpso.on.ca/DoctorDetails/L-Klein/0117032-70489

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

Concerns

Source: ICR Committee
Active Date: June 21, 2019
Expiry Date:

Summary:
Specified Continuing Education and Remediation Program:

A summary of a decision of the Inquiries, Complaints and Reports Committee in which the disposition includes a Specified Continuing Education and Remediation Program (“SCERP”) is required by the College By-laws to be posted on the register, along with a note if the decision has been appealed.

A SCERP is one of the dispositions that the College’s Inquiries, Complaints and Reports Committee may make in connection with a matter before it, and this disposition requires the member to complete an education and remediation program specified for the member. A note will also be posted when all the elements of the SCERP have been completed. The summary will be removed from the register if the decision is overturned on appeal or review. Note that this requirement only applies to decisions arising out of a complaint dated on or after January 1, 2015 or if there was no complaint, the first appointment of investigators dated on or after January 1, 2015.

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

SUMMARY

Dr. Lazar Victor Klein (CPSO# 70489)

1.Disposition

On March 16, 2018, the Inquiries, Complaints and Reports Committee (the Committee) ordered general surgeon Dr. Klein to complete a specified continuing education and remediation program (SCERP).

The SCERP requires Dr. Klein to:

·Practice under the guidance of a Clinical Supervisor acceptable to the College for six months

·Undergo a reassessment of his practice by an assessor selected by the College approximately six months following completion of the SCERP

·Review relevant Clinical Practice Guidelines, including literature for guidelines on early identification and management of sepsis, as well as College policies on Medical Records and Test Results Management, and provide a written summary of the documents with reference to current standards of practice, how it is applicable to Dr. Klein’s situation, as well as how Dr. Klein has made, or plans to make, changes to his practice.

2.Introduction

A family member of a deceased patient complained to the College that Dr. Klein failed to provide adequate care and treatment to the patient during the patient’s December 2014 hospital admission with a possible small bowel obstruction, in that he failed to respond to or follow up on the patient’s abnormal blood work result (the urinalysis showed >100,000 E.Coli), and failed to follow up on the family’s request for an autopsy (which was ultimately not performed). Prior to this admission, the patient had been self-catheterizing for a few years, but was otherwise well and mobile.

3.Committee Process

In August 2016, a previous panel of the Committee issued advice to Dr. Klein on several aspects of his care. The complainant appealed the Committee’s decision to the Health Professions Appeal and Review Board (the Board). In a decision dated November 7, 2017, the Board confirmed the Committee’s decision to issue advice to Dr. Klein with regard to documenting his care when he is the most responsible physician (MRP), and bringing this case to morbidity and mortality rounds to raise awareness and provide education.

However, it directed the Committee to reconsider its decision to issue advice to Dr. Klein on other aspects of his care relating to test results follow-up and narcotics prescribing.

On March 16, 2018, a Surgical Panel of the Committee, consisting of public and physician members, met again to review the relevant records and documents related to the complaint, following the Board’s review.

The Committee always has before it applicable legislation and regulations, along with policies that the College has developed, which reflect the College’s professional expectations for physicians practising in Ontario. Current versions of these documents are available on the College’s website at www.cpso.on.ca,under the heading “Policies & Publications.”

4.Committee’s Analysis

The Committee was of the view that the urinalysis results, along with the patient’s history of self-catheterization and prior urinary tract infections (UTIs), the significant increase in her white blood cell (WBC) count (from a normal level of 9,000 at admission to 22,000 by 9:00 am on December 4), and her falling oxygen saturation should have alerted Dr. Klein and hospital staff to the strong possibility of sepsis.

The Committee noted that in his response to this complaint, Dr. Klein indicated that he did not consider the possibility of a sepsis diagnosis.

Furthermore, although he claimed to have first seen the patient at approximately 9:00 am on December 4, he failed to document the increased WBC, both at this time and at his subsequent 6:00 pm reassessment.

The Committee was concerned about the significant failure to treat a highly likely UTI with appropriate antibiotics within 12-24 hours of admission, which should have occurred with or without the associated diagnosis of a small bowel obstruction.

Furthermore, even if the patient’s abdominal examination did not suggest a strangulated small bowel obstruction or other acute intra-abdominal condition, the Committee noted that there was no indication that Dr. Klein considered the reason for the patient’s seriously elevated WBC count, which he continued to claim was non-specific.

Given Dr. Klein’s failure to offer any explanation for this concerning information in his various responses to this complaint, the Committee felt he demonstrated a lack of insight regarding his failure to properly manage the patient’s care.

The Committee noted that a prudent physician should have recognized the above mentioned results as highly indicative of an inflammatory response, such as septic shock, and initiated appropriate antibiotics.

The Committee was not in a position to determine what caused the patient’s death, but noted that the dose of narcotics the patient received was minimal, and that there was no information to suggest that the narcotics, which were in fact ordered by a different physician, were inappropriate at the time of the initial order.

With respect to medical record-keeping, the Committee was concerned that Dr. Klein did not write any notes at any time during the patient’s admission, which does not meet the standard of care and does not comply with the College’s policy on Medical Records.

Furthermore, this lack of documentation made it difficult for the Committee to assess the true extent and quality of care that Dr. Klein provided to the patient.

The Committee noted that the involvement of residents or students does not absolve physicians from their own documentation responsibilities.

The Committee noted that Dr. Klein has a significant history with the College, which include cases raising both clinical and record-keeping issues, for which he has received advice and been cautioned.

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

IMAGINE IF HPARB HAD O ACCEPTED MY REQUEST FOR RECONSIDERATION, DEATHS AFTER TERRA'S MAY VERY WELL HAVE BEEN PREVENTED.

Our newly elected Conservative Government and the Health Minister must step in to correct this injustice!!!

From the College’s magazine “Dialogue” April Issue 2009

“Either party can then make an application to HPARB following which HPARB can direct the ICRC to continue the investigation, make recommendations to the ICRC as HPARB sees appropriate, or take over the investigation.”

This was denied and during the third review the panel appeared surprised that I had mentioned this and also appeared to be unaware of this procedure.

Had they taken over the investigation and/or granted my request for Reconsideration the further deaths occurring and adverse events under this surgeon may well have been averted!

MY Request to HPARB for Reconsideration of their third decision with regard to Procedural Fairness and Principals of Natural Justice --- Denied by HPARB

Ms Vauthier

HPARB

From your letter dated, January 12, 2015

“With respect to the Board’s decision in the matter of 08-CRV-0097, the Board has reviewed your request and can find no basis upon which to reconsider its decision. A reconsideration by the Board is discretionary and will only be undertaken in exceptionally circumstances that demonstrate the Board acted outside of its jurisdiction, did not consider an issue it was mandated to determine, or that its processes were in breach of natural justice or lacked procedural fairness. In 08-CVR-0097 the Board returned your complaints to the Investigations, Complaints and Reports Committee of the College of Physicians and Surgeons of Ontario for further assessment. The Board conducted its review in accordance with its legislated mandate and there is nothing to suggest its review was not carried out in accordance with the principals of natural justice or that is lacked procedural fairness. As such, the Board will not be reconsidering its decision in the matter of 08-CVR-0097.”

What a bullshit response!

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

THE BASIS FOR RECONSIDERATION IS CLEARLY STATED BELOW:

#1 Having the Chair for the third appeal, who pretty much control the entire proceedings from London, Ontario (Forest City Lawyers - London) as is the College's Independent Opinion Provider, Dr. Brian Taylor.

No problem perhaps, but it certainly explains how this HPARB panel completely came up with their incredible decision and prevented me from giving my oral presentation.

I would have thought the Chair would have excused himself from this panel!

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

#2 The contradictory CPSO's opinion with their own expert as well as the factual documentation within Terra's medical records!

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

In response to a request for further information from the College, the IO provider also set out the following information:

* The standard of practice for open bowel resections is to provide antibiotic prophylaxis.
However, such administration would not reduce the risk of anastomotic leak.

* The standard of practice would be to administer prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only and not opening the bowel, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.

AWKILBY’s Response: The above is pure BS. He knew before he converted to a laparotomy!!

Note the following: This proves that Dr. Klein was going to attempt laparoscopically a colon resection for a mesenteric mass. This was before he converted to a laparotomy!!!

Note the Procedure Desc. In the chart I submitted for the third appeal.

Note the Procedure Desc. In the following chart:

“Laparoscopic Colon Resection Attempted For Mesenteric Mass”

The second Procedure Desc. indicates the laparotomy.

And from Dr. Taylors’(the College’s I.O)letter to Angela Bates May 8^th, 2011,

“During the surgery on July 11 2006, Dr. Klein realized that the mass was not separable from the colon or retroperitoneum and obtained consultation with a colleague and went ahead with an open right colectomy. This is well documented in the operative note on page 48.”

From Dr Klein’s own notes:

At the time of laparoscopy, a large cyst could be seen in the mesentery of the right colon. It was densely adherent to the bowel as well as densely adherent to the lateral abdominal wall. It felt very solid and not at all in keeping with a simple mesenteric cyst. We therefore made the decision to convert to an open procedure.

The fascia was divided. The peritoneal cavity was entered under direct vision. A 10 mm trocar was inserted. Pneumoperitoneum was obtained. A 5 mm subxiphoid and 5 mm suprapubic port were placed under direct vision. We immediately could see the large mass in the right upper quadrant and the findings were as above. We did not feel that this was at all easily accessible laparoscopically and could not separate the plane from the lateral abdominal wall as well as from the colon. At this point, we made a decision to convert to a laparotomy

From Dr Klein’s letter to Terrra’s Family Doctor

So, he has suspected this was a possibility Three months prior to the operation

TELEPHONE (416)782-2616 960 LAWRENCE AVE WEST

FAX (416) 7*2-5899SUITE 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

Issue before the Committee

HPARB directed the Committee to reconsider this matter in light of the question of whether Dr. Klein met the standard of practice concerning the use of preoperative antibiotics.

Addendum Report from the IO Provider

The IO provider set out the following information in an addendum to the IO report:

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

AWKILBY’s Response: The outcome is not part of the complaint!

* Most general and colorectal surgeons administer antibiotics preoperatively prior to laparoscopic or open colorectal surgery, as they have been shown to reduce the incidence of wound infection. Antibiotics, however, have not been shown to decrease the incidence of anastomotic leak.

AWKILBY’s Response: Temporarily forget the anastomotic leak which was not in my complaint.. The above statement indicates the Standard of Care that was not followed by Dr. Klein.

#3 The complaint was about the Standard of Care not my daughter’s death. Interesting to note the College always mentions the tragic outcome. Stick to the Standards of Care not the Death. HPARB got sidetracked away from Standard of Care and somehow interpreted the Standard of Care not resulting in the death. This was not the complaint.

How can HPARB not focus on the actual wording from the Independent Opinion Provider and the College with respect to their statement contained within the Second and Third Decisions?

· "The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case."

Neglected equals Negligence

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

"The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case."

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

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

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

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

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

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

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

This was extremely unfair and the procedural process was definitely affected negatively. It makes one wonder whether HPARB had already decided well before, especially considering the following:

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

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

--Totally ignored my expert's opinions.

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

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

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

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

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

From letter sent to the College by Dr. Klein

July 13, 2011

Ms. Angela Bates Manager, Committee Support Area Investigations and Resolutions

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

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

Antibiotics

The independent assessor is correct that Ms. Kilby did not receive preoperative antibiotics. I agree with the independent assessor's opinion in response to your subsequent letter that preoperative antibiotics would not have been a contributing factor to the anastomotic leak. Antibiotics are used to prevent or treat an infection. They have no preventative or beneficial effect for an anastomotic leak. Furthermore, it is not my practice to prescribe antibiotics for a planned laparoscopic surgery with possibility of conversion to an open procedure As I have explained in my initial response, Ms. Kilby did develop a superficial wound infection postoperatively that was treated appropriately. I do not feel that the wound infection 'was in any way related to the outcome of this case.

L. Klein

AGAIN, WE ARE TALKING ABOUT STANDARD OF CARE NOT THE OUTCOME.
Oh, my God!!!! Dr. Klein has not learned a thing from Terra's death and is obviously going to continue as he did!

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

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

Health Minister

July 21, 2019

Our Darling Terra Dawn;
Thirteen years you’ve been gone.
You departed from us to ascend beyond.

Thinking of you throughout the years,
Bring such joy but also the tears.
Longing to see you, I have no fears.

Our present lives have severely weathered.
Four throbbing hearts bound securely together,
With hugs and kisses we are tethered.

Missing you terribly is so true!
With fond memories we think of you.
At times like these, we’re no longer blue.

As a tiny tot walking hand and hand,
Along the beach upon the sand;
That for me was our wonderland!

The warmth of the sun in the sky;
A rainbow emerges way up high.
“Oh, how I love you” is what I sigh.

We send our love to you.
“Forever Within Our Hearts”
Love Mom, Dad and Brandy

July 21, 2018

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

TERRA 2018 ©
Twelfth Christmas

Terra, An Angel In Our Lives

Twelve years have gradually passed,
Our enduring love will forever last.
Those cannot possibly understand,
The loss we still can’t comprehend.

Christmas’ just can’t be the same,
Without you present to hear your name.
We still decorate your grave,
As we try so hard to be brave.

But memories of you are all we possess,
Of Christmas’ past and our happiness.
The years go by without you here,
Still releasing many a tear.

We have missed you since you went away,
Your voice; your laughter each and every day.
Our hearts so sadden and fragmented,
And our lives are so segmented.

Our world has fallen utterly apart,
Ever since the day you did depart.
We carry on the Christmas traditions you loved.
Praying you can see them from far above.

Twelve years have gradually elapsed,
Our enduring love we will forever grasp.
Those cannot possibly understand,
The loss we still can’t comprehend.

Merry Christmas our darling daughter dear.

Love Mom, Dad and Brandy
*********************************************

Update as of March 22, 2019.

E-mail from MPP Steve Clark's Office notifying me the Ministry of Health is preparing a response to my numerous e-mails sent to Christine Elliott that were never answered. We will see how long it takes to get this response!

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

All the parties/individuals mentioned have prevented me from finding closure and have left my grieving process as follows:

Ms Elliott, Another one to ignore and not respond to.

After reading this, feel free to let our Minister of Health know about your concerns and please share this post if you feel it to be of importance to you friends and relatives.

Our Minister of Health.
christine.elliott@pc.ola.org
christine.elliottco@pc.ola.org

Let us just let this surgeon continue as is, without the public having any opportunity to look into past/present complaints, investigations and decisions with regard to Dr. Laz Klein. He has multiple deaths on his hands.

Ms Elliott is doing absolutely nothing with regard to my concerns nor apparently those of the rest of Ontario's citizens.

Ms Elliott has been well aware of the failings of the CPSO, and HPARB dating back to when she was MPP, then as the Ontario Patient Ombudsman, and now as an elected MPP again, and appointed as Health Minister. Yet, does nothing.

Apparently the Conservative government will not take any action or investigation.

So, I have been screwed over by the CPSO, previous Health Ministers and their ministries, the CCO, HPARB, the DIOC, Patient Ombudsman's Office and Ontario's Ombudsman. How the hell can you all accept was done to my daughter did not prove to be a prime example of medical negligence contributing to the death of an Ontario Citizen. By allowing the College and HPARB's decision to stand you all have negatively impacted on further operations done in the same manner as being acceptable Standards of Care which it clearly is NOT!

Far too many Ontario citizens have been abused by all of the above and a public inquiry should be held with respect to all of them, But of course that would take GUTS. Yes and perhaps you could use the $326 Million dollar Reimbursement Fee we paid last year to the doctors/surgeons to cover their membership fees in the CMPA.

Mr Ford, you save the taxpayers millions every year if you put an end to this practice instead of picking on Education.

An Ontario citizen has no hope of attaining true transparency and accountability when this government obviously puts the medical profession above the interests and safety of its citizens.

E-mails sent to our Health Minister:
March 22, 2019 to go along with all of the ones below:
March 8, 2019 ignored by Ms Elliott
February 18, 2019 ignored by Ms Elliott
January 25, 2019 ignored by Ms Elliott
December 19, 2018 ignored by Ms Elliott
December 13, 2018 ignored by Ms Elliott
November 22, 2018 ignored by Ms Elliott
November 13, 2018 sent by the Premier to Miss Ellliott ignored by Ms Elliott
October 18, 2018 ignored by Ms Elliott
August 11, 2018 ignored by Ms Elliott
July 12, 2018 ignored by Ms Elliott
June 17th, 2018 ignored by Ms Elliott

That makes Twelve ignored e-mails sent with no acknowledgement of receiving them nor replying to them.
*********

From: Jiggins, Michael
Sent: March 26, 2019 11:58 AM
To: Arnold Kilby
Subject: RE: CPSO TRANSPARENCY--bullshit

Good afternoon, Mr. Kilby.

I have been in touch with Minister Elliott’s office today and a response to your inquiries is being prepared.

Regards, Michael Jiggins | Executive Assistant
Office of Steve Clark, MPP
Leeds—Grenville—Thousand Islands and Rideau Lakes
613-342-9522 | 1-800-267-4408
**********
Subject: Re: CPSO TRANSPARENCY--bullshit

Mr.Jiggens, I thank you for your response. WHY DOES IT TAKE SO LONG for the Health Minister to respond?

I can't help but suspect when I receive her response, snow will be falling within my house. I suspect they are carefully drafting "a cover-up" response and tell me nothing can be done.

I sincerely hope I will be wrong. Further deaths by this very same surgeon and others whose negligence is covered up by all will solely rest on all those who know the truth but do nothing to ensure Ontario citizens' rights to transparency and accountability is attained. This would truly be a great objective for the Conservatives to achieve should it choose to do so.

An explanation as to why the lack of response would be greatly appreciated, or at the very least why my e-mails were never acknowledged.

The Minister's close relationship with the CEO of Humber River Hospital where this surgeon is granted hospital privileges should and must not play a role. As well, the fact the past CEO, Dr. Devlin is now a Health Advisor to the Conservative government should not play a role and continue the cover up of medical negligence!

I wish the media would expose all who have maintain to cover up medical negligence contributing to the deaths of so many by this surgeon!

In Ontario, Canada.covering up medical negligence is the number one rule for our Politicians, the CPSO, the Chief Coroner's Office, the Death Investigative Council, the Health Professions Appeal and Review Board, the Ontario Patient Ombudsmen, the Ontario Ombudsman, the Hospitals, the Minister and Ministry of Health. Quite a list, and except for the CPSO, our tax dollars pay for the rest.��
The past Ontario Liberal Government did nothing. THE PRESENT CONSERVATIVE ONE DOES THE SAME! They will do nothing in Health Care that would piss off the CPSO and CMPA. There will always be adverse events, but the number could be greatly reduced if those in authority would act. I would imagine that all provinces are infected by the same corrupt, immoral institutions that are taxpayer funded to promote and protect patient safety but in actuality do the opposite.
��

The past Ontario Liberal Government did nothing. THE PRESENT CONSERVATIVE ONE DOES THE SAME! They will do nothing in Health Care that would piss off the CPSO and CMPA. There will always be adverse events, but the number could be greatly reduced if those in authority would act. I would imagine that all provinces are infected by the same corrupt, immoral institutions that are taxpayer funded to promote and protect patient safety but in actuality do the opposite.
��

So, apparently the Chief Coroner's Office goes completely unchecked and can continue to cover up medical negligence contributing to deaths.

We now have no one to oversee not only this office but also the CPSO, HPARB, the DIOC and Hospitals. So Sad.

I do not believe the response. They have political authority to investigate the initial coroner's investigation if they can not order a re-investigation.

From: MCSCS Feedback
Sent: January 16, 2019 2:33 PM
To: awkilby@hotmail.com
Subject: Letter from the Honourable Sylvia Jones, Minister of Community Safety and Correctional Services

Please see attached response from the Honourable Sylvia Jones, Minister of Community Safety and Correctional Services. The text of the response also appears below.

MC-2018-1728

By e-mail

January 15, 2019

Mr. Arnold Kilby

awkilby@hotmail.com

Dear Mr. Kilby:

Thank you for your e-mail of December 10th regarding the death of your daughter. Please accept my condolences on your loss.

As the Minister of Community Safety and Correctional Services, I have no legal authority to direct the Chief Coroner to reopen an investigation. I also cannot provide direction or advice on how an investigation should be conducted.

Death investigations and decisions regarding the investigations come under the purview of the Office of the Chief Coroner. As such, I have shared your message with Dr. Dirk Huyer, Chief Coroner for Ontario.

Best wishes,

Sylvia Jones

Minister

c: Dr. Dirk Huyer

Chief Coroner for Ontario

News: This is not Terra's case but another case whereby a patient died. It appears Dr. Laz Klein has been given cautions before according to the following take from an HPARB Review held on July 12, 2017 at Toronto, Ontario

It is the further decision of the Health Professions Appeal and Review Board to return the matter to the Inquiries, Complaints and Reports Committee of the College of Physicians and Surgeons of Ontario and to require it to reconsider its decision to issue advice to the Respondent regarding following up on abnormal laboratory test results and appropriate dosing and monitoring of narcotics administered to a critically ill unmonitored patient.

By Committee, HPARB is referring to the College.

The Committee also concluded that the Respondent’s oversight of the Resident’s care of the patient was inadequate. Those concerns gave rise to the advice issued to the Respondent by the Committee.

At the Review, the Applicant re-iterated these issues and submitted that the Committee’s failure to deal with all of her concerns renders the decision unreasonable. The Applicant also submitted that the Committee’s decision to issue advice to the Respondent was, given the significant and numerous care deficiencies involved in this matter, not strong enough and for that reason, unreasonable.

The Committee identified the need to provide advice to the Respondent concerning documentation deficiencies. Neither party suggested that the Committee’s decision to provide this advice was not reasonable. The Board finds that this aspect of the Committee’s decision is reasonable and is supported by the information in the Record, particularly the additional information provided to the Committee by the Respondent in which he details the nature of his interactions with residents, and his insight into and the proposed changes to his practice as they relate to this issue. As the Committee specifically noted, it is this insight and the Respondent’s stated intention to make changes to his practice which allowed the Committee to conclude that it was appropriate, despite the Respondent’s conduct history with the College, to issue advice on this issue

However, the Board finds that the Committee’s conclusion that it “saw no reason to conclude that [the Respondent’s] care was inappropriate” is inconsistent with its own previously identified concerns about patient care. Specifically, in considering the care provided to the patient the Committee identified two specific issues of concern.

The Committee noted the absence of information in the medical record that appropriate action was taken in response to this information. The Board notes that the patient’s white blood cell count (“not an insignificant finding” according to the Committee) was not followed up on. The Board also notes that the medical record indicates that several issues, including the white blood cell count, were communicated to the Respondent during the day of December 4, 2014 and follow-up appears to have been requested but it is unclear if it occurred. The Committee’s view that the general surgery team “should have followed up on [the patient’s] abnormal test results, particularly those that raised the suspicion of sepsis” is supported by the information in the Record.

The Committee decided to issue advice to the Respondent on these care related issues. The Board finds that this disposition is not supported by the Record and is unreasonable.

As noted above, the Committee specifically considered the Respondent’s conduct history with the College. The Committee indicated that the Respondent’s “history with the College, which includes several complaints on a number of aspects of [the Respondent’s] care, raised some concern for the Committee”. The Board has reviewed the Respondent’s history with the College and finds that the Committee’s concern is reasonable.

The Board notes that in respect of the care related issues identified by the Committee, (and in contrast to the issues related to the Respondent’s record keeping previously described) the Committee does not note, and there is no information in the Record to indicate, that the Respondent had demonstrated the insight that might alleviate the concerns of the Committee arising from the Respondent’s conduct history with the College.

The Board notes that the Respondent’s conduct history with the College includes prior complaints involving the care of patients, including medication issues, that have previously been identified as concerns by the panels of Committee assigned to assess them and have resulted in advice being provided to the Respondent. The repetition of similar concerns highlighted in this case would appear to indicate that previous remediation attempts by the Committee have failed to yield the desired result. There is nothing within the Committee’s decision to indicate how the issuance of another advice in this matter will protect the public interest in light of the Respondent’s conduct history.

Given, in this matter, the differences described above between the information in the Record touching upon those issues related to the documentation of patient care and those related to the actual care provided, the Board concludes that the Committee’s disposition, as it relates to the two care issues it identified, is unreasonable. The Board finds that with respect to the two concerns identified by the Committee which relate to the care provided to the patient, the issuance of advice does not fall within the range of outcomes that can reasonably be supported by the information before the Committee and cannot withstand a somewhat probing examination. The Board finds that this particular aspect of the Committee’s decision is not defensible in respect of the facts and the law.

The Board concludes that this matter be returned to the Committee requiring it to reconsider its decision to issue advice to the Respondent regarding following up on abnormal laboratory test results...

It is the further decision of the Board to return the matter to the Committee and to require it to reconsider its decision to issue advice to the Respondent regarding following up on abnormal laboratory test results

and the following take from a CPSO decision Active Date: March 16, 2018
Note: This matter has been appealed to the Health Professions Appeal and Review Board.
DR. KLEIN'S appeal proved to be somewhat successful as you will no longer find any of the following listed on the CPSO website under this surgeon's record! So, the public will have no idea as to what disciplinary actions were taken!

On March 16, 2018, the Inquiries, Complaints and Reports Committee (the Committee) ordered general surgeon Dr. Klein to complete a specified continuing education and remediation program (SCERP). The SCERP requires Dr. Klein to:

· Practice under the guidance of a Clinical Supervisor acceptable to the College for six months

· Undergo a reassessment of his practice by an assessor selected by the College approximately six months following completion of the SCERP

· Review relevant Clinical Practice Guidelines, including literature for guidelines on early identification and management of sepsis, as well as College policies on Medical Records and Test Results Management, and provide a written summary of the documents with reference to current standards of practice, how it is applicable to Dr. Klein’s situation, as well as how Dr. Klein has made, or plans to make, changes to his practice.

The Committee was of the view that the urinalysis results, along with the patient’s history of self-catheterization and prior urinary tract infections (UTIs), the significant increase in her white blood cell (WBC) count (from a normal level of 9,000 at admission to 22,000 by 9:00 am on December 4), and her falling oxygen saturation should have alerted Dr. Klein and hospital staff to the strong possibility of sepsis.
The Committee noted that in his response to this complaint, Dr. Klein indicated that he did not consider the possibility of a sepsis diagnosis. Furthermore, although he claimed to have first seen the patient at approximately 9:00 am on December 4, he failed to document the increased WBC, both at this time and at his subsequent 6:00 pm reassessment.

The Committee was concerned about the significant failure to treat a highly likely UTI with appropriate antibiotics within 12-24 hours of admission, which should have occurred with or without the associated diagnosis of a small bowel obstruction. Furthermore, even if the patient’s abdominal examination did not suggest a strangulated small bowel obstruction or other acute intra-abdominal condition, the Committee noted that there was no indication that Dr. Klein considered the reason for the patient’s seriously elevated WBC count, which he continued to claim was non-specific.

Given Dr. Klein’s failure to offer any explanation for this concerning information in his various responses to this complaint, the Committee felt he demonstrated a lack of insight regarding his failure to properly manage the patient’s care. The Committee noted that a prudent physician should have recognized the above mentioned results as highly indicative of an inflammatory response, such as septic shock, and initiated appropriate antibiotics.

With respect to medical record-keeping, the Committee was concerned that Dr. Klein did not write any notes at any time during the patient’s admission, which does not meet the standard of care and does not comply with the College’s policy on Medical Records. Furthermore, this lack of documentation made it difficult for the Committee to assess the true extent and quality of care that Dr. Klein provided to the patient. The Committee noted that the involvement of residents or students does not absolve physicians from their own documentation responsibilities.

The Committee noted that Dr. Klein has a significant history with the College, which include cases raising both clinical and record-keeping issues, for which he has received advice and been cautioned. The Committee agreed with the Board that the repetition of similar concerns in this case appears to indicate that the previous remediation attempts have not been successful. This, along with the Committee’s concern about Dr. Klein’s persistent lack of insight into his shortcomings in this case, suggested that a more significant disposition was required to adequately protect the public, as outlined above.

The Board notes that the Respondent’s conduct history with the College includes prior complaints involving the care of patients, including medication issues, that have previously been identified as concerns by the panels of Committee assigned to assess them and have resulted in advice being provided to the Respondent. The repetition of similar concerns highlighted in this case would appear to indicate that previous remediation attempts by the Committee have failed to yield the desired result. There is nothing within the Committee’s decision to indicate how the issuance of another advice in this matter will protect the public interest in light of the Respondent’s conduct history.

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

It has been Ten months since I contacted the Minister and not one single response to date. Aug 30/18

Subject: Minister of Health

I am formally requesting a meeting with you ASAP. Please speak with MPP Steve Clark with regard to my concerns.

*** NOTE: B. Bybrick was the head of the CPSO at the time involved in the third decision, which clearly indicates the top priority of bringing my complaint to a final conclusion regardless of the medical facts and contradictory statements by the College and I suspect HPARB colluded with the CPSO as proven by HPARB's third decision and denial of my two requests to review it's decisions.

The Ontario Health Minister MUST investigate or risk losing all credibility as an elected member of the Legislature, as a member of the Conservative Cabinet and as Ontario's Minister of Health!

Over the past numerous years, I have asked the Minister of Health to address my concerns with regard to the CPSO and HPARB

Mr Hoskin's response was basically to say he had no authority to intervene or question the process and decisions by both the CPSO and HPARB.

-----COMPLETE BULLSHIT OF A RESPONSE

This was and is a lie as you will see. but I will shorten it

The following excerpt comes from Mr Hoskins' letter to the College Presidents and Registrars/Executive Directors as seen below:

What a lovely motherhood statement with no authoritative action taken!

"My hope is that we can work collaboratively to implement these steps as we work together to maintain the public’s trust in our health care system. However, as Ontario's Minister of Health and Long-Term Care, my ultimate responsibility is to the people of Ontario. I reserve the right to take any and all necessary measures to ensure that the public interest remains paramount, including exercising the powers reserved to me under subsection 5(1) of the RHA including the ability to require Councils to do anything that, in my opinion, is necessary or advisable to carry out the intent of the RHPA and the health profession Acts."

HE FAILED ALL ONTARIO CITIZENS BY NOT ACTING!

You, as our new Conservative Health Minister, do have the authority to investigate holding both the CPSO and HPARB accountable for an inept, dishonest investigation into my complaints and enacting appropriate legislation in the Legislature to ensure this never happens again. You should also involve the Minister of Correction to do the same with regard to the Chief Coroner's Office and the DIOC, as both institutions are complicit in the cover up of medical negligence and covering up their own role in such.

According to Regulated Health Professions Act you do have the authority to look into the CPSO either personally or through the Advisory Council. You may erroneously consider this as possible interference but it is your responsibility to do so, and you are mandated to do so!

--matters concerning the quality assurance programs undertaken by Colleges;

-- each College’s patient relations program and its effectiveness;

-- require the Council to do anything that, in the opinion of the Minister, is necessary or advisable to carry out the intent of this Act, the health profession Act

AND question

--whether regulated professions should no longer be regulated;

Duty of Minister

3. It is the duty of the Minister to ensure that the health professions are regulated and coordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board. 1991, c. 18, s. 3.

Powers of Minister --“Council” means the Council of a College;

5. (1) The Minister may:

(a) inquire into or require a Council to inquire into the state of practice of a health profession in a locality or institution

(b) review a Council’s activities and require the Council to provide reports and information;

(c) require a Council to make, amend or revoke a regulation under a health profession Act, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act;

(d) require a Council to do anything that, in the opinion of the Minister, is necessary or advisable to carry out the intent of this Act, the health profession Acts, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act. 1991, c. 18, s. 5 (1); 2009, c. 26, s. 24 (1)

A great injustice has taken place. This case exemplifies the very reason why Bill 29 should have been passed but was not, and the importance of the Minister of Health acting on my concerns. Just imagine if this happened to me, what other citizens have gone through??

--They are not placing patients and patient safety first therefor they are completely ineffective when it comes to investigating complaints

My daughter went through a colon resection and a tumor removed without the mandatory antibiotic prophylaxis, she also did not receive any antibiotics for the abdominal infection of the incision whereby all staples were removed. As well, she did not receive any antibiotics for the presence of "many gram negative bacilli". NO ANTIBIOTICS WHATSOEVER DURING HER TIME IN THE HOSPITAL. SHE BLED TO DEATH 12 HOURS AFTER DISCHARGE.

IS THE COLLEGE MAINTAINING THE APPROPRIATE STANDARDS?

OR, ARE THEY ACTIVELY COVERING UP SURGEON NEGLIGENCE!

E-mail sent to all MPPs

E-mail sent individually to every Ontario MPP.

How about doing something about Medical Negligence and how the Minister of Health and all parties do all they can to cover this up. Especially since Premier Ford's, Medical Advisor, Reuben Devlin, was the CEO of the hospital where my daughter suffered this negligence resulting in her death-- bled out 12 hours after being discharged.

But you all do absolutely nothing to expose medical negligence in the death of my daughter covered up by this present government and the past one.

All MPPs should be addressing this issue and raise when possible during the question period at Queen's Park.

If you take the time to look at the blog and pay close attention to the medical records and the medical opinions from surgeons throughout the world except for Ontario and Canada who won't respond for obvious reasons, you will see that a cover up has occurred to protect not only the surgeon but all individuals appointed and/or elected to serve the interest of Ontario.

Many MPP will simply say since I am not their constituent and that this does not concern them.

BUT IT SHOULD AS THIS DEMONSTRATES THAT YOUR OWN CONSTITUENTS WILL NOT TRULY FIND THE MEDICAL PROFESSION ACCOUNTABLE AND THAT THE TRUTH WILL BE CONCEALED by the CCO, the Ontario Ombudsman's Office, the DIOC, the Ontario Patient Ombudsman, HPARB, the Ministry of Health and the previous Ontario Governments.

Those above are merely protecting themselves now for not acting when they should have so many years ago. Your constituents deserve better. Even Ms Horwath has dropped the ball! And I am sure you will be ordered to not look into this.

The Premier does not respond to my e-mails too as do most of you with the exception of a standard automated response.

My daughter:

--did not receive the mandatory antibiotic prophylaxis required for open abdominal surgery. --did not receive antibiotics when the abdominal incision became so infected that all staples were removed

-- as well as when test result indicated the presence of "many gram negative bacilli" (in same category as C difficile) and still no antibiotics

---- she bled out less than 12 hours after discharge from hospital

DEAR MPPs, is this how you treat your constituents?

It is now August 22 and still not a word from My MPP Steve Clark. His office was really good prior to the Conservatives being elected but since then it would appear Mr Clark nor his staff wish to explain how this present government have become involved in the cover-up of medical negligence!!!

-- please explain to me how a patient not having the above done did not receive antibiotics when the abdominal incision became so infected that all staples were removed

--please explain to me not having the two above done how a patient did not receive antibiotics for the presence of "many gram negative bacilli" present-----

NO ANTIBIOTICS GIVEN AT ALL! IT TOOK OVER TEN MONTHS TO GET THIS RESPONSE from Ms Ellliott ??????????

I would certainly like to hear a response from my MPP Mr. Clark with respect to the "bullshit" response from our Minister of Health. It took this long to come up with this standard reply. She obviously paid absolutely no regard to her authority as set out in legislation which I have previously sent. I would like her to explain in detail why she is unable to act and contradict the authority granted to her through legislation. She is not unable to act--- she is unwilling to act!

From Christine Elliott's letter to me.

"I regret to hear that you continue to feel that your concerns regarding the investigations have not been appropriately addressed."

IT WOULD BE NICE FOR MS ELLIOTT TO EXPLAIN TO ME HOW MY CONCERNS HAVE BEEN APPROPRIATELY ADDRESSED.?

--"It is the duty of the Minister to ensure that the health professions are regulated and co-ordinated in the public interest,that appropriate standards of practice are developed and maintained

Minister's Response

PLEASE CONTACT YOUR OWN MPP AND EXPRESS YOUR CONCERNS. Should you wish to contact Ms Elliott:
christine.elliott@pc.ola.org christine.elliottco@pc.ola.org

When Ms Elliott was the Ontario Patient Ombudsman, she recused herself in my case due to her close friendship with the CEO of Humber River Hospital. Does this relationship continue to interfere with her role as Minster of Health?
*****

From: Correspondence Services (MOHLTC)
Sent: May 8, 2019 9:03 AM
To: awkilby@hotmail.com
Subject: Response from the Ministry of Health and Long-Term Care 361-2018-4087- nb

361-2018-4087

Mr. Arnold Kilby
awkilby@hotmail.com

Dear Mr. Kilby:

Thank you for your email regarding your concerns about the investigations into your late daughter's care at the former Humber River Regional Hospital. You and your family have my deepest sympathies.

I would like to assure you that accountability and transparency are important to me and the Ministry of Health and Long-Term Care.

While I understand that you are not satisfied with the outcomes of these independent investigations; unfortunately, neither I, nor ministry staff, can intervene or become involved in individual cases.

Please accept my condolences for your loss.
Sincerely
Original signed by Christine Elliott

Deputy Premier and Minister of Health and Long-Term Care

*********

The Following was sent to my MPP, Premier Ford, and Andrea Horwath
doug.fordco@pc.ola.org doug.ford@pc.ola.org
steve.clark@pc.ola.org
ahorwath-co@ndp.on.ca
MPP Steve Clark,

IT TOOK OVER TEN MONTHS TO GET THIS RESPONSE??????????

I would certainly like to hear a response from Mr. Clark with respect to the "bullshit" response from our Minister of Health. It took this long to come up with this standard reply. She obviously paid absolutely no regard to her authority as set out in legislation which I have previously sent. I would like her to explain in detail why she is unable to act and contradict the authority granted to her through legislation. She is not unable to act--- she is unwilling to act!

"I regret to hear that you continue to feel that your concerns regarding the investigations have not been appropriately addressed." IT WOULD BE NICE FOR MS ELLIOTT TO EXPLAIN TO ME HOW MY CONCERNS HAVE BEEN APPROPRIATELY ADDRESSED.?

--"It is the duty of the Minister to ensure that the health professions are regulated and co-ordinated in the public interest, that appropriate standards of practice are developed and maintained

--please Ms Elliott explain to me how a patient can undergo open abdominal surgery to remove a tumor and have a colon resection done without the mandatory antibiotic prophylaxis being administered

-- please Ms Elliott explain to me how a patient not having the above done did not receive antibiotics when the abdominal incision became so infected that all staples were removed

--please Ms Elliott explain to me not having the two above done how a patient did not receive antibiotics for the presence of "many gram negative bacilli" present-----NO ANTIBIOTICS GIVEN AT ALL!

Ms Elliott, if you had seriously look at all the medical concerns I presented, why did you not address all of them with the CPSO. Have you ensured that the appropriate standards of practice are developed and maintained? I would like to have a written response of your correspondence with the CPSO and their responses to your questions. By your letter, it appears you did not investigate at all! You merely sat back for the past ten months and did not address a single concern I pointed out to you and your Ministry!

When it is proven that the CPSO and HPARB totally disregard the medical factual information which conflicts completely with the CPSO decision, The Ministry must intervene to ensure this injustice does not occur again and to set the record correct. THIS IS A COMPLETE FAILURE NOT ONLY BY THIS MINISTRY BUT THE CONSERVATIVE GOVERNMENT.

At the very least HPARB should have accepted my request for reconsideration when the medical facts contradict the CPSO's decision in many ways, not the least being Dr. Klein certainly did know a resection had to be done prior to converting to open surgery. According to the operational record under procedure one--he attempted a colon resection prior to converting! Even in a letter to Terra's family doctor, he stated this was a possibility!

The CPSO did a "piss poor" investigation into my complaint and did all they could to deflect and defend the surgeon and not protect the public.----Their actions in this case proves this without a doubt but the Health Minister and the Conservative government does nothing to address this atrocity."

How can the Ministry/Government allow HPARB's decision to stand and thus set a precedence of open surgery being done without mandatory antibiotic prophylaxis being administered now considered a STANDARD?

I guess this Conservative government is no different than the Liberal one. They merely want to preserve and protect their own self-interests and place the well-being of the electorate well behind their high powered political supporters--big business and those who have money! It appears time for a third party to be elected to head up the government of Ontario, one that truly represent the welfare of the electorate!

Steve, you are very fortunate that you are in a strong, conservative riding! But many of your fellow MPP's are not in such a amiable situation.

This Ministry response definitely proves the Conservatives place the general public well behind the interests of those who have undoubtedly abused their role as an elected/appointed official.

I am sincerely interested in Mr Clark's response to this unjust and "cop out" response by Ms Elliott. Breach of Trust is definitely in play in this case.

According to Regulated Health Professions Act you do have the authority to look into the CPSO either personally or through the Advisory Council. You may erroneously consider this as possible political interference but it is your responsibility to do so, and you are mandated to do so!

According to the following act, the Minister of Health and the Ministry does have the authority to ensure that the College indeed must act first and foremost in the interest of the public. So, when I get the standard reply why they can't intervene, it is a falsehood.

The CPSO and HPARB are not operating in the public interest when they total ignore the factual, medical proof contained within the hospital records and only accept fabricated opinion.

Regulated Health Professions Act

Duty of Minister

3. "It is the duty of the Minister to ensure that the health professions are regulated and co-ordinated in the public interest, that appropriate standards of practice are developed and maintained and that individuals have access to services provided by the health professions of their choice and that they are treated with sensitivity and respect in their dealings with health professionals, the Colleges and the Board.
**************************************

Medical Opinion

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

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

A. Dear Mr Kilby: I have read the sad account of your daughter's illness and the medical society's review and find the review flawed and inadequate. I cannot be an expert witness since I am no longer a practicing surgeon. However, I formerly served on our San Francisco Medical Society's Review Panel. Your daughter's surgeon was wrong and failed to observe your daughter's presenting laboratory and physical findings of intra-abdominal sepsis and wound infection. The surgeon's "slap on the wrist" and review submitted by the Society must have been upsetting to him as a caring surgeon. This may be the only consolation you can ever see for your daughter's death. Hopefully he will have learned from this experience and it will help him provide better care for future patients.

James P. Geiger, MD, FACS COL. MC US ARMY, Retired

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

B. Mr. Kilby,  Again, I am sorry about the delay in my response and, more importantly, very sorry about your daughter's death and the difficulty that you are having in trying to get the system to recognize the errors that seem to have been made in her tragic death. To preface my comments, as you know, I am a pediatric surgeon and do not operate on adults. That being said, I did complete an adult general surgery residency prior to my peds surgery fellowship and am Boarded in adult general surgery in addition to pediatric surgery by the American Board of Surgery. 

As I review the file that you attached, there are several concerns that come to mind. You indicated that she did not receive appropriate bowel preparation prior to surgery. Even though there is some controversy re: bowel preps and performing surgery on the right colon, I think most surgeons would proceed with a mechanical bowel prep prior to an operation where possible right hemicolectomy was possible. However, there is very good evidence that mandates that patients receive broad spectrum IV antibiotics prior to having colon surgery, especially if they haven't received a bowel prep. If this wasn't done this is not in line with the standard of care in the US. 

Also, I have concerns that the nurses documented for Terra's abdominal exam that her abdomen was "large" for the last several days of her stay in the hospital. More importantly, they document for a number of days prior to her discharge that there was a foul smelling odor and that the wound was "oozing copious amount of purulent discharge" during this entire time as well is very concerning. This doesn't happen with a superficial wound infection. These things happen when there is an anastomotic breakdown and leakage through the wound and possibly into the peritoneal cavity. If I recall, you indicated that a physician didn't even see Terra or examine her for the last couple of days while she was in the hospital? I would be very curious to read their last few notes in the chart and if they didn't document anything b/c they didn't see her, that is inexcusable. 

In regards to colon anastomoses breaking down and causing an acute hemorrhagic event to where someone would bleed out within 12 hours, I have a hard time believing that and have never heard of this happening before, especially over a week out from surgery. She clearly should have been tolerating a diet fairly well before she was released. Again, all of my comments have to be considered in light of the fact that I don't practice on adults and may not be absolutely up to date on everything re: colon surgery in adults.

However, I doubt that any of my above concerns are too far off base, if at all. Ideally, you would be able to find a surgeon that practices on adults, is credentialed by the ABS if in the US or one in Canada that co- corroborate my concerns. I hope my comments help and wish you the best in your efforts to correct the system that appears to be failing you and your family.

All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015 

*****

Mr. Kilby, I have reviewed the document and stand by the comments and concerns that I have sent to you through various emails. In addition to those, my only other comments are:

 1. It is very concerning that the nurses repeatedly documented in the chart that her abdomen was large and there was foul odor coming from the wound. Since there was no documentation from the surgeon re: an exam on multiple days, then one can only infer that no surgeon examined her on those days. 

2. Gram-negative bacteria on the cultures from a wound with foul drainage suggest an intestinal injury or anastomotic leak. 

3. Preoperative antibiotic prophylaxis is the standard of care in the US and, I would imagine, the same in Canada. 

4. I can't believe that any physician or surgeon would release a patient from the hospital without seeing the patient or, at least, speaking with the nurses caring for the patient by phone. 

Hope these comments, as well as those that I have made in the past, help your cause. All the best, David David A Lanning, MD, PhD Surgeon-in-Chief, Children's Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 Richmond, VA 23298-0015

While complications can happen with any operation, I think the key thing with your daughter's care is that it appears to me that there was evidence that there was a problem before she left the hospital that was not picked up by the doctors, either because they ignored the evidence or didn't see / examine her. How long was she at home after her discharge from the hospital before she returned to hospital

/ ED D. Lanning MD

“It is also concerning that she had not passed stool and was quite distended.” D. Lanning

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

C. I have reviewed the data you supplied and the data from the colorectal surgeon (acting as an independent peer review). I am at a loss to understand the opinion he offered given the abdominal incision was leaking foul discharge which would mandate re-exploration, or at the very least, a CT scan of the abdomen which would likely have shown significant intra-abdominal fluid, suspicious for anastamotic issues. I have four children and my only prayer is to be in the ground before any of them……Short of not agreeing with the expert opinion offered by the independent physician I don’t know how I can help. Your daughter’s loss was tragic and it would appear to me preventable.

Good luck with your appeal if that is the direction you chose….Moe Lyons MD FACS

I am very sorry for your loss. I am sure the wounds are still very painful 4 years later. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). 

The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. Having said all of that it the lawyers for the doctors are correct; medicine is an art (sometimes performed very poorly) not a science. See the SCIP initiatives available online (Google SCIP initiatives) to better understand when, and what type of antibiotics are recommended prior to colon surgery. Good luck with your inquiry and again I'm sorry for your loss......................

Moe Lyons,

Maurice Lyons, 

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D. Dear Mr. Kilby, I just read through the attachment, and I recall reading your prior email.

My personal opinion is that your daughter died of septic shock related to dehiscence of her bowel anastomosis complicated by acute hemorrhage.

Apparent lapses in care are:

1) Lack of peri-operative antibiotics (I am not a general surgeon and do not know if this fails to meet standard care for right colon surgery).

2) Discharging your daughter with ongoing diarrhea of unexplained etiology,

3) Prolonged period of inadequate nutrition,

4) Nursing records that appear to be at odds with the physician record of the abdominal exam,

5) Failure to distinguish the intra-abdominal catastrophe from the wound infection.

It is self-evident that she was discharged prematurely or she would not have died outside the hospital of a devastating post-operative complication.

The big questions are: would a reasonable general surgeon have acted differently, and did her surgeon practice according to the standard of care – I seriously doubt that he did and I think a good surgeon would have done a more thorough investigation prior to discharge.

Things to consider:

1. The low hematocrit prior to discharge is not evidence of malpractice as this is common with acute illness such as what your daughter exhibited.

2. It would be interesting to see if there was a platelet count prior to discharge.

3. The temperature curves and the reported abdominal fullness are concerns that seem discounted by the College assessment.

As I told you previously, I am a father of an almost 3 year old girl and I now have a 6 month old son and a 4 year old son. I cannot imagine losing any of them particularly in such circumstances. Only you can decide if your quest for justice is worth further fight. I do not understand the Canadian system, so I cannot judge. Your case would be helped if you could find a Colorectal surgeon to review it. Unfortunately, most surgeons would not take interest and I do not personally know anyone who can help you. I do wish you the best and I hope that at some phase you can find peace.

Max Mitchell MD FACS

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E. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. “It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.” I'm sorry to hear about the death of your daughter. A parent should never lose a child.

Allan Stewart MD

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F. Dear Mr. Kirby: From what I remember and my review of the information you sent me my opinion is that your daughter received suboptimal care approaching malpractice-at least by US standards. I would have to assume that Canadian standards are equivalent to US standards but from the response I read perhaps they are not.

Best wishes, Steven J. Phillips, MD FACS

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H. GET A BETTER LAWYER. RRG SWCVTS

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I. Hello Mr. Kilby, It is very difficult to comment sufficiently on your question. There are just so many issues that I may not be aware of and questions that would need to be answered to give you an adequate answer to your question. I can say that for many years I have encouraged patients to build themselves up prior to surgery and to begin using amino acids as soon as possible after surgery. And I have given amino acids to patients so they can begin using them as soon as possible since I do not agree with the often followed practice of near fasting for patients after surgery - the body needs the amino acids to begin the healing process.

I am really sorry to hear of your daughter's case and I am so sorry for your loss. I do hope that someday physicians will be more proactive about improving their patient's nutritional status before and after surgery. I am not optimistic given the general disregard for nutrition that exists anyway.

God bless you, Roger Roger Trubey Dr PH, MPH, ND

You are welcome, Arnold. All I can say is that here in the States you would have a solid case for litigation. I don't encourage frivolous lawsuits or ambulance chasing but some cases can be so egregious that the only way hospitals and physicians will learn is to pay for their mistakes with the hope that the pain is such that it will save others from your daughter's fate.

God bless you, Roger

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J. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered.

Matthew M. Cooper, MD FACs

Mr. Kilby: I looked over the materials you sent. I am once again sincerely sorry for your loss and trust that your daughter will live on in your hearts and thoughts. There are several items here that in combination raise concern. Individually, they may have been overlooked as insignificant. Further, hindsight may allow piecing together a potential pattern that may not have been detected as they occurred. 

Were peri-operative prophylactic antibiotics administered? There is a suggestion that they may not have been.

1. It is standard of care to do so for a limited time around the time of operation. 

2. I am concerned about the description of the abdominal examination progressing from "rounded" to "large" in the context of no clear normalization of bowel function. Is that to be interpreted as a distended abdomen? Were there normal bowel sounds? Was flatus present indicative of returning function? Or was there a postoperative ileus? If function was not returning normally in the presence of a progressively distending abdomen, that should raise concerns that might require imaging of the abdomen but certainly resolution prior to discharge. 

3. The nutritional aspect is contributory in that with a prolonged postoperative ileus, supplemental nutrition should reasonably have been considered. 

4. Such a bleeding complication after such surgery is certainly a possibility but should be exceedingly rare. If, as you suggest, your daughter's complications were part of a series of such problems then, indeed, a system or operator issue is suggested which satisfies the stated requirement for a complete investigation. 

If I were in your place, I would do the following: 

1. Contact the American Board of Surgery to see if they have an Expert Review Panel to which you could send this case for review. 

2. Canada must have a physician licensing board to whom the above questions could be raised - particular to your daughter's care as well as the potential system issues. 

3. If you have not already, you may address these questions to your daughter's surgeon. Keep a paper trail of the questions, and the response. 

Matthew M. Cooper, MD FACs 

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K. “The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge.”

Paul Kirshbom, MD Emory University School of Medicine

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L. “If there is a documented infection it is mandatory to treat it with antibiotics” Wendel Smith, M.D

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M. “Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case”

Ron Hill, MD, FACS

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N. What troubles me from the material you sent is the expert's/ coroner's opinions as to the cause of death. Patients do not die from bleeding at the staple line of an intestinal anastomosis. When such bleeding occurs, it is manifested by significant BLEEDING PER RECTUM, which to my knowledge your daughter did NOT demonstrate. If she died of "intraperitoneal bleeding", that could have come from either a disrupted anastomosis or from larger blood vessels ligated during the resection of the mesenteric cyst and her right colon.

If indeed her abdomen was distending, and her pulse rate rising over an observable period of time, then the really important issue was why was she not rushed back into the operating room when it was clear that an intra-abdominal catastrophe was occurring? I would agree that CAT scans are not necessary to establish an emergency situation, so what was the time delay between what her condition was upon discharge until she was brought back to the hospital? I think it more likely you would get more useful information from the dictated operative report from her original surgery, from personal review of her medical records to see what her condition was when leading up to her discharge, and from the coroner's report of the autopsy findings. 

Anastomotic disruption following a RIGHT colon resection is quite rare actually, and the range stated in the expert's report probably reflects the overall leakage rate from ALL colon anastomoses. Such leakage/disruption is much more common in lower (or "distal") anastomoses, closer to the rectum. If her anastomosis did "disrupt", as alluded to, then it is usually a TECHNICAL ERROR on the part of the operating surgeon, especially because of the young age and apparently excellent former health of the patient. If there is sufficient proof of the above, then an investigation of the surgeon's performance both in this case and others might lead to "systemic" issues which deserve correction. 

The main thrust of such investigations should be prevention of similar outcomes, with a willingness to confront all the causative factors, including surgeons' performances. I hope the above clarifies your thinking, from an insider's perspective. Please let me know your thoughts.

yours sincerely, Mark Helbraun, MD, FASCRS 

Hello again Mr. Kilby: Now you are getting to the important issues in this case! If indeed she died 12 hours after discharge, then the emphasis in your investigation should focus on what was happening to your daughter in the 24 hours prior to discharge from the hospital.It is inconceivable to me that the autopsy report would not contain more detail than what you have given me regarding the status of her ileal-to-colonic anastomosis, since that would be the area that would demonstrate what (if any) disruption of the bowel occurred. 

Since there was "no rectal bleeding" prior to discharge, what bleeding she was having would have been intra-abdominal, and if those counts were falling in the hours prior to discharge, that also should have sent up red flags of warning to anyone who was paying attention. The time plot becomes critical to reconstructing events in a fair and honest way. Again, look carefully at the autopsy results, the operative note, and the version of events leading up to discharge that you have been given. I suspect you would agree that there is a more fitting memorial to your daughter than a garden, and that memorial would be a living, breathing accountability system which would ensure that events like what occurred to Terra would never happen again. These are sometimes called "never events" in our system here, and they are investigated to the maximum. Keep me posted.....

Mark Helbraun MD, FASCRS Mark Helbraun, MD, FASCRS Member of the 2010-2011 International Council of Coloproctology 35 years experience Academic Colon & Rectal Spec Hackensack, NJ Hackensack University Medical Holy Name Hospital Holy Name Hospital, Teaneck, NJ Hackensack University Medical Center, Hackensack 

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O. Dear Mr. Kilby, Based only on the information you have provided I find it difficult to justify what appears to be a "whitewash" of the patient's cause of death. The points you have raised are--in my opinion--legitimate reasons to question the validity of classifying her death as "natural" and would support your complaint of inadequate investigation. She unmistakably died of surgical complications that were arguably survivable with less flawed management. Under ordinary circumstances I would be willing to consider testifying on your behalf after undertaking an appropriate first-hand examination of the records. Please accept my regrets and best wishes. 

Benson B.Roe, MD,FACS, Professor Emeritus. Department of Surgery, University of California at San Francisco Medical Center

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The following was sent first to HPARB requesting a reconsideration of the Third HPARB decision in which they denied my request. I then contacted the Ombudsman’s Office asking them to get involved. This was pointless waste of my time as well. The Current Health Minister duty must delve into the CPSO and HPARB, as it is quite evident that both have abused their position to cover up negligence by a surgeon resulting in the death of my daughter and have thus failed all citizens in Ontario.

Ms Boucher,

RE: my complaint submitted to the Ombudsman's Office with regard to HPARB:

"was not carried out in accordance with the principals of natural justice and lacked procedural fairness."

Appearances:

The Applicant: Arnold Kilby

Support for the Applicant: Murray Kilby

Support for the Applicant: Hilda LeBlanc

Support for the Applicant: Maie Liiv

For the Respondent: Katherine Booth, Counsel

For the College of Physicians and Surgeons of Ontario: Angela Bates (by teleconference) for the the consecutive time

The selection below also indicates how the procedure during my third appeal was not fair as I was cut short and not allowed the opportunity to complete my oral presentation, so I could comment on the matters related to (a) and (b) below:

And since this was third time I have appealed the College's decision, the Board should have 2(b) required the College to send a representative instead of allowing them for the third time to take part via telephone conference call-- it is a fifteen minute walk from the CPSO to HPARB

Regulated Health Professions Act, 1991

S.O. 1991, CHAPTER 18

Consolidation Period: From December 3, 2015 to the e-Laws currency date.

Last amendment: 2015, c. 30, s. 28.

Conduct of review

33. (1) In a review, the Board shall consider either or both of,

(a) the adequacy of the investigation conducted; or

(b) the reasonableness of the decision.

Procedure

(2) In conducting a review, the Board,

(a) shall give the party requesting the review an opportunity to comment on the matters set out in clauses (1) (a) and (b) and the other party an opportunity to respond to those comments;

(b) may require the College to send a representative;

(d) may permit the parties to make representations with respect to issues raised by any questions asked under clause (c); and

(e) shall not allow the parties or the representative of the College to question each other. 1991, c. 18, Sched. 2, s. 33.

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

THE BASIS FOR RECONSIDERATION IS CLEARLY STATED BELOW:

#1 Having the Chair for the third appeal, who pretty much control the entire proceedings from London, Ontario (Forest City Lawyers - London) as is the College's Independent Opinion Provider, Dr. Brian Taylor.

No problem perhaps, but it certainly explains how this HPARB panel completely came up with their incredible decision and prevented me from giving my oral presentation. Both are highly notable men in London and I am confident they may have met many times at public, political and social events.
I would have thought the Chair would have excused himself from this panel!

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

#2 The contradictory CPSO's opinion with their own expert as well as the factual documentation within Terra's medical records!

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

In response to a request for further information from the College, the IO provider also set out the following information:

• The standard of practice for open bowel resections is to provide antibiotic prophylaxis.
However, such administration would not reduce the risk of anastomotic leak.

• The standard of practice would be to administer prophylactic antibiotics in connection with laparoscopic procedures if the bowel were involved; however, in this case, Dr. Klein believed he would be dealing with a cyst only and not opening the bowel, so the standard would not require administration of prophylactic antibiotics for the laparoscopic procedure.

AWKILBY’s Response: The above is pure BS. He knew before he converted to a laparotomy!!

Note the following: This proves that Dr. Klein was going to attempt laparoscopically a colon resection for a mesenteric mass. This was before he converted to a laparotomy!!!

Note the Procedure Desc. In the chart I submitted for the third appeal.

Note the Procedure Desc. In the following chart:

“Laparoscopic Colon Resection Attempted For Mesenteric Mass”

The second Procedure Desc. indicates the laparotomy.

And from Dr. Taylors’ (the College’s I.O) letter to Angela Bates May 8^th, 2011,

From Dr Klein’s own notes:

Issue before the Committee

HPARB directed the Committee to reconsider this matter in light of the question of whether Dr. Klein met the standard of practice concerning the use of preoperative antibiotics.

Addendum Report from the IO Provider

The IO provider set out the following information in an addendum to the IO report:

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

AWKILBY’s Response: The outcome is not part of the complaint!

• Most general and colorectal surgeons administer antibiotics preoperatively prior to laparoscopic or open colorectal surgery, as they have been shown to reduce the incidence of wound infection. Antibiotics, however, have not been shown to decrease the incidence of anastomotic leak.

AWKILBY’s Response: Temporarily forget the anastomotic leak which was not in my complaint.. The above statement indicates the Standard of Care that was not followed by Dr. Klein.

How can HPARB not focus on the actual wording from the Independent Opinion Provider and the College with respect to their statement contained within the Second and Third Decisions?

· "The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case."

Neglected equals Negligence

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

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

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

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

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

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

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

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

--Totally ignored my expert's opinions.

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

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

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

From letter sent to the College by Dr. Klein

July 13, 2011

Ms. Angela Bates Manager,

Committee Support Area Investigations and Resolutions

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

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

Antibiotics

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

L. Klein

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

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

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

More Medical Experts

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

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

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

1. Yes Kumar (B. Sivakumar MD)

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

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

Douglas Iddings MD

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

Dale D Burleson, MD

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5.  Mr. Kilby,

First, I am very sorry for your loss.

To answer your questions in general. Bowel cleansing is a matter of surgeon's preference prior to colon resection. There is evidence to show that the outcomes are not significantly different with or without a bowel preparation for colon surgery.

Antibiotics are recommended for colon surgery just prior to the start 
of the operation but should be stopped within 24 hours unless there 
are clinical indications to continue beyond the 24 hour period.  
These are the guidelines in the US and the goal of perioperative 
antibiotics is to prevent wound infections from surgery.

Sincerely,    Daniel H. Hunt  MD

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

W Mourad  MD
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7.  Dear Sir/Madam

I am sorry to hear about your daughter's outcome. To answer your question, the 
colon bowel prep has been in debate for few years. Some surgeons do not feel it is
necessary while others still use it. The antibiotic prophylaxis is 
used to prevent infection during and after 
surgery. As I am aware, both practices may not increase or decrease the 
incidence of postoperative bleeding
  I hope this will answer your question and help you deal with the event. Please feel 
free to ask more questions. I hope that your daughter is recovering well.

Sincerely;   Niazy M. Selim, MD, PhD, FACS
 Associate Professor of Gastrointestinal/Laparoscopic, 
 Endoscopic and Robotic Surgery
 Medical Director of Bariatric Program.    Department of Surgery

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8.  I am sorry for your loss   Usually antibiotic are given iv 
prior to colon surgery
 I hope you will find peace in your future       
Amelia Grover, MD
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 9.  YES     Willie Melvin  MD

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

Your Welcome, Dr. DeNoto MD

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

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

Helen Chan MD

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

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

Michael H. Wood, MD, FACS

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

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

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16. Hi Mr. Kirby,

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

Gregory Gallina MD

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

Harold Kennedy MD

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

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19. Hi Mr Kilby-

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

Elliot Newman MD

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

Best Regards Dr.Tvaruzek MD

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

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

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

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

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

hugo gomez-engler

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

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

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

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26. yes Malcolm Steel MD

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

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

Adrian Greenstein, MD

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

Sanjeev Sharma MD FACS

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30. Yes Sent from my iPhone

Cohen, Robbin MD

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31. Arnold.

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

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

Matt Slater, MD

Associate Professor

Clinical Director, Adult Cardiac Surgery OHSU Sent from my iPhone

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32. YES todd grehl MD

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33. Just this one... yes

Anthony P Furnary MD

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

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35. Dear Arnold,

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

Kind regards,

David Jayne MD Senior Lecturer in Surgery Leeds

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36. Yes Demeester, Steven MD

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

FF. fernando Fleischman M D

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

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

Luis Castro. MD

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39. Mr Kilby,

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

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

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40. Dear Mr. Kilby,

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

Regards, Douglas Boyd Professor of Surgery University of California Davis

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

Sent from my iPhone HOMAYOON Ganji

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

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

Long, William :LPH Dir. Tra

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

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

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44. Dear Mr. Kilby,

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

Cord Cordell H. Bahn MD

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

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

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

Michael Wood MD

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48. Arnold

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

Mike Perelman MD

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

Yes Diethrich, Edward MD

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

SWCVTS@aol.com

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51. Mr. Kilby,

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

Stanley Carson, MD

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

Absolutely.

HP MD

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

I have no pressures from any organization.

BBRoe Benson Roe

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54. Dear Mr. Kilby,

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

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

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

Antibiotics administered to patients prior to colorectal surgery

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

The review found 260 studies which had recruited over 43 thousand people undergoing abdominal surgery. The studies had some limitations in relation to the number of people who remained in the studies and the possibility that the results were affected because some of the researchers in the studies knew which people had received antibiotics before surgery. However, when the results were analysed effect of prophylactic antibiotics was consistently beneficial meaning that these limitations were unlikely to have had a major impact on the nature of the overall results. Abdominal surgical wound infection in patients having operations on the large intestine occurs in about 40% of patients if antibiotics are not given. This risk can be greatly diminished by the administration of antibiotics prophylactically before surgery. The antibiotic(s) given usuallly needs to cover different types of bacteria some of which need oxygen (aerobic bacteria) and others which do not need oxygen (anaerobic bacteria).. They are usually given via a canula injected into a vein, though there is evidence that a combination of oral and intravenous antibiotics may provide more protection. This last finding raises a problem in that current clinical practice is to avoid mechanical cleansing of the colon because it is not thought to be necessary before surgery (and not popular with patients). Studies that found a benefit to oral antibiotics were done at a time when mechanical cleansing of the colon was routinely done. In the light of current practice regarding mechanical cleansing before surgery of the colon, the benefit of oral antibiotics is uncertain.

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56. Yes

Grantham, Nathan MD

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57. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Yes
John Calhoon MD Professor and Head CT Surg UTHSCSA

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58. AK:

The standard of practice for prevention of wound infection in colon surgery is to use prophylactic antibiotics.

The description of your ordeal following your daughter’s death suggests that a satisfactory closure will only be achieved by thinking outside the box. You are correct in your assessment of the constraints of the legal response to malfeasance. Novelists, magazine writers, television inquiry shows and personally committed politicians are the alternative methods of casting light into sordid corners.

Who asked you to write me?

Bill Murphy MD

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59. Mr Kilby,

I have no idea how the Canadian system works and I have to preface my remarks with the comment that I obviously only have your side of this story. Also, I am a pediatric heart surgeon so your daughter's case is not within my area of expertise.

In the US this would have been settled or tried in court. I would think antibiotic prophylaxis for colorectal surgery is routine and indicated - at least 15 years ago when I last did general surgery. Without seeing the facts I cannot determine if this played an important part in the unfortunate outcome for your daughter.

I have great sympathy for you and the lack of transparency you describe is alarming. If I were in your shoes I would sue.

Max Mitchell MD

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

Hello Arnold, Thank you for contacting Hadassah.

The answer to your question is yes.

Best Regards, Isabelle Stroweis Hadassah External Relations Division

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

operation?

Yes- that is standard. Blackmon, Shanda, M.D.

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62. Yes antibiotic prophylaxis prior to colon surgery is standard

Whether this would have saved your daughter is unclear however.

Brinkman, William T MD

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

Arnold,

I am truly sorry for your loss. I believe pre-op antibiotics should have been given. I have included a link that may be helpful.

Derek Derek von Haag MD

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

Prophylaxis is standard of care to my knowledge

I am very sorry for your loss.

Matt Cooper MD

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65. We still adhere to the fact that patients should have a dose of antibiotics at the time of surgery for most colorectal procedures especially those involving a resection. Some hospitals give up to three doses as prophylaxis, although there is no evidence for this. Karen Nugent

Honorary Secretary

Association of Coloproctology of Great Britain & Ireland

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66. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation? Likely should have received

antibiotics

Baron Hamman MD

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67. I’m sorry for your loss. I can’t imagine losing either of my boys (6 & 3).

In the United States, it is standard of care to administer appropriate antibiotics within one hour of surgical incision for any case deemed at risk for infection. We get in trouble for any case not administered and documented as such.The US is more into malpractice and I can’t speak to Canadian law. My cousins are lawyers in Duluth and Chicago and would tell you that each case has its own issues and merits. No action will return your daughter to you; that doesn’t mean you shouldn’t pursue this with the national body and perhaps your lawyers.My parents are also retired teachers/pastor and ran Luther Village for a summer in the 60’s. Ontario is one of the most beautiful provinces in the world and I’m sure your daughter was the same. AT Trachte, Aaron Dr.

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68. Mr. Kilby,

I am terribly sorry to hear about you loss. I have two children and can’t imagine the pain.As you said I am a cardiothoracic surgeon so I probably can’t help on the details of your daughter’s case. But the answer to your question on antibiotic prophylaxis is a clear yes. 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. When a patient “falls out” (i.e. one of the SCIP guidelines was not followed), the individual doctor receives a letter from the director of the medical staff.

Here is a link to one article showing that following SCIP guidelines decreases surgical site infections following colorectal surgery.

http://www.ingentaconnect.com/content/sesc/tas/2008/00000074/00000010/art00028

Lishan Aklog, MD Chair, The Cardiovascular Center

Chief of Cardiovascular Surgery St. Joseph’s Hospital and Medical Center

500 W. Thomas Rd, Suite 500 Phoenix, AZ 602-406-2996 (Assitant Beth)
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69. Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

Yes indeed. That is the standard of care

Dr. MacMillan MD

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70. Dear Mr. Kilby, Please accept my sympathy over the tragic loss of your daughter. Whether the lack of antibiotics before surgery was the essential factor that brought about her demise is still unclear and may always be so. There could have been some other problem during the colon resection which could have led to contamination. This remains unknown. Meanwhile, you are left to cope with your loss and the mental anguish associated. As one who has also lost a young daughter, I believe I can share your grief. I can also affirm that, while not easy, you must do all that you can to go forward with your life, honoring your daughter’s memory.

Yours truly, Denton A. Cooley, MD

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71. I am very sorry for your loss. I am sure the wounds are still very painful 4 years later. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. Having said all of that the lawyers for the doctors are correct; medicine is an art (sometimes performed very poorly) not a science.

See the SCIP initiatives available online (Google SCIP initiatives) to better understand when, and what type of antibiotics are recommended prior to colon surgery.

Good luck with your inquiry and again I'm sorry for your loss......................

Moe Lyons, Maurice Lyons,

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

The short answer is “yes”. I’m truly sorry for your loss, sj

Scott B. Johnson, MD Associate Professor

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

The answer is yes. What was the cause of death of your daughter? She was obviously very sick. Was she diabetic? Obviously she had a wound infection but what lead to her death is not clear at all. My advice if you are not getting anywhere is to seek a legal opinion.

John Reza Mehran, MD

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74. Dear Mr Kilby:

I have looked over some of the material about your daughter.

I am certified in surgery and thoracic and cardiac surgery. I trained at UCLA (mostly, also U of Minnesota Hospital and Johns Hopkins). I don't currently see patients, but review cases for the Arizona Medical Board.

The big problem is apparently not cleaning the colon with laxatives or enema prior to surgery. Antibiotics don't help and likely are contra indicated. I can find specific references at our medical school.

Feel free to contact me

TW Christiansen MD twc4441@aol.com

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75. Mr Kilby-

I read with great interest your email and I am very sorry for your tremendous loss.

You are right, I am a cardiothoracic surgeon, but I completed a General Surgery Residency as well.

All patients used to receive pre-operative antibiotics prior to any colonic surgery. I would be surprised if this has changed.

Unfortunately, this did not cause her death, but from what it sounds like may have contributed to it.

As I am sure you know, when we have poor outcomes, it typically stems from a series of errors/omissions/etc.

Again, a tragic story, and I hope that you may find some resolution and closure.

Kypson, Alan MD

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

Arnold

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

Mike Perelman MD

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

Mr. Kilby,
My condolences to you and your family on the untimely death of your daughter.

It is standard of care in the United States that all patients undergoing bowel surgery should receive pre-operative prophylactic antibiotics at least 20 min before the incision is made. As a cardiothoracic surgeon, I do a fair amount of esophageal surgery. The same rule applies in regards to this issue.

Sincerely,
MPC Michael P. Collins, MD, FACS Chief, Division of General Thoracic Surgery
Intermountain Medical Center and LDS Hospital
Clinical Professor of Surgery
Division of Cardiothoracic Surgery
University of Utah School of Medicine

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78. Mr. Kirby: My opinion to antibiotic prophylaxis is generally yes for patients undergoing open colon resection. How this relates to your daughters care remains unknown unless the entire case can be scrutinized. My sympathies for your loss.

Steven J. Phillips, MD

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

yes Mark S. Allen MD

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80. Optimal bowel preparation for colon surgery includes mechanical cleansing of the colon the evening prior to surgery and an intravenous dose of broad spectrum antibiotics immediately prior to beginning the operation. This dose is usually given in pre-operative holding or by the anesthesiologist during the skin preparation and draping.
Sorry for your sorrow. Robert L Replogle. MD.

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

Yes. Within 30 min of

incision. Jbz Zwischenberger, Jay MD

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

The answer to your question is "yes". I am so sorry to hear of your heart break!
Hendrick Barner MD

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

yes Walter G Wolfe MD

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

Yes – SOC Miller, Daniel Sent from my Verizon Wireless BlackBerry

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85. It is standard that all pts receive perioperataive antibiotics with a goal of administering them within 30 minutes prior to skin incision. It is a well validated quality outcome parameter.

John V. Conte, M.D. Professor of Surgery Johns Hopkins University School of Medicine

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

Dear Sir
The answer to your first question is yes. Marcelo Cardarelli, MD

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87. Dear Mr. Arnold, I am very sorry for your loss, however, as you pointed out in your message, I am not the right person to review your daughter’s case. While your frustration with the system and the responses you have gotten to your questions is very clear, I find it difficult to believe that the Canadian medical system is engaged in a conspiracy of some sort involving British surgeons and everyone involved in the case. I think you are giving them far too much credit with regard to organization and cohesive intent. In my opinion, your frustrations are more likely the result of the disorganization and delays that are typical of large medical administrative units. Again, I am sorry for your loss and I hope you find the answers you are looking for.

Sincerely, Paul Kirshbom, MD Emory University School of Medicine

Dear Mr. Kilby, The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. In this business, patients sometimes die (and as a pediatric cardiac surgeon, when that happens, it is truly devastating for all involved). It is unavoidable sometimes, but the one thing that can be avoided is lack of communication and clarity with the family. I think that if you had received that from the beginning, you likely could have moved past this painful time in your life. I honestly hope that you get the information you seek and that you can move on. The loss of your daughter was certainly a tragedy, regardless of the circumstances. The greater tragedy would be to allow that event to rule the remainder of your own life.

I wish you the best of luck. Paul Kirshbom, MD

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

In answer to your question, she should have received prophylactic antibiotics and a bowel prep prior to surgery. Ron Hill, MD, FACS ***********************************************************************

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

Absolutely yes, it is malpractice not to!

Sorry about your loss. Regards, Luca Vricella Luca A. Vricella, MD, FACS

Associate Professor of Surgery and Pediatrics Johns Hopkins University

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90. I assume this was an elective (i.e. not an emergency) colon resection.

In the United States, the practice is to perform at least a mechanical bowel prep before an elective colon resection and in all circumstances perioperative antibiotics are given, usually prior to the incision. The duration of antibiotic administration depends somewhat on what is found at operation, but in most circumstances they are stopped not later than 48 hours post-op. I hope this is helpful and am sorry for your terrible loss.

Lynn H. Harrison, Jr., MD Clinical Director

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

Yes Peter M. Scholz, MD & James W. Mackenzie Professor of Surgery

Associate Dean for Clinical and Translational Research

Department of Surgery

UMDNJ-Robert Wood Johnson Medical School

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

Yes Sent from my Verizon Wireless BlackBerry

Joshua Sonett MD

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93. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.

Allan Stewart MD

I'm sorry to hear about the death of your daughter. A parent should never lose a child.

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94. Mr. Arnold Kilby: I feel sorry for your daughter outcome. Most of your observations and questions make sense. The legal system should be able to address them. I do not believe that anyone outside Canada can be of any help.

Sincerely R. Neirotti Rodolfo A. Neirotti, M.D., Ph.D., FETCS

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95. I can only say by the description here that there must have been some kind of contamination either during or after surgery most likely coming from the bowel itself based on the gram negatives you describe.

Good luck with your search for answers, I hope you get them. God Bless. Cristy Smith MD

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96. Dear Mr. Kilby,
I feel very sorry and regret what you are experiencing, and completely understand your reaction.
A patient undergoing open surgery should always have antibiotics at the time of inducing anesthesia and repeat the dose if the operation last more than 6 hours.

I hope this may help you. Good luck and best regards,

Paolo Macchiarini MD
pm pmacchiarini@thoraxeuropea.eu

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97. I am indeed a CVT surgeon and not qualified in General Surgery but it is my understanding that prophylactic antibiotics are given with induction for colonic surgery. I regret your loss and hope you find answers to your questions. Goldman, Dr. Bernard Bernard.Goldman@sunnybrook.ca

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98. Dear Mr Kilby,

Your questions seem utterly reasonable. As you rightly note I am a cardiothoracic surgeon, so through this reply I am asking John Black, President of the Royal College of Surgeons in England to put you in touch with someone better equipped to answer your questions.
I am sorry that the immense pain you must be feeling at the loss of your daughter is being made worse by difficulty in having some very simple questions answered.
I hope we can help you. Bruce Keogh Bruce.Keogh@dh.gsi.gov.uk
Sir Bruce Keogh NHS Medical Director

Message sent from a Blackberry handheld device.

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99. Mr. Kilby

I feel for your sorrow and please accept my sincere feelings. As a cardiothoracic surgeon, it is not appropriate for me to answer a question regarding abdominal surgery. However, I support using of prophylactic antibiotics before major surgery.

Sertac Cicek, MD

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100. Mr Kilby-

First and foremost, I am ever so sorry for your loss and terrible tragedy. Obviously, I am in no position to legitimately comment on the adequacy of care your daughter received. But I certainly can answer your question.
Generally speaking, pts undergoing colon surgery should receive intravenous antibiotics within 60 minutes prior to their incision. The specific goal is to prevent wound infection-the antibiotics do not seem to decrease the incidence of any other surgical complication (such as a leak or abscess).

Again, my sincerest sympathies

Neil Hyman MD

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101. Intravenous Antibiotic prophylaxis is standard when performing a colon resection regardless of whether it is done laparoscopically or via open methods.
Best of luck.

RL Whelan

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102. Dear Arnold Kilby

Anti-biotic prophylaxis should be given at time of surgery according to practice guideline in US and in China as well while performing transabdominal colon resection based on evidence-based colorectal surgery, I think. In my opinion, your daughter may have die from postoperative infection or sepsis.

Regards

Wan-Jin Shao

Chief Consultant Colorectal Surgeon,

Clinical Professor American Society of Colorectal Surgeons(ASCRS )member

Department of Colorectal Surgery Nanjing University of Chinese Medicine Hospital

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103. Receiving ATBs preoperatively before an abdominal surgery is a standard of care. Regards feza Feza H. Remzi, M.D. | Chairman | Department of Colorectal Surgery

Cleveland Clinic | 9500 Euclid Ave.-A30 | Cleveland, OH 44195 | (216) 445-5020

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104. Dear Mr. Kilby:

As a father of a twenty-something daughter, and a long-time practioner of colorectal surgery for over 30 years, I can relate to your circumstances and your grief. The short answer is obviously YES, your daughter should have been prepared for elective colon surgery with both a mechanical (purgation) and an antibiotic bowel preparation. These have been the standard for at least the last 30 years, spanning to the time before I began training as a surgeon in 1972. Extensive clinical research had provided data as to the efficacy and safety of that approach, so it was completely standard to do both preps prior to elective colon surgery. Having said that, and believe me when I say it, I STILL use both preps for my own operative cases and am rewarded with very low sepsis and very low overall complication rates. However, some less-than-brilliant surgeons have in the last 5 or so years begun to advocate for colon surgery without mechanical preparation beforehand! I believe both the data and the conceptual rationale for this approach to be very flimsy indeed. They claim that bowel prep is "expensive" (pure B.S., to use the American vernacular), is "intolerable" to the patient (we do it all the time for colonoscopy, for example), and that purgation interferes with the "microcirculation" of the colon. That latter "factoid" is trotted out as the reason for why those publishing surgeons claim to have LOWER complication rates when the bowel is left unprepped before surgery. They claim that interfering with the microcirculation impairs colon healing, leading to higher rates of anastomotic leakage and postoperative sepsis. In American jurisprudence, you would have no trouble finding dozens of surgeons who would be happy to testify that bowel preparation is still mandatory ("standard of care") for elective, safe colon surgery. I do not know the consensus of opinion on this topic in Canada.

Suffice it to say, on the basis of the few facts of your daughter's case presented in your short email to me, I would conclude that she was poorly, even negligently served by the surgeon entrusted with her care.

Unfortunately, I have seen in the American system, that if we did not have strong legal sanctions against negligence, many doctors would literally get away with murder. There will always be failures of judgment which lead to patient harm, as long as physicians remain fallible human beings. But my belief is that the surgeons who are promulgating colon surgery without suitable bowel preps are willfully ignoring decades of safety experience. They are trying to "reinvent the wheel", when bowel prep has an established safety record over many decades. One might reasonably ask the question "why" they would tamper with success, and that is a long, fruitless discussion from your standpoint. In brief, I believe it boils down to a question of surgical ego, where some surgeons are hell-bent to prove that they are so good they can evade the norms established by mere mortal surgeons such as myself.

Again, my condolences to you and your family. You are experiencing tragedy of the first order, and it always pains me especially when such stories come at the hands of intelligent, well-motivated surgeons who are charged above all to "do no harm" (primum non nocere).

Sincerely yours, Mark Helbraun, MD, FASCRS

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105. Dear Sir:

I am so sorry for the loss of your daughter. The clinical picture that you describe is that she died from infectious complications related to a peritonitis and sepsis from post operative complications. The causes are multiple, but after colonic surgery a usually fatal complication is an anastomotic suture leak (breakdown).

Most colo-rectal surgeons will prepare the colon and give pre operative antibiotics. But this will not prevent a technical suture problem. The autopsy report should have those details. The operative report should help.

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106. Taken from article entitled When is Primary Anastomosis Safe in the Colon?

2005 Surgery in Africa Monthly Reviews and 2010 update

Antibiotics with activity against aerobic and anaerobic bacteria need to be given parenterally in the peri-operative period alone. Their post-operative use should be restricted to cases with established infection. Pre-operative oral antibiotics may have an added value.

In elective colon operations there appears to be no value to mechanical bowel preparation. Even as I write this, my surgical prejudices rebel against such a notion.

Brian Ostrow MD, FRCS(C) Guelph, Ontario Canada

Adjunct Lecturer Office of International Surgery
University of Toronto Canada

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107. Dear Mr. Kilby I'm very sorry to hear of your loss.

The short answer to your question is yes, giving an antibiotic prior to an elective colon resection is the standard of care in the US. In the US the sequence of events that you describe would usually generate a lawsuit.

You may find the following websites helpful http://www.qualitymeasures.ahrq.gov/search/search.aspx?term=Colorectal+Surgery+Specialty&umls=1 (the website for the national guidelines regarding standard surgical practices)

www.fascrs.org (website of the American Society of Colon and Rectal Surgeons)

www.facs.org (website for the American College of Surgeons)

American College of Surgeons

www.facs.org

The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

http://www.cags-accg.ca/ (the Canadian Association of general Surgeons)

Sincerely Tonia Young-Fadok MD

Tonia M. Young-Fadok, MD, MS, FACS, FASCRS
Professor of Surgery, Mayo Clinic College of Medicine
Chair, Division of Colon and Rectal Surgery
Mayo Clinic, AZ
5777 E Mayo Blvd Phoenix, AZ 85054 Phone: 480-342-2697 Fax: 480-342-2866
youngfadok.tonia@mayo.edu

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108. Hello

I have reviewed the material. My opinion is you should try to hire an attorney to proceed with this case. I have done a lot of expert work in the field of cardiothoracic surgery which is what I do daily. I have always worked with a lawyer. I think there are a lot of problems with this case and you have a strong case to proceed. There are lawyers who could guide you with proceeding with this case. I am not familiar with the Canadian procedures for medico-legal cases. Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. We do this for our cardiac patients and they have not had any bowel procedures. Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case

Thanks Ron Hill, MD, FACS

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109.  There is very good evidence that mandates
 that patients receive broad spectrum IV antibiotics
 prior to having colon surgery, especially if they 
haven't received a bowel prep.  If this wasn't done 
this is not in line with the standard of care in the US.                                                                                                                  
David A Lanning, MD, PhD
 Surgeon-in-Chief, Children's Hospital of Richmond
 Virginia Commonwealth University Medical Center
 PO Box 980015
 Richmond, VA 23298-0015
 Office (804) 828-3500

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 110.  Mr. Kilby:

Were peri-operative prophylactic antibiotics administered? 
 There is a suggestion that they may not have been.  It is standard of 
care to do so for a limited time around the time
of operation.

Matthew M. Cooper, MD FACs    
*******************************************

Medical Facts

Numerous examples and proof of negligent care can be seen clearly within Terra’s medical records seen below:

THE MEDICAL FACTS!

A)--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

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

B)**-- ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE

--the enlarged abdomen?---That is a sign of something wrong.

Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid (Ascites is an accumulation of fluid in the abdominal cavity.), or air

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

C) Abdomen and Resting Pulse Rates Nursing Records

Description of Terra’s Abdomen high pulse rate? 34/38 above 90

July 11th
1133 hrs 105
1143 105

1630 flat 106

1709 98

1730 101

2000 flat 104

July 12th
0000 flat 104
0400 flat 105

0800 flat 116
1300 flat 194???? This is not a typo from me. It is in the record!
1605 flat 101

2000 103
July 13th

0820 rounded 110
1130 rounded 105

1615 rounded 102

2100 rounded
2015 rounded 107
July 14th
0500 rounded 126
0815 rounded 97
1200 rounded 95
1500 rounded 117

1600 rounded

1857 rounded

2000 rounded 110

July 15th
0530 rounded 94
0910 rounded 97
1300 rounded
1800 rounded 108

2107 rounded

July 16th
0530 rounded 98
1130 rounded 105

1310 rounded 96

2000 large 102

July 17th
0700 large 93
0951 large 104

1437 98

2200 large 108

July 18th
0517 large
0600 large

1000 large 86

1510 large

1600 large 90

2000 large 85

July 19th
0925 large 93
1957 large 96

July 20th
0039 large
0800 large 88 Terra was released

D)HCT Hematocrit Count Ref. 0.36 to 0.48

July 18 0.35

Day 6 0.35

Day 4 0.32 All 5 tests are below normal

Day 3 0.32 range

Day 2 0.34

Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia.

Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding etc

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"**

**E)*RBC Red Blood Count Ref. 4.20-5.40

July 18 4.20

Day 6 4.16

Day 4 3.80 1 test at well low of normal range &

Day 3 3.78 other 4 below normal range

Day 2 3.95

Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body.

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

F)ABS LYMPH# Absolute Lymphocytes Count Ref. 1.5 - 4.0

July 18 0.9

Day 6 0.7

Day 4 0.5 All 5 tests are well below

Day 3 0.8 normal range

Day 2 1.0

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

G)many PMN’s (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process. The presence of many PMN’s implies an inflammatory process.

PMN’s are the hallmark of acute inflammation

PMN’s are rapidly recruited to tissues upon injury or infection

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"**

H)low Absolute Lymphocyte (type of white cells to fight infection)? B cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. are responsible for making antibodies

T cells, a type of lymphocyte (white blood cells), have an important role in the body's immune system. enhance the production of antibodies by B cell

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

I)HB Hemoglobin Ref. 120-160

July 18 119

Day 6 117

Day 4 107

Day 3 106

Day 2 111 ALL BELOW THE STANDARD

The vital role of hemoglobin in transporting oxygen from the lungs to the rest of the body is derived from its unique ability to acquire oxygen rapidly during the short time it spends in contact with the lungs and to release oxygen as needed during its circulation through the tissue

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

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

Individually, perhaps the test scores may be dismissed but collectively there is an indication of something going wrong and required further investigation!

J) seriousness of the oozing, infected abdominal incision. Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.

FROM NURSES’ CHARTS

July 15th

Page 109 853 hrs incision oozing
910 no odour, no oozing
Page 105 1300 no odour but dressing soaked with purulent foul smelling fluid

Page 103 1430 foul odour

Page 98 2000 site #1 leaking

Page 94 2152 foul odour

July 16th Page 86 1030 foul odour
Page 83 1310 no odour, but larger purulent foul drainage from the umbilicus

Page 78 2000 no odour, but larger purulent foul drainage from the umbilicus

Page 76 2200 foul odour

July 17th

Page 74 0445 foul odour

Page 73 0630 foul odour

Page 71 0700 no odour but large purulent foul drainage from umbilicus

Page 66 1400 large amount of drainage from umbilicus

Page 65 1700 foul odour

July 18^th

Page 62 0045 foul odour

Page 60 0900 foul odour

Page 58 1300 foul odour

Page 56 1560 7 staples removed — wound gaping wound oozing copious amount of purulent fluid

Page 55 1600 oozing incision

July 19th

Page 51 0815 foul odour

Page 49 0925 wound oozing copious amount of purulent fluid

Page 48 1500 foul odour

Page 45 1957 oozing incision

Page 44 2100 foul odour

July 20th

Page 43 0039 oozing incision

Page 41 0800 oozing incision
1000 foul odour
Terra was released.

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"**

K)no nutritional supplementation to ensure her nutritional needs were met. Terra was on a liquid diet of juice, jello, brothe and tea for 8 ½ days. (last two meals were regular) This diet should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. Terra received no nutritional supplements. She was receiving only 687 calories per day that equates to a starvation diet. With no nutritional supplementation!!!!!

The full liquid diet is low in iron, vitamin B12, vitamin A, and thiamine. It should not be used for a long period of time unless vitamins, iron, or liquid nutritional supplements are added. The full liquid diet does not provide enough energy, protein and many other nutrients. This diet is temporary and should not be used for more than 5 days

TAKEN FROM USDA National Nutrient Database for Standard References 2004

1. LACKING 83.2% OF TOTAL DAILY IRON INTAKE! Iron is required for the formation of haemoglobin in red blood cells, which transport oxygen around the body. Iron is also required for normal energy metabolism

1. Iron Deficiency = The recommended dietary allowance required by an adult female for Iron is 18 mg/day

Terra’s diet contained: Jello .01 mg Tea .02 mg Broth .06 mg Juice .92 mg

Terra would have received 3.03 (16.8%) mg per day in the course of her 3 daily meals. This means she was lacking 14.97 mg per day!

2. LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE! Vitamin K is not readily stored within the body, thus the importance of the daily requirement. The over riding effect of nutritional Vitamin K deficiency is to tip the balance in coagulation toward a bleeding tendency.

2. Potassium Deficiency =The recommended dietary allowance required by an adult female is 90 micrograms of Vitamin K per day.

Terra’s diet contained: Jello 0 mcg Tea 0 mcg Broth 0.2 mcg Juice 0 mcg

Terra would have received .6 (point 6) (.7%) mcg in the course of her 3 daily meals. This means she was lacking 89.4 mcg daily!

3. LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE! Supports a healthy immune system, energy metabolism and protein synthesis

3. Magnesium Deficiency =The recommended dietary allowance required by an adult female is 255 mg/day (milligrams) of Magnesium per day.

Terra’s diet contained: Jello 1 mg Tea 5 mg Broth 0 – 3 mg Juice 12 mg

Terra would have received 63 (25%) mg in the course of her 3 daily meals. This means she was lacking 192 mg daily!

4. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE! Vitamin E is the major lipid-soluble antioxidant in the cell antioxidant defence system and is exclusively obtained from the diet.

Vitamin E significantly strengthens the immune system; supplies oxygen to the blood, which is then carried to the heart and other organs.

4. Vitamin E Deficiency =The recommended dietary allowance required by an adult female is 15 mg (milligrams) of Vitamin E per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .13 mg Juice .02 mg

Terra would have received .45 (.03%) mg in the course of her 3 daily meals. This means she was lacking 14.55 mg daily!

5. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE! Blood coagulation is dependant on calcium.

5. Calcium Deficiency =The recommended dietary allowance required by an adult female is 1000 mg/day (milligrams) of Calcium per day.

Terra’s diet contained: Jello 4 mg Tea 0 mg Broth 4 mg Juice 20 mg

Terra would have received 73 (.73%) mg in the course of her 3 daily meals. This means she was lacking 927 mg daily!

6. LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE! It is also required for cell differentiation and therefore for normal growth and development, and for normal vision and for the immune system.

6. Vitamin A Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Vitamin A per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.5 mg

Terra would have received 7.5 (.01%) mg in the course of her 3 daily meals. This means she was lacking 682.5 mg daily!

7. LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE! assists the body in the production of collagen, a basic component of connective tissues. Collagen is an important structural element in blood vessel walls, gums, and bones, making it particularly important to those recovering from wounds and surgery.

IMPORTANT: Inflammation in the tissues causes the breakdown and destruction of collagen fibers. Sutures will pull away from damaged tissues whether the tissues are damaged by disease or medical negligence. Any infected tissue which is separated by surgery will be slow to heal, or may fail to heal.

7. Vitamin C Deficiency =The recommended dietary allowance required by an adult female is 75 mg/day (milligrams) of Vitamin C per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 2.2 mg

Terra would have received 6.6 (9%) mg in the course of her 3 daily meals. This means she was lacking 68.4 mg daily!

8. LACKING 93% OF TOTAL DAILY FIBRE INTAKE!

8. Dietary Fibre Deficiency =The recommended dietary allowance required by an adult female is 25 mg/day (milligrams) of Dietary Fibre per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice .5 mg

Terra would have received 1.5 (6%)mg in the course of her 3 daily meals. This means she was lacking 23.5 mg daily!

9. LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE! protects against infection, and enhances the immune system;

9. Phosphorus Deficiency =The recommended dietary allowance required by an adult female is 700 mg/day (milligrams) of Phosphorus per day.

Terra’s diet contained: Jello 30 mg Tea 2 mg Broth 19 mg Juice 17 mg

Terra would have received 204 (29.1%) mg in the course of her 3 daily meals. This means she was lacking 496 mg daily!

10. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE! protects against infection, and enhances the immune system; Zinc is also required in wound healing.

10. Zinc =The recommended dietary allowance required by an adult female is 8 mg/day (milligrams) of Zinc per day.

Terra’s diet contained: Jello .01 mg Tea .04 mg Broth .36 mg Juice .05 mg

Terra would have received 1.38 (17.3%) mg in the course of her 3 daily meals. This means she was lacking 6.62 mg daily!

11. LACKING 99.9% OF TOTAL DAILY COPPER INTAKE! Needed for the formation of red blood cells and body needs copper to be able to use iron properly.

11. Copper =The recommended dietary allowance required by an adult female is 900 µg/day (microgram mcg) of Copper per day.

Terra’s diet contained: Jello .032 µg Tea .018 µg Broth .246 µg Juice .030 µg

Terra would have received .978 µg (microgram) in the course of her 3 daily meals. This means she was lacking 899.022 µg daily!

12. LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE! In immune function and infection prevention, and selenium deficiency has been reported in patients after intestinal surgery

12. Selenium =The recommended dietary allowance required by an adult female is 55 mg/day (milligrams) of Selenium per day.

Terra’s diet contained: Jello 1.5 mg Tea 0 mg Broth 1.7 mg Juice .2 mg

Terra would have received 10.2 (18.5%) mg in the course of her 3 daily meals. This means she was lacking 44.8 mg daily!

13. LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE! Because of its constant demand and limited storage thiamine is required daily. enhances circulation, assists in blood formation, carbohydrate metabolism and digestion; plays a key role in generating energy acts as an anti-oxidant, protecting the body from degenerative effects

13. Thiamin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Thiamin per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth .004 mg Juice .052 mg

Terra would have received .168 (15.3%) mg in the course of her 3 daily meals. This means she was lacking .932 mg daily!

Thiamine is an essential coenzyme in carbohydrate metabolism. Because of its constant demand and limited storage thiamine is required daily.

14. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE! Necessary for red blood cell formation, anti-body production, cell respiration, and growth

14. Riboflavin =The recommended dietary allowance required by an adult female is 1.1 mg/day (milligrams) of Riboflavin per day.

Terra’s diet contained: Jello .008 mg Tea .025 mg Broth .015 mg. Juice .042 mg

Terra would have received .09 (8.2%) mg in the course of her 3 daily meals.

This means she was lacking 1.01 mg daily!

15. LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE! the maintenance of the gastrointestinal tract. It is required for the release of energy from food
15. Niacin =The recommended dietary allowance required by an adult female is 14 mg/day (milligrams) of Niacin per day.

Terra’s diet contained: Jello .001 mg Tea 0 mg Broth .711 mg Juice .181 mg

Terra would have received 2.679 (19.1%) mg in the course of her 3 daily meals. This means she was lacking 11.321 mg daily!

16. LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE! Vitamin B6, also called pyridoxine, is essential in the breakdown of carbohydrates, proteins and fats. Pyridoxine is also used in the production of red blood cells.

16. Vitamin B-6 =The recommended dietary allowance required by an adult female is 1.3 mg/day (milligrams) of Vitamin B-6 per day.

Terra’s diet contained: Jello 0 mg Tea .002 mg Broth .024 mg Juice .045 mg

Terra would have received .213 (16.4%) mg in the course of her 3 daily meals. This means she was lacking 1.087 mg daily!

17. LACKING 100% OF TOTAL DAILY VITAMIN B-12 INTAKE! Helps in the formation of red blood cells Vitamin B12 deficiency impairs the body’s ability to make blood, accelerates blood cell destruction

17. Vitamin B-12 =The recommended dietary allowance required by an adult female is 2.4 mg/day (milligrams) of Vitamin B-12 per day.

Terra’s diet contained: Jello 0 mg Tea 0 mg Broth 0 mg Juice 0 mg

Terra would have received 0 mg in the course of her 3 daily meals. This means she was lacking 2.4 mg daily!

18. LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE INTAKE!

Calorie intake for a Female at Terra’s weight

Daily Requirement

Sedentary 1,816 - 1,982 Carbohydrates 130 grams per day

Low Active 2,016 - 2,202 Protein 46 grams per day

Active 2,267 - 2,477

Very Active 2,567 - 2,807

Jello 84 calories 19.16 g carbohydrates 1.65 g protein

Tea 2 calories .53 g carbohydrates 0 g protein

Broth 29 calories 1.76 g carbohydrates 5.35 g protein

Juice 114 calories 28.2 g carbohydrates .25 g protein

Total = 687 calories 148.95 g carbohydrates 21.75 g protein

Protein = Terra was lacking 21.75 g of protein per day!

Terra was only consuming 687 calories daily. A starvation diet is listed as below 1200.

19. LACKING 57% OF TOTAL DAILY CALORIE INTAKE BASED ON HER BASAL METABOLIC RATE. TERRA WAS OBTAINING ONLY 687 CALORIES PER DAY AND THAT IS IF SHE CONSUMED ALL OF HER LIQUID DIET FOR THE DAY.* A starvation diet (Starvation diets (less than 800 calories per day) does not mean the absence of food. It means cutting the total caloric intake to less than 50% of what the body requires.

20. LACKING 47.3% OF TOTAL DAILY PROTEIN INTAKE! Nutritional depletion has been demonstrated to be a major determinant of the development of post-operative complications. Gastrointestinal surgery patients are at risk of nutritional depletion from inadequate nutritional intake and surgical stress.

All is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS"

L)ALL THE STAPLES BEING REMOVED FROM THE ABDOMINAL INCISION AND THAT TEST RESULTS INDICATED THE PRESENCE OF MANY GRAM NEGATIVE BACILLI (SAME CATEGORY AS C DIFFICILE)

Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This pathogenic capability is usually associated with certain components of gram-negative cell walls, in particular the lipopoysaccharide (also known as LPS or endotoxin layer). The LPS is the trigger, which the body’s innate immune response receptors sense to begin a cytokine reaction. It is toxic to the host.

Gram-negative bacteremia is today's hospital scourge. Although antibody prophylaxis does not lower the infection rate, it prevents the serious consequences of gram-negative infections and thus improved the overall prognosis.

Did the expert ever consider endotoxin shock due to release of endotoxins by gram-negative bacteria? Or hematogenic shock which is the loss of fluid from the circulating blood volume, so that adequate circulation to all parts of the body cannot be maintained. This results in reduction of oxygen transported to the tissues thus explaining the necrosis of the tissue surrounding the resectioned colon. ---according to the autopsy report

This is apparently of no concern to the CPSO, HPARB, the Hospital and the Chief Coroner's Office! "BS

Breathing It should be noted that Terra’s breathing to the most part indicated concern. (see hospital records) Also comments regarding eating.

July 11

1133 short of breath on exertion, occasional cough

July 12

0000 eupnea, air entry decreased, occasional cough

800 eupnea, air entry decreased, short of breath on exertion

1300 eupnea, air entry decreased,

1605 nutrition—probably inadequate

1605 eupnea, air entry decreased,

July 13

820 short of breath on exertion, occasional cough

1130 eupnea, air entry decreased, short of breath on exertion

0415 not tolerating current diet, shortness of breath on exertion

1615 eupnea, decreased air entry – lower lobes

1730 not tolerating current diet, nauseated

July 14

0500 eupnea, decreased air entry – lower lobes, shortness of breath on exertion

815 eupnea, decreased air entry – lower lobes, occasional cough

1200 eupnea, decreased air entry – lower lobes, cough in am

1338 ate about half of what was served

1856 eupnea, decreased lower lobe

2000 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes, oxygen delivered nasal

July 15

0530 eupnea, decreased air entry – lower lobes, oxygen delivered nasal,

0910 air entry decreased – lower lobes, not able to clear airway of secretion,

1300 air entry decreased – lower lobes, not able to clear airway of secretion

July 16

0530 oxygen delivery – room air

0830 not tolerating current diet, nausea, save tray to try and eat later

0835 eupnea, decreased air entry – lower lobes

1310 eupnea, decreased air entry – lower lobes

2000 unable to clear airway of secretion, oxygen delivery – room air

July 17

0700 oxygen delivery – room air

0800 not able to clear airway of secretion, eupnea, decreased air entry – lower lobes,

0900 not tolerating current diet, does not normally eat in morning, save tray to try and eat later

1400 eupnea, decreased air entry – lower lobes

According to the records from 2200, July 17 through to Terra’s release, it appears there was no difficulty with her breathing and eating her liquid diet

Definition of eupnea --normal, good, unlaboured ventilation, sometimes known as quiet breathing or resting respiration**

dirk huyer CCO

Eleventh Christmas Without You, 2017

So many just don’t comprehend!
Those who do have experienced the same!

When your parents die, you have lost your past.
Memories of your youth are what you hold on to.

When your child passes, you have lost your future.
Memories, yes, but what was yet to come has expired too!

So at present, I merely exist.

Christmas’ are to be better than the first,
Instead each one is followed by the worst!

Four were the members of our family,
Now in solitude we remain at three.

At this time of year, I am so unhappy; that’s my life!
Love you, Terra.
Love you Brandy,
Love you Paulette.

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!

From: Dirk.Huyer@ontario.ca
To: awkilby@hotmail.com
CC: Julia.Noonan@ontario.ca
Subject: Terra Dawn Kilby
Date: Sat, 28 Jun 2014 16:33:44 +0000

Dear Mr. Kilby,

Thank you very much for coming to see Ms. Noonan and me on June 26. While we may not agree on some things, I do believe it was a positive meeting in that both of us had an opportunity to discuss the death investigation and many other issues leading up to the death of your daughter. Please extend my appreciation to your family members who attended as well -- their questions and perspectives positively added to our discussion.

Regarding the e-mails that you sent following our meeting, I am not going to revisit what we already discussed around sarcasm, personal addresses etc. You and I provided our views on that and I respectfully am putting that in the past.

Moving forward, as I told you, I will not be engaging in further dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest.

At this time, I will address your point about "necrosis of tissue surrounding the resection that broke down" as it is an issue I did not focus upon in our meeting. I am of the opinion that the tissue necrosis arose as a complication of the surgical procedure, specifically the staple line. Based upon the information available the exact physiologic process that caused the tissue necrosis to occur cannot be determined. There was no evidence in the post mortem examination report to indicate that an acute infective process was directly involved.

Again, I am pleased to have met you and your family in person and appreciate the time and effort you have dedicated in finding more answers regarding the tragic death of your daughter. I understand that our meeting may not have provided the result you hoped for but I do think it was an open, candid conversation.

Take care,

Dirk Huyer

Dirk Huyer MD

Chief Coroner for Ontario

Forensic Services and Coroner’s Complex
25 Morton Shulman Avenue,

Toronto, Ontario,

M3M 0B1

647-329-1814

416-314-4030(fax)

MY RESPONSE TO THE ABOVE

With respect to “Based upon the information available the exact physiologic process that caused the tissue necrosis to occur cannot be determined. There was no evidence in the post mortem examination report to indicate that an acute infective process was directly involved.”

“…appreciate the time and effort you have dedicated in finding more answers regarding the tragic death of your daughter.”

This is because of an inept death investigation and not wanting to dig deeper to explain the above! Why should I be finding the answers?
I think Dr. Huyer's own words supports my assertion of a faulty, biased death investigation.

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:

--with regard to Terra Dawn Kilby Those who should be held accountable by the newly elected Conservative government in 2018

Premier of Ontario --Premier Wynne, Premier McGuinty, Premier Ford--Conservative

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

Ontario Ministers of Corrections --Yasir Naqvi, Madeleine Meilleur, Sylvia Jones--Conservative

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

Defeat the above who in are still present in the next election 2018

CPSO -- Angela Bates Manager Committee Support Area Investigations and Resolutions--then Director, Regulatory Affairs at Retirement Homes Regulatory Authority no longer there and presently founded her own company SIGNAL REGULATORY SOLUTIONS angela.bates@signalregulatory.com , Sandra Keough Investigator

HPARB --Chair Janice Vauthier--should be replaced and not be appointed to any Ontario government position, Past Chair Linda Lamoureux---now Executive Chair of Safety, Licensing Appeals and Standard Tribunals of Ontario,--should be replaced and not be appointed to any Ontario government position, Lori Coleman Registrar--should be replaced and not be appointed to any Ontario government position, Anna Dunscombe--should be replaced and not be appointed to any Ontario government position

Third Appeal Chair Tom Kelly, Members Stephen Jovanoviorc and Brenda Petryna--these three should never be allowed to serve on any Ontario appeal/review board

Ontario Ombudsman --Paul Dube Ombudsman--should be replaced and not be appointed to any Ontario government position, A Marin-Ombudsman, Investigator Lorraine Boucher- Investigator--should be replaced and not be appointed to any Ontario government position, Fran Cappe-Investigator,

Humber River Hospital --CEO B. Collins--now CEO of the hospital--should be replaced and not be appointed to any Ontario government position, past CEO Rueben Devlin,

Ontario Chief Coroner’s Office --Dr. D. Huyer,--should be replaced and not be appointed to any Ontario government position Dr. A. McCallum--now head of Onge,--should be replaced and not be appointed to any Ontario government position '

Dr. A. Lauwer--now CEO of Ross Memorial Hospital in Lindsay, Ont--should be replaced and not be appointed to any Ontario government position

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

--All should be replaced and not be appointed to any Ontario government position

Ontario Patient Ombudsman --Christine Elliott, Investigator Marie Claire Muamba --authority and mandate should be expanded especially in light of the Ontario Ombudsman, P Dube's inaction

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

Inspector Bradley McCallum--should be investigated with regard to inadequate handling of my submission for Breach of Trust complaint vs Chief Coroners past and present and he should be replaced

OIPRD -- Director Gerry McNeilly

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

Mr Shanoff who wrote the two articles in the Sunday Toronto Sun sent me this from a woman who contacted him. --a very knowledgeable nurse
******************************************************************************

"I read with interest your article in the Sunday Sun October 13, 2013. titled “Why did woman die after routine surgery?”. I applaud you for bringing the circumstances surrounding this case to public attention. I feel it is a pity that innocent people must bare their hearts and their private lives in such a public fashion to get the attention they deserve and also to expose the injustice that permeated their lives.

As a former ICU nurse, who spent most of my nursing years in large academic teaching hospitals, I could say the reason for the woman’s death is a no brainer! However, not having seen the hospital records, I speak cautiously.

Several indicators from nursing records points to a “foul odour” and “purulent discharge” Both of these observations strongly point to an underlying infective process going on beneath the skin surface. Purulent discharge, as observed in this case, means the pus from the infection is significant enough in quantity that it is draining out wherever it can, which, after surgery, is usually through the operative incision. This is one of the VERY basic and elementary observations after any surgery. AND the procedure once the discharge has been observed, is to “swab” (do a culture of) the discharge, so that microbiology can determine the type of bacteria responsible. The microbiology / bacterial report then identifies which antibiotics would be best used to combat the infective process, so that appropriate antibiotics can then be ordered by the physician/surgeon. “Cultures” used to take a few days to process, but currently, preliminary results can be obtained the same day. Even without microbiology testing, surgeons have been educated to know what types of bacteria are most prevalent in certain situations.

I see no mention at all that the woman was started on antibiotics either on the 15th of July, the day the nursing records indicated the purulent drainage was first observed. or, at any point in time prior to the woman’s discharge. If this is the case would negligence be a good word to use here? It is a standard of Nursing Practice, to report such findings as “discharge” immediately to the Surgeon and obtain an order for antibiotics. If the hospital utilized the “Pathways” model of post-op care, then there should have been “standing orders” in place to give direction. Regardless, there is absolutely no excuse for antibiotics not being ordered immediately when discharge was first observed.

It would seem to me that having had this discharge for 5 days…. at least for 5 days that it was observable…… where was the surgeon doing his post-operative checks on his patients? It is also a well know fact that abdominal infections are a dangerous game to play. It is also well known that by the time the infective process is observable on the surface of the skin at the incision, there is much more going on “inside”, beneath the skin surface. You are only seeing what is “overflowing”, so to speak.

Some surgical procedures are best handled with antibiotics given prophilactically prior to surgery, especially when the risk of infection is high (such as is the case with certain abdominal surgeries). Optimal post operative care and surgical ouycome is sometimes contingent on good pre-operative care. For both agencies, the CPS and the HPARB to give minimal attention to the fact that antiobiotics were NOT given, is totally inexcusable.. It is almost like they are denying the contribution this makes to the post-operative infective process…..like they are excusing themselves from antibiotics having any responsibility or role in the woman’s health… or lack of it. Malpractice? Whatever it is, this is inexcusable, both for the two review boards and for the surgeon..

Further to the infective process ongoing in this woman’s abdomen, the infection sometimes does NOT stop here. It is also a basic concept in medicine and very elementary, that infective processes, when untreated or not affectively treated, can evolve into septicemia (infection in the blood) and septic shock (where your body starts to shut down from the infection) ….. and death. This is the NO BRAINER ! This is where I fail to see how both agencies, the College and the Review Board, don’t seem to be paying any attention, whatsoever, to rudimentary medicine !!

I am also dismayed at the length of time it took for this surgeon to complete the Hospital Discharge Summary and I also assume that the operative records are included in this five month delay. Every hospital has policies governing the length of time physicians have to complete paperwork before hospital privileges are revoked…. Which means that doc cannot practice in that hospital. Health Record Departments are very diligent in constantly reminding the offenders of unfinished paperwork and of consequential impending suspensions. Five months is a long time. Was this period of time within the framework of that hospital’s policy…. Or was his privileges suspended which prompted him to complete the operative records and then have his privileges re-instated? My biggest concern with incomplete or absence of prompt record keeping is that the margin of error increases exponentially as time passes.

I am also troubled by the reactions of the College and the Review Board. The shrugging -off of responsibility back and forth speaks to me of not wanting to address this issue and get to the bottom and be forthcoming with answers.,,,, or not wanting to give answers. Often in cases where there is compelling evidence of mismanagement and allegations of mismanagement, this behavior by The College is repeated. Is this a “big name” or prominent surgeon that is involved in this case, and both agencies are trying to minimize the impact on his career and reputation? Who is covering for who here? Having worked in the system for 46 years, I feel confident in saying that this is not an uncommon practice amongst physicians and also not an uncommon practice by the College. If you look at other “worst scenario” cases where there have been complaints or questions asked of the College, how many times have complaints been dismissed when the evidence is pretty compelling? The “Old Boys Network” is still alive and kicking even in this era of supposed accountability.

I also question the reason Humber River Regional Hospital would “create a memorial garden with a plaque in Terra’s name”. This is again not the “normal” or usual practice after a patient dies expectedly or unexpectedly, whether inside its doors or without. What does the hospital know that they are not telling….. or even worse, not admitting to. A friend of mine received a card and gift basket after being hit in an accident. Legally, this is an admission of guilt. Are we seeing the same admission of guilt here? Is this the hospital’s way of offering an “olive branch” to cloud the truth. I believe there is more to this than meets the eye.

I have many opinions about the Legal system in this great land of ours, but this may be the only way this poor father is going to get any answers to his questions. Docs are terrified of legal action, but it usually gets their attention. What is needed is a careful and shrewd lawyer who is knowledgeable in medical practice; that is, has available the academic knowledge with acceptable and competent medical practices required for this case, Armed with knowledge, should he delve into available information on this woman’s case, I am assured the answer should come pretty quickly.

AWK --NOTE -- IF ANY OF THE MPP'S HAVE HEARD OF THE CMPA THEN YOU KNOW THAT THE ODDS OF LEGAL ACTION IS FINANCIALLY IMPOSSIBLE, ESPECIALLY SINCE OUR OWN GOVERNMENT HAS CONTRIBUTED ONE BILLION DOLLARS OVER THE PAST TEN YEARS TO THIS INSTITUTION!

No, the father has a very valid and heartfelt point of view when it comes to finding answers to his daughter’s death. Money does not bring your child back, and this reflects my own thoughts after I lost my son tragically at the same age. To lose a child, no matter the cause, is very painful, and for many years to come. The pain is magnified many times over, when negligence and stupidity is at the root of the cause of death. I admire his persistence and his thinking. However, in spite of our best hopes and well intended thinking, legal action may be the only way to eventually find the answer he seeks. My heart goes out to this father. I truly hope that some of the things I have said, will be of help in finding his answers; and maybe some day bring relief and comfort to his heavy heart."
***********************

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.

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

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!

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, 26 October 2013

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

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.
******************************************************************************
Dear Surgeons from outside of Canada,

Many of you may or may not recall responding to me several years ago with regard to the untimely death of my 28 year old daughter.

I thought that I would give you an update as to where my struggle for transparency and accountability stands at present after seven years.

Just to note, there were more deaths via this same surgeon after my daughters; the most recent that I know of is last December.

You may wished to pass on to any of your patients, friends or family that should they visit Ontario, Canada and need hospitalization there will be no transparency or accountability should an adverse event take place. That is what I am still striving for.

My struggles continue but I thought that I would let you read the two newspaper articles written in the Toronto Sun newspaper a week or so ago. As well, as what my MPP stated last week in the Ontario Provincial Legislature.

The two articles below due to word limit restrictions could not explain the entire failings of the Ontario College of Physicians and Surgeons, the Health Professions Appeal and Review Board and the Liberal Provincial Government presently in power. There are still complete failings with respect to the Chief Coroner's Office of Ontario and the Death Investigative Oversight Council. All at first were protecting the surgeon's reputation, the went into self-protection mode when I submitted complaints against them.
************************
Hello Thank you for the update. I hate to say this but I think the only way you will find out some answers is to sue. It looks like a cover-up to me. I am glad I do not live in Canada. Good luck and may God speed. Ronald xxxxx, MD, FACS
*************************************
Dear Mr Kilby,
I very well remember your email and the tragic loss of your daughter. I wish you all the best on your mission for justice!
It seems like your family deserves it
Alan xxxx MD FACS
*******************************

I hope you can get some peace. It looks like your efforts have not gone unnoticed. I wish you the best!

Charlie xxxxx, MD
***********************************************
***************************************************************
A letter sent to Mr. Shanoff who wrote the two articles in the Toronto Sun. Mr. Shanoff was kind enough to forward to me.

I read with interest your article in the Sunday Sun October 13, 2013. titled “Why did woman die after routine surgery?”. I applaud you for bringing the circumstances surrounding this case to public attention. I feel it is a pity that innocent people must bare their hearts and their private lives in such a public fashion to get the attention they deserve and also to expose the injustice that permeated their lives.

As a former ICU nurse, who spent most of my nursing years in large academic teaching hospitals, I could say the reason for the woman’s death is a no brainer! However, not having seen the hospital records, I speak cautiously.

Several indicators from nursing records points to a “foul odour” and “purulent discharge” Both of these observations strongly point to an underlying infective process going on beneath the skin surface. Purulent discharge, as observed in this case, means the pus from the infection is significant enough in quantity that it is draining out wherever it can, which, after surgery, is usually through the operative incision. This is one of the VERY basic and elementary observations after any surgery. AND the procedure once the discharge has been observed, is to “swab” (do a culture of) the discharge, so that microbiology can determine the type of bacteria responsible. The microbiology / bacterial report then identifies which antibiotics would be best used to combat the infective process, so that appropriate antibiotics can then be ordered by the physician/surgeon. “Cultures” used to take a few days to process, but currently, preliminary results can be obtained the same day. Even without microbiology testing, surgeons have been educated to know what types of bacteria are most prevalent in certain situations.

I see no mention at all that the woman was started on antibiotics either on the 15^th of July, the day the nursing records indicated the purulent drainage was first observed. or, at any point in time prior to the woman’s discharge. If this is the case would negligence be a good word to use here? It is a standard of Nursing Practice, to report such findings as “discharge” immediately to the Surgeon and obtain an order for antibiotics. If the hospital utilized the “Pathways” model of post-op care, then there should have been “standing orders” in place to give direction. Regardless, there is absolutely no excuse for antiobiotics not being ordered immediately when discharge was first observed.

It would seem to me that having had this discharge for 5 days…. at least for 5 days that it was observable…… where was the surgeon doing his post-operative checks on his patients? It is also a well know fact that abdominal infections are a dangerous game to play. It is also well known that by the time the infective process is observable on the surface of the skin at the incision, there is much more going on “inside”, beneath the skin surface. You are only seeing what is “overflowing”, so to speak.

Some surgical procedures are best handled with antibiotics given prophilactically prior to surgery, especially when the risk of infection is high (such as is the case with certain abdominal surgeries). Optimal post operative care and surgical ourcome is sometimes contingent on good pre-operative care. For both agencies, the CPS and the HPARB to give minimal attention to the fact that antiobiotics were NOT given, is totally inexcusable.. It is almost like they are denying the contribution this makes to the post-operative infective process…..like they are excusing themselves from antibiotics having any responsibility or role in the woman’s health… or lack of it. Malpractice? Whatever it is, this is inexcusable, both for the two review boards and for the surgeon..

Further to the infective process ongoing in this woman’s abdomen, the infection sometimes does NOT stop here. It is also a basic concept in medicine and very elementary, that infective processes, when untreated or not affectively treated, can evolve into septicemia (infection in the blood) and septic shock (where your body starts to shut down from the infection) ….. and death. This is the NO BRAINER ! This is where I fail to see how both agencies, the College and the Review Board, don’t seem to be paying any attention, whatsoever, to rudimentary medicine !!

I am also dismayed at the length of time it took for this surgeon to complete the Hospital Discharge Summary and I also assume that the operative records are included in this five month delay. Every hospital has policies governing the length of time physicians have to complete paperwork before hospital privileges are revoked…. Which means that that doc cannot practice in that hospital. Health Record Departments are very diligent in constantly reminding the offenders of unfinished paperwork and of consequential impending suspensions. Five months is a long time. Was this period of time within the framework of that hospital’s policy…. Or was his privileges suspended which prompted him to complete the operative records and then have his privileges re-instated? My biggest concern with incomplete or absence of prompt record keeping is that the margin of error increases exponentially as time passes.

I am also troubled by the reactions of the College and the Review Board. The shrugging -off of responsibility back and forth speaks to me of not wanting to address this issue and get to the bottom and be forthcoming with answers.,,,, or not wanting to give answers. Often in cases where there is compelling evidence of mismanagement and allegations of mismanagement, this behavior by The College is repeated. Is this a “big name” or prominent surgeon that is involved in this case, and both agencies are trying to minimize the impact on his career and reputation? Who is covering for who here? Having worked in the system for 46 years, I feel confident in saying that this is not an uncommon practice amongst physicians and also not an uncommon practice by the College. If you look at other “worst scenario” cases where there have been complaints or questions asked of the College, how many times have complaints been dismissed when the evidence is pretty compelling? The “Old Boys Network” is still alive and kicking even in this era of supposed accountability.

I also question the reason Humber River Regional Hospital would “create a memorial garden with a plaque in Terra’s name”. This is again not the “normal” or usual practice after a patient dies expectedly or unexpectedly, whether inside its doors or without. What does the hospital know that they are not telling….. or even worse, not admitting to. A friend of mine received a card and gift basket after being hit in an accident. Legally, this is an admission of guilt. Are we seeing the same admission of guilt here? Is this the hospital’s way of offering an “olive branch” to cloud the truth. I believe there is more to this than meets the eye.

I have many opinions about the Legal system in this great land of ours, but this may be the only way this poor father is going to get any answers to his questions. Docs are terrified of legal action, but it usually gets their attention. What is needed is a careful and shrewd lawyer who is knowledgeable in medical practice; that is, has available the academic knowledge with acceptable and competent medical practices required for this case, Armed with knowledge, should he delve into available information on this woman’s case, I am assured the answer should come pretty quickly.

No, the father has a very valid and heartfelt point of view when it comes to finding answers to his daughter’s death. Money does not bring your child back, and this reflects my own thoughts after I lost my son tragically at the same age. To lose a child, no matter the cause, is very painful, and for many years to come. The pain is magnified many times over, when negligence and stupidity is at the root of the cause of death. I admire his persistence and his thinking. However, in spite of our best hopes and well intended thinking, legal action may be the only way to eventually find the answer he seeks. My heart goes out to this father. I truly hope that some of the things I have said, will be of help in finding his answers; and maybe some day bring relief and comfort to his heavy heart.

Saturday, 12 October 2013

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

Official Records for 22 October 2013

Hansard Transcripts

MEMBERS’ STATEMENTS

HEALTH CARE ACCOUNTABILITY

Mr. Steve Clark:

I rise on behalf of a constituent whose name should be familiar to every MPP. We’re just some of the many people Arnold Kilby has written to in his quest for truth behind the death of his daughter, Terra Dawn. She died seven years ago at the age of 28, following routine surgery at Humber River Regional Hospital.

Since that terrible day when his daughter died shortly after being discharged, Arnold has been on a mission—not for revenge, not for money. He wanted two simple things—two things he frankly should never have had to ask for, let alone wage a seven-year battle for that continues today. He wanted an admission that basic precautions weren’t taken prior to her surgery and afterwards, when it was clear something had gone terribly wrong. He also wanted what every parent would: an assurance that Terra Dawn’s death wasn’t in vain, that the mistakes made would lead to changes.

It proved to be a mission impossible. If the seven years of hell Arnold spent trapped in an alphabet soup of agencies tells us anything, it’s that true accountability and oversight of Ontario’s medical profession exists in name only. No patient or parent should have to endure this. I commend Sun Media columnist Alan Shanoff for bringing Arnold and Terra Dawn’s story to light.

That’s why today I’m calling on the Minister of Health and Long-Term Care and the College of Physicians and Surgeons to create a truly open and transparent medical oversight and accountability system.

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

HEALTH PROTECTION
AND PROMOTION
AMENDMENT ACT, 2011 /

Mr. Steve Clark:
The freedom of information—I have a constituent, Arnold Kilby, who I think has emailed every single, solitary one of the members of this Legislature probably 100 times. His daughter, Terra Dawn, passed away a number of years ago and he has been fighting ever since to get answers from the hospital board.

He has been up against a brick wall with the Health Professions Appeal and Review Board; the College of Physicians and Surgeons has been like a brick wall to him to get answers. The Death Investigation Oversight Council—this man has tried to get answers from the hospital, from ministers. I remember he wrote the Minister of Community Safety, and the OPP came to his door questioning him about his emails. I couldn’t believe it.

All the man wants are some answers. He certainly doesn’t have the means to litigate. All he wants are some answers surrounding his daughter. I can appreciate what he has gone through with these bodies, the brick wall that he has hit, and to have further provisions removed for freedom of information at hospitals—I just don’t understand that.

In my own discussions in this House, just in the last couple of weeks, about the South East LHIN and the surgery department at Brockville General Hospital, I brought up this plan twice in the House. My critics say that I’m creating this mirage. I’ve seen the plan. A doctor shared with me the plan and shared with me the discussion around the plan. All I asked was that it be taken off the table. If I was such an extreme MPP to bring this up that it was at the far end of the spectrum, why didn’t you just take it off the table? I asked for a public meeting to take place. Well, lo and behold, I read the daily newspaper in Brockville this morning, and the headline is, “Surgery Update Heard Secretly by BGH Board.” When I see schedule 15 restricting freedom of information, and I see LHINs operating in a shroud of secrecy in a significant recommendation that would gut the surgery department, and I suggest gut the Brockville General Hospital, I have every right to bring it up as the MPP in that riding. I can’t believe, when I read the local paper, that this update by the LHIN would be held in a secret meeting with the board. I can’t understand it.”

Taking away freedom-of-information rights from hospitals: I can’t support that. I can’t support it because of the issues with my surgery department, but more importantly, because of my constituent Arnold Kilby and his poor daughter and the answers that he has been trying to get. We need to make sure that he has that opportunity.

*********************************************************
THREE YEARS AGO, MR CLARK BROUGHT IT UP

Legislative Assembly of Ontario

Second Session, 39^th Parliament

Official Report of Debates (Hansard)

Re: Excellent Care For All Act, 2010

Second Reading

Tuesday, May 4, 2010

Mr. Steve Clark:

I am pleased to rise to provide some comments to the member for Scarborough-Rouge River. I listened to his comments about quality and value, and also about accountability in this Excellent Care for All bill.

On Friday, I met with one of my constituents, Arnold Kilby from Lansdowne, whom I think has e-mailed every member of this Legislature hundreds and hundreds of times with a concern about the system. His daughter, Terra Dawn Kilby, passed away in 2006, 12 hours after her release from a Toronto-area hospital. He has many unresolved issues with respect to the care she received in that hospital. I know that he’s written to the Minister of Health and Long-Term Care and also to the Minister of Community Safety, expressing his concerns that the system let her down; that there wasn’t an accountable system; that he can’t seem to get answers on the fact that there should be things put in place at the hospital and in the health care system that make the government accountable for what happens at these facilities; and the fact that, in his case, with his daughter Terra Dawn, he still, three years after her death, cannot get answers from this government or from the hospital involved. You know, it’s not an issue of taking the government to court. All he wants is a bill that puts some accountability back in the system that would ensure what happened to him and his family never happens again.

I’ve looked at this Bill 46. I looked at Hansard from yesterday, at what the minister said, and I don’t see that this bill has that accountability for Arnold Kilby, that it has that accountability with a hospital so that it adequately addresses his concerns. I would like someone to address that at some point in the future.
******************************************************************************

Why did woman die after routine surgery?

Terra Dawn Kilby died at age 28 — and no one is to blame?

By Alan Shanoff ,Toronto Sun

First posted: Saturday, October 12, 2013 06:32 PM EDT

trerraDawn — Arnold Kilby and his daughter Terra Dawn liked to hike up to the top of Lansdowne’s Blue Mountain every Thanksgiving. Terra Dawn died after routine abdominal surgery in 2006, and no one has explained why.

Arnold Kilby wants answers. He wants to know why his daughter, Terra Dawn, died at the age of 28 after routine surgery to remove a noncancerous tumour from her abdomen. The operation took place in July, 2006 at Humber River Regional Hospital. Shortly after commencing the operation in a minimally invasive laparoscopic manner, the surgeon converted the surgery to an open operation.
The surgery was said to have been “uneventful,” in other words successful.
Terra was discharged on July 20. She was dead within hours of arriving at home and Kilby has been searching for answers ever since.
Among his questions: Why was Terra discharged when, according to a decision by the Health Professions Appeal and Review Board, there were “consistent observations in the nursing charts of a foul odour and an oozing incision with large purulent discharge — commencing July 15 and continuing to the date of his daughter’s discharge”?
Why was she released when her abdomen was distended, at a time when she hadn’t had a normal bowel movement?
Why had the surgery taken place without the prior administration of antibiotics?
Kilby didn’t sue. He didn’t want money; he wanted an apology, an acknowledgment of error and a commitment to fix things.
So in 2007, he filed a complaint with the College of Physicians and Surgeons of Ontario complaints committee.
But the CPSO dismissed the complaint. In doing so, it couldn’t come up with any reason why Terra died.
Not satisfied, Kilby requested a review of the decision by the Health Professions Appeal and Review Board.
The HPARB concluded the CPSO decision was unreasonable and sent the case back to the CPSO, directing it to address Kilby’s questions.
The second CPSO decision wasn’t much better.
There were answers of a sort, but the CPSO still wasn’t certain of what occurred. The direct cause of death could not be ascertained.
Yet the CPSO was clear no one was to blame and there were no grounds for a disciplinary hearing against the surgeon.
But the CPSO did caution the surgeon over his five-month delay in completing Dawn’s discharge summary and stated “the routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by (the surgeon) in this case. The Committee would suggest that (the surgeon) consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case.” The surgeon was told he “may wish to consider” the use of preoperative antibiotics in future cases.
Of course Kilby sought review of the second CPSO decision. If the routine use of antibiotics prior to bowel surgery is “important” then why was the surgeon merely told to “consider” its use? How can we be sure the surgeon’s “oversight” did not contribute to Terra’s death?
The HPARB agreed and sent the case back to the CPSO.
The third CPSO decision didn’t advance the situation much further. There was still no answer as to the reason for Terra’s death. Kilby sought review by the HPARB for a third time.
But this time the HPARB decided to uphold the CPSO decision. It’s almost as if the HPARB threw up its arms and said, “we’re sorry, we tried to help you but we are up against a brick wall.” So, six years after the initial complaint, with three CPSO investigations and three HPARB reviews, no one seems to know why Terra died.
Barring any formal inquest, and Kilby has been denied his request to hold one, he still has no answers.
He only has the fact of his daughter’s death, which apparently occurred for no reason. No one is to blame. No one was at fault. No one has apologized.
But the hospital did create a memorial garden with a plaque in Terra’s name.

Secret medical cautions

CPSO’s remedial disciplinary action for doctors is kept confidential to protect docs’ reputations

By Alan Shanoff ,Toronto Sun

First posted: Saturday, October 19, 2013 06:33 PM EDT

Last week’s column on the unexplained death of Terra Dawn Kilby leads me to the topic of secret medical cautions issued by the College of Physicians and Surgeons of Ontario (CPSO).
Cautions issued to doctors are a form of remedial disciplinary action taken by the CPSO.
They don’t constitute findings of negligence or professional misconduct. They are intended to be educational or remedial, to provide advice and direction to physicians.
The CPSO issued two cautions to Terra’s surgeon.
The first arose from the surgeon’s five-month delay in completing Terra’s patient discharge summary.
The CPSO cautioned the surgeon on the need for timely documentation of discharge summaries.
The second caution related to the failure to use antibiotics prior to Terra’s bowel surgery.
The CPSO cited the surgeon’s failure to use pre-operative antibiotics as an “oversight” and cautioned him to “individualize the use of pre-operative prophylactic antibiotics for patients where it is warranted”.
While the CPSO was generally satisfied with the surgeon’s care, these two cautions seem far from trivial, particularly since Terra died within days of her surgery.
They are the sort of thing that ought to be on the surgeon’s public record.
But even if you knew this surgeon’s name — and, of course, you wouldn’t because the cautions are not associated with his name on any public record — you wouldn’t find any record of these cautions on the CPSO site.
That’s because the CPSO treats its cautions as confidential, something the public isn’t allowed to access.
In addition, the CPSO doesn’t do any follow up to verify whether recipients of cautions modify their practice to comply with the cautions.
It’s almost as if the cautions don’t really exist, as if they’ve been issued solely as an attempt to placate angry complainants.
But why does the CPSO treat its cautions as confidential? Everyone knows doctors make mistakes.
If a doctor has made a mistake serious enough to warrant a caution, surely the public has a right to know.
But at present, the protection of a doctor’s reputation is considered more important than the public’s right to know.
That’s the case even where multiple cautions have been issued against the same doctor.
Record not available
I’m not saying that’s the case with Terra’s surgeon because I don’t know. There is no record anyone can access to find the number of cautions issued against any doctor.
But this may change. The CPSO is now accepting public feedback concerning a set of draft transparency principles to “guide future decisions about making more information available to the public”.
The deadline for feedback is November 1. Information on how to make submissions can be found at http://policyconsult.cpso.on.ca/?page_id=2416 .
If we want to have meaningful transparency, to provide real information to the public, we ought to be going much further than making cautions against doctors a matter of public record. We ought to be making much more data public.
At a minimum, we ought to be able to access data on mortality and complication rates pertaining to every surgeon paid out of the public purse.
At present, the public can only access mortality rate figures for public hospitals in Canada.
These figures are available at the Canadian Institute for Health Information website. The CIHI issues an annual hospital standardized mortality ratio, which compares the actual to expected deaths at each public hospital.
But in England, the National Health Service issues individual surgeon’s mortality rate statistics.
That would be a good start, but to achieve real transparency we ought to have easy access to every doctor’s record.
That includes cautions, complaints, negligence lawsuits, complication and mortality rates, both for Ontario and any other jurisdictions in which the physician has practised.
Give us credit. We understand not every complaint or lawsuit means a doctor is incompetent.
We understand honest mistakes happen and that some deaths are unavoidable.
But treat us as adults and give us the information we need in order to make meaningful decisions. After all, it’s our lives that are at stake.

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I wish to thank all who have read this excellent articles by Alan Shanoff.

I am the father of Terra Dawn Kilby.
I have been let down by the Hospital, the Chief Coroner's Office, the Death Investigative Oversite Council, The Ontario College of Physicians and Surgeon, the Heath Professions Appeal and Review Board and by the entire Liberal Caucus, and unfortunately by the Opposition Parties--totally ignored by past Premier Dalton McGuinty, present Premier Kathleen Wynne, NDP leader, Andrea Horwarth and Conservative leader, Tim Hudak.
Both Ms Meilleur and Ms Matthews who have the responsibility to oversee the Coroner's Office and the College have also totally ignored my pleas.

HOW CAN THEY ALL BE AFRAID OF THE COLLEGE. CHANGES MUST COME ABOUT BUT IT IS UP TO THE PUBLIC TO DEMAND THOSE IN OFFICE TO DO THEIR JOB.

Mr Shanoff did a remarkable job of describing my frustrations. But there remains so much more to the story. I sincerely thank Mr Shanoff for hearing my pleas.

Rest in Peace, Terra.
You are "An Angel In Our Lives"
Love You Forever
A. W. Kilby

The Surgeon

lklein@hrrh.on.ca surgery@misgroup.ca CEO of HRRH

Rueben Devlin

Dr. Bert Lauwers Dr. Andrew McCallum

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COMMENTS FROM THE TORONTO SUN READERS.

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Livia

It seems obvious that something was wrong by the nursing charts. How could she have even been discharged? My heart is with you.

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Suchstuff

Such a sad story made worse by the lack of closure for the family. There's something really wrong with physician oversight that puts the interests of paying members before the interests of the public whom they have promised to protect. How can the hospital or physician learn from their mistakes if they won't even acknowledge them? Oversight in name only from the College and again from our government's HPARB - if they haven't got any teeth - what's the point of being there? This man has waited 7 years for an answer - shame on our health care system (and the fake oversight that goes with it) for ignoring and avoiding his questions.

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bafflegab
Anybody who has ever complained to the CPSO quickly discovers it is a waste of time. I know from experience. The CPSO let the public down with respect to the Dr.Charles Smith debacle - the Wia Ping butchery - and countless other public scandals. In every case we discover long after that the College had provided covered for the doctors rather than protected the public. And now this. The CPSO is not to be trusted. The CPSO promises to protect the public but in fact poses a danger to the public. The CPSO needs to be shut down and its cover-up artists (employees) need to move on to some other line of work. Something more honest. Put simply, everything you need to know about the CPSO (its investigators, its administrators and its executive) is clear from reading Mr. Shanoff's accounting of it pathetic behaviour in this sad case.
bafflegab
CPSO and its penchant for secret, remedial cautions is placing Ontarians at risk for all manner of abuse. Botched surgeries by incompetent surgeons which result in death is but one area in which the CPSO has a shameful record of hiding complaints. Drs. Wai Ping and Austin butchered many patients before they were finally held to account - and only because their abuses had begun to be covered in the mainstream press did the College finally act instead of hide complaints about these surgeons. One would have hoped the CPSO would have learned something by now with respect to the need for transparency - but it has not. Secret cautions and CPSO dithering has undermined not only the public's trust in the medical profession - but also in the legal profession. For years the CPSO was aware of Dr. Charles Smith's "woeful ineptitude" to which he finally confessed at the Goudge Inquiry. But during the years that Dr. Smith's medical testimony was sending innocent Ontarian's to prison - the CPSO was sitting on complaints and secret remedial cautions kept out of the public eye (google Goudge Inquiry transcripts). So the CPSO owns a chunk of responsibility for all those wrongful imprisonments.

...
Ontario's CPSO is a disgrace. It is inhabited by too many arrogant, ignorant, paternalistic fools who seek to protect doctors from accountability rather than to protect the public. The CPSO needs to be shut down and the people who work so diligently to keep the public in the dark (arguing that to much information would "confuse" the public) need to go find honest work.
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Suchstuff

CPSO, when they cloak third party medical opinion vendors with immunity by way of 'secret' remedial cautions, has become a danger to the safety of vulnerable accident victims. CPSO could care less what the public thinks and won't until our government puts the public's interest above the interests of physicians and abolishes this ineffectual and sometimes deadly promise of oversight. There are good doctors out there - too bad CPSO doesn't get it that the public has lost confidence in ALL doctors when they protect just a few. HPARB, without teeth, is just a second act with the same story.

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John
Like most so called "professional" review boards they sure circle the wagons in time of troubles. Eventually people get worn out or run out of money battering against the wall of silence that greets them and then it's business as usual.

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Dachshunds
My condolences Mr.Kilby, how truly tragic and unnecessary your daughters death must be, I hope you get the answers and apologies you so rightfully deserve. May your "Angel" rest in peace and may this never happen again to another family as the results from her unfortunate passing. I will hug my daughter a little closer today and hope something positive comes from all these inquiries and examinations of this "uneventful and successful" surgical procedure. My heart goes out to you and yours and I hope you can somehow find closure in this mess. You are a better man than I, Mr.Kilby and your daughter was very lucky to have a father such as yourself, its too bad she didn't have a better surgeon. Bless you Mr.Kilby, and bless you Terra, lest your passing be in vain...David

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Deepwell
The college of physicians and surgeons is having a consultation on their transparency when it comes to complaints about their members. It's an issue that affects all patients who have a right to know whether the doctor who treats them has a bad track record. Right now there is no transparency as Mr. Kilby has found out - the CPSO is all about protecting their members and nothing about protecting the public from bad doctoring like this. Consumers should let the college and our government know that we won't tolerate abuse of the public in this way and that their lack of action to protect the vulnerable should result in charges against those who are contributing to wrongful deaths. If the CPSO isn't part of the solution then they are part of the problem. Look up 'draft transparency principals' on the CPSO website - and let the cpso know that their oversight is worse than none at all - it is facilitating bad doctoring. Thank you Mr. Kilby (and Mr. Shanoff) for exposing this often fatal flaw of the lack of physician oversight in Ontario and my sincere sympathy for the loss of a loved one.

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Ruledbythemoon
They are scared of a lawsuit so nobody is going to put down anything concrete in writing that could be used later. Makes you wonder why we even have a review board?

I had similar surgery at NYGH a couple years ago and they would not discharge me till I had pooped. Not easy when you are on a liquid diet but that was their rule.
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InScarborough55* My sincerest condolences Mr. Kilby to you and your family. It is just so sad that someone is allowed to die because the supposed expert is incompetent. And then to have the board, supposedly put in place to oversee these experts and root out the bad ones, just defends them is beyond irrational.

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G_Goon Don't stop Mr. Kilby my wife works in the health care system all sorts of mistakes made that never see the light of day. So sorry for your loss stay strong stay focused.

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Z71guy G_Goon
I too was in a relationship with a critical care nurse who routinely told me of unreported medical errors committed by both doctors and nursing staff. I would wager that more lives are lost unnecessarily to medical treatment errors than impaired drivers. But where is the uprising of MADD - mothers against dumb doctors?? You'll never see it because of coverups, lack of reporting and oh yeah, they bury their mistakes......unfortunately literally in cases such as Ms. Kilby's.
No SIU type agency to hold doctors to a higher standard, how long overdue is this? A doctor shortage? Pfffft....please. This is an internally controlled monopoly controlled by the college of physicians to keep supply low and their demand and earnings high. This province has many highly qualified medical applicants kept from becoming practicing doctors for made up conditions to control the supply of services. The numbers relegated to veterinary school or dentistry , qualified foreign doctors refused to be recognized just to control supply - absolutely criminal. The recent expansion of nurse practitioners needs to continue.. For logic sake there are medical apps available for iphones that can make many medical tests simpler and almost instantaneous. Doctors are not gods but unfortunately many feel they are. Keep the pressure on Mr. Kilby

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Kickyourproblemstothecurb
sir I saw the web page and am shocked that there was no inquest given the circumstances. I presume you have a COMPLETE copy of her chart. go through it with a fine tooth comb. check for phone calls made to ANY doctor re the condition of the wound and any abnormal lab results or vital signs. after all, if they are documenting the bad condition of the wound before discharge, then they must have called a doctor to come and see it. and then the doctor called is responsible to act appropriately. frankly, wonder how she got discharged with a surgical wound in that condition. did the doctor who did the operation write the discharge orders?
ps check the labs if any done the week of her discharge in particular the INR. and look at the medications she was on just before discharge. If she had a high INR then the doctor would have been called and a medication change order written
ps application called pocket lab values available for iphones, ipods through the apple web site. very easy to use and very informative
very sorry for the loss of your loved one. and i hope you get the answers you want. hope I've been of some help. we went looking for answers ourselves after losing a loved one years ago.
OMG and he never ordered any antibiotics? i am so sorry and frankly don't understand how this happened.
god bless you because you have the courage and strength to try to make sure this doesn't happen to someone else.
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Maie

Harmed patients and bereaved family members describe their ordeals with the College of Physicians and Surgeons of Ontario on the webpages of the Coalition for Physician and Surgeon Oversight www.cpso.co. Some name names. Many of the patients are dead. All of the doctors are still practising. Thank you Alan Shanoff.
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Brandy Kilby

Thank you for bringing attention to this injustice. More people need to be aware of what is happening in our medical system. My sister's death is very public and so should be the circumstances regarding her death (and the surgeon's mistakes).

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Additional Comments

Shannon I hope that public attention to this helps your family finally get the answers you deserve Mr. Kilby. She was a sweet girl from what I remember of her from school and I was sad to her hear of her passing. I felt your frustration and I hope you, your wife and Brandy can get the answers and heal.
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I cannot imagine what you're going through. However having almost died myself after routine cryotherapy procedure at Toronto General a few years ago, I think I can relate to the sad frustration that ensues. Please let me know if I can be of any help.
Kind regards,
Hana
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Well done Arnold "Never, ever, ever give up" were very wise Churchill words that still ring true. We have had a couple of very difficult weeks (our family dog of 12 years had to be put to sleep) at the same time as we are preparing for a joyous occasion as we are proud parents of the groom at a wedding next week
Our thoughts and prayers remain with you.
Anne and Dave
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"I'm sorry that it's taken so long... it shouldn't have. I think of you and the entire family often. You were all a big part of my growing up"
Christie
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Hi Arnold. Just returned home from holiday. So glad to see your story. Don't ever give up. We must make people aware of what is really happening.
Mary-lou.
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Barb Collins COO of Humber River Regional Hospital

"These are Mr Kilby fax and not the truth. Weird the reporter did not ask and rather unfair as we did apologize many times. Disappointed in the sun now too?

AWK sent the following to Ms Collins after receiving the above:
Apology
noun, plural apologies.
1. a written or spoken expression of one's regret, remorse, or sorrow for having insulted, failed, injured or wronged another;

Ms Collin,
You and HRRH have never given a true apology. What you and HRRH have given is the same as I received from hundreds of people who attended Terra's wake and from hundreds of people since. They, as well as you, offered an expression indicating you're "sorry for my loss", or "sincerest condolences for the death of your daughter." etc.
You and HRRH have never felt regret, remorse or sorrow for having "failed, injured or wronged" Terra. That would be a true apology.
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Jenn ARNOLD AND PAULETTE I AM SO SORRY ITS BEEN TO LONG WITH NO ANSWERS I REALLY HOPE THIS COVERAGE HELPS GET SOME ANSWERS FOR YOUR FAMILY SHE WAS AN AMAZING AND LOVING PERSON
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I have no doubt that Terra had developed an infection and died from it.

You wanted answers from the doctors but they cover for each other and they will never tell you.

I think that you must sue them and hold them responsible.

If they had fixed your tire one day and it blew 5 days later the garage would be responsible.

The Hospital and the doctor who discharged Terra are responsible in this case.

No need for them to say so: find an expert, give them the medical Chart and have them testify.

If you ask for no money as compensation, then the damage is not quantifiable and it appears unsubstantiated.

Please put a dollar value on this, find a lawyer to take it on contingency and go after the doctor and the Hospital who did this to your daughter.

Best regards

Diana

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Dawn Happy that someone is helping you get this story out there. Your daughter was always very kind and friendly.
Keep up the work Mr Kilby
Bless you for your perseverance and courage.
D
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Yes - it is unfortunate comments were not left open longer. I did my share of forwarding the article but I know my contacts will not see it until tomorrow. It's a start. Give yourself credit.
Arnold: Just read this and am very pleased with how the journalist handled Terra Dawn's story. Congratulations for your persistence. Maie
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What wonderful support for you Arnold. I love the insider comments about the errors that go on.
Was the surgeon the doc who released your daughter with all those symptoms?
Barb     AWK-Yes, he was and he didn't even see her the morning of her release.
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orrdj I agree - I did not open the article until after we got home this evening, and I would have liked to respond. The article was very good - but still leaves so much unanswered. Jan

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A well-written column that concentrates on the essential information, although more

could have been added, had length permitted. What cannot be conveyed unfortunately

is the appalling ignorance of so many in powerful positions, the callousness and the foot dragging.

Let's hope the Sun will consider a more investigative piece after this. 
Helen

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I bought the paper what an amazing job done on the article about Terra

maybe this is what was needed  to get the message out, I hope it helps a great deal on top of

everything that you have already done
...............thinking of you guys all the time xoxoxo
    love Debbie and Leo
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Sue A well-written article - I hope that something comes from people reading this article and that those responsible

will be held accountable


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Mike  I can't believe that after all this time, you and your family still have to live through this hell.

 I hope that you soon find the answers you need and deserve. My thoughts and prayers are with 

all of you, especially on a day such as today. 

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Congratulations Arnold, some small payoff for your tireless campaign  Julie 

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Wonder no longer, Arnold.  I have the link and it will appear on my site Sunday 

(to late for tomorrow as the stories have already been compiled).  I will add that I understand 

why you are asking these questions (I have two daughters remaining but I lost the youngest at 

age 12 in 1992 to cancer) and you have my sympathy.  I would be angry also.

Thank you for making me aware and "take care".  Your questions are valid.


Jack

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12th Christmas

Terra, “An Angel In Our Lives”

Twelve years have gradually passed,

Our enduring love will forever last.

Those cannot possibly understand,

The loss we still can’t comprehend.

Christmas’ just can’t be the same,

Without you present to hear your name.

We still decorate your grave,

As we try so hard to be brave.

But memories of you are all we possess,

Of Christmas’ past and our happiness.

The years go by without you here,

Still releasing many a tear.

We have missed you since you went away,

Your voice, your laughter each and every day.

Our hearts so sadden and fragmented,

And our lives remain so segmented.

Our world has fallen utterly apart,

Ever since the day you did depart.

We carry on the Christmas traditions you loved.

Praying you can see them from far above.

Twelve years have gradually elapsed,

Our enduring love we will forever grasp.

Those cannot possibly understand,

The loss we still can’t comprehend.

Merry Christmas Our Darling Daughter Dear.

Love Mom, Dad and Brandy

July 2014

July 2014 Terra Dawn Kilby April 22, 1978 – July 21, 2006 “An Angel In Our Lives” Friends and family will gather this day, To celebrate and offer these words to say: “We love you dearly and miss you too, Within our hearts, we are still blue.” We have completed our present eighth year. Not a day has passed without shedding a tear. Terra, our daughter, so caring you are, Sending your kisses to us from afar. Very few comprehend the pain in our hearts, Expanding continuously since the day we did part. The stars up above and us down below; Our present lives here feeling so hollow. In a heavenly realm you now do reside, Performing your role as our spirit guide. Two precious gems given at birth; One now in Heaven and one still on Earth. Love Dad, Mom and Brandy. ****************

July 21st, “Spirit” called you away.

July 21st Marks Year Seven

Terra Dawn Kilby

April 22, 1978 - July 21, 2006

An Angel In Our Lives

July 21^st marks Year Seven,

Since you left to go to Heaven.

Clouds still hover up above,

Teardrops fall -- expressing our love.

Listening to a mourning dove’s cry

Hearts still bleeding when we said good-bye

Our darling Terra, we all love you,

Family and friends, still miss you, too!

Fond memories when we reminisce.

Sending our love with every kiss.

Our lives continue without you here,

We feel you with us with each tear.

Prayers and thoughts of love are sent,

While flowers adorn your monument.

From all of us who meet each year.

To honour you, my darling dear.

LOVE DAD, MOM AND BRANDY

Christmas 2020

CPSO updated decision

Health Minister

E-mail sent to all MPPs

Minister's Response

Medical Opinion

More Medical Experts

Antibiotics administered to patients prior to colorectal surgery

Medical Facts

Numerous examples and proof of negligent care can be seen clearly within Terra’s medical records seen below:

THE MEDICAL FACTS!

15. LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE! the maintenance of the gastrointestinal tract. It is required for the release of energy from food

dirk huyer CCO

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

Saturday, 26 October 2013

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

Saturday, 12 October 2013

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

HEALTH PROTECTION
AND PROMOTION
AMENDMENT ACT, 2011 /

Why did woman die after routine surgery?

Terra Dawn Kilby died at age 28 — and no one is to blame?

Secret medical cautions

CPSO’s remedial disciplinary action for doctors is kept confidential to protect docs’ reputations

Terra

Graduates of York University

Terra Dawn Kilby

Graduates of SUNY

Christmas 2020

CPSO updated decision

Health Minister

E-mail sent to all MPPs

Minister's Response

Medical Opinion

More Medical Experts

Antibiotics administered to patients prior to colorectal surgery

Medical Facts

Numerous examples and proof of negligent care can be seen clearly within Terra’s medical records seen below: THE MEDICAL FACTS!

15. LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE! the maintenance of the gastrointestinal tract. It is required for the release of energy from food

dirk huyer CCO

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

Saturday, 26 October 2013

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

Saturday, 12 October 2013

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

HEALTH PROTECTION AND PROMOTION AMENDMENT ACT, 2011 /

Secret medical cautions

CPSO’s remedial disciplinary action for doctors is kept confidential to protect docs’ reputations

Terra

Graduates of York University

Terra Dawn Kilby

Graduates of SUNY

Numerous examples and proof of negligent care can be seen clearly within Terra’s medical records seen below:

THE MEDICAL FACTS!

HEALTH PROTECTION
AND PROMOTION
AMENDMENT ACT, 2011 /