Angela Bates Manager Committee Support Area Investigations and Resolutions--then 
---now Executive Chair of Safety, Licensing Appeals and Standard Tribunals of Ontario,
Lorraine Boucher- Investigator
--now CEO of the hospital
--now head of Onge,
--now CEO of Ross Memorial Hospital in Lindsay, Ont
--Christine Elliott, Investigator Marie Claire Muamba
CHRISTMAS 2015
Terra Dawn Kilby
Joyous Noel for all to hear;
Celebrate Terra, my daughter dear.
Christmas morn is not the same;
Gift exchanges without your name.
Heaven embraced you ten years ago;
Tears appear, as it begins to snow.
The frigid air steals my breath away;
Just as it transpired on your departure day.
Snowflakes tumble from the heavenly skies;
Thawing softly upon sadden eyes.
Joyous Noel for all to hear;
Celebrate Terra, my daughter dear.
Crystals materialize on the window panes;
Blood flows through my frozen veins.
Illuminating the earth are festive lights;
Your starlit skies enlighten our nights.
Ponds and rivers commence to freeze;
Within my soul, your hugs do squeeze.
My heart has experienced such a loss;
Missing you -- the day you did cross.
In the distance, church bells ring;
Within broken hearts we still can't sing.
Joyous Noel for all to hear;
Celebrate Terra, my daughter dear.
Love Dad, Mom and Brandy
*********************
She is very secretive when it comes to her visual appearance as she refuses to attend HPARB appeals even though it is only a fifteen minute walk from the CPSO Offices to HPARB. For my three HPARB appeals she was there only via telephone conference calls.
But I believe I have her picture and can see why she wants her appearance to be hidden. She looks a lot like a hemorrhoid!
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It is incredible how broken the Health Care System within Ontario with respect to Accountability and Transparency. The very institutions that were created to protect the citizens of Ontario have failed them!
Our Liberal government is just a guilty; as Premier Wynne and her Caucus have repeatedly ignored my pleas for help.
Karma
---it also refers to the spiritual principle of cause and effect where intent and actions of an individual (cause) influence the future of that individual (effect).
---for every event that occurs, there will follow another event whose existence was caused by the first, and this second event will be pleasant or unpleasant according as its cause was skillful or unskillful --The urge to nourish pain and quell joy is known as being unskillful, unethical or bad.
The most recent e-mail sent to every single MPP in Ontario. This was just one of many attempts to show our elected officials of the bias death investigation conducted by the Chief Coroner's Office of Ontario as the did not do a thorough investigation.
Date: Thu, 15 Oct 2015 21:05:47 -0400
DEAR MPP,
CC: ALL MPPS
PLEASE READ THIS ONE (even if you have ignored all of my other e-mails)
I AM SURE CONSTITUENTS OF YOURS HAVE HAD TO DEAL WITH THE CCO. IF THEY CAN ABUSE THEIR RESPONSIBILITY IN THIS CASE, THEN I AM POSITIVE THE CCO HAVE DONE SO TO MANY OF YOUR OWN CONSTITUENTS. YOU OWE IT TO THOSE WHO ELECTED YOU. MY CASE MERELY INDICATE THE SERIOUS PROBLEM WITHIN OUR HEALTH CARE INSTITUTIONS. (HOSPITALS, CCO, DIOC, CPSO, HPARB AND THE LIBERAL CAUCUS)
THE CCO WILL NOT TRULY CONDUCT A THOROUGH DEATH INVESTIGATION WHICH INVOLVES A FELLOW MEMBER OF THE CPSO!
Dear MPP Assistants--this e-mail is for you as well, so you can see how your MPP has ignored my numerous requests for his/her help. You may copy and resend this to your friends, family and others so they will know what to expect should an adverse event occur.Past Chief Coroner of Ontario, Mr. Andrew McCallum, past Deputy Chief Coroner of Death Investigations, Bert Lauwers and the present Chief Coroner, Dirk Huyer are involved firstly in concealing the negligence of a surgeon which did play a role, even in a minor way, the death of a young 28 year old woman in July of 2006. Dr. McCallum is guilty of protecting his Deputy Coroner and Dr. Huyer is guilty of covering up the faulty death investigation by the CCO! All three being members of the CPSO place their allegiance to the College rather than "Speaking For The Dead To Protect The Living".
 |
| Past Chief Coroner who support his subordinate below. He left his position before my complaint was heard by the Death Investigative Oversight Council |
 |
| Dr. B. Lawers, Deputy Chief Coroner, conducted the death investigation and supported his independent, unnamed opinion provided whose report was full of omissions. He also left his position before my complaint was heard by the DIOC. |
 |
| Dr. D. Huyer-- covering up the negligence of the two above with regard to a thoroughly faulty and biased death investigation. Admitted that there were patient care issues that he felt had nothing to do with Terra's death. Pure Bullshit. He said it was not his job to notify the Minister of Health, the C.PSO or the Hospital. Again-- pure Bullshit |
Yet, it is my opinion based upon the medical record, my research and my own medical experts that all three failed the citizens of Ontario. Their inept death investigation may have resulted in many more deaths.It
should be noted that there were several deaths after my daughter's
death in 2006. This Office, without public knowledge temporarily shut
down the hospital department due to 5 or 6 deaths in 2009 to Feb. of
2010!
This same surgeon added another notch to his scalpel in Dec of 2012 with the negligent death of a 27 year old woman!
DR LAZ KLEIN
AS AN ELECTED MPP, WHEN WILL YOU CHANGE THIS ABUSE WHICH INVOLVES THE CCO, THE DIOC, THE CPSO, HPARB AND THE FAILURE OF PAST HEALTH MINISTERS AND THE PRESENT HEALTH MINSTER (oversees the CPSO and HPARB) AS WELL AS THE PAST AND PRESENT MINISTERS OF CORRECTION.(oversees the CCO and DIOC)????
They will definitely not conduct a thorough, unbiased death investigation if it involves a colleague of theirs who is also a member of the CPSO. Changes must be made to protect the citizens of Ontario.
They failed to:
1. Conduct a death investigation in a manner that is effective and accountable.
2. Conduct a high quality death investigation to ensure that no death will be overlooked, concealed or ignored. (By basing all of their decision on a medical expert consultant whose report omitted numerous crucial factors)
3. To help improve public safety and prevent deaths in similar circumstances (apparently there were 6 more deaths by the bariatric department of this hospital during 2009 and up to Feb. 2020 under similar circumstances—it is almost impossible for me to obtain the details but the Chief Coroner’s Office and the hospital would have them-----these deaths may have been prevented if my daughter’s death was thoroughly investigated) by denying my request for my daughter’s death to go before the Patient Safety Death Committee and denying my daughter’s death be looked into by the Eastern Ontario Coroner through a review. (I know that legislation prohibited me from questioning the denial of a public inquest which I feel definitely limits a citizen’s right to appeal a wrong decision)
4. Making sure their concerns and needs of grieving families are met as this office has refused repeatedly to answer specific questions and concerns I have had and relayed to them. They have also refused to communicate with me via telephone, faxes, e-mails.
They failed by:
5. Overlooking, concealing and ignoring crucial factors related to my daughter’s care or lack of care which in turn did factor into her death
Is it not incumbent for the Office whose finances are paid by the public purse to pursue and ensure patient safety is protected especially when the hospital refuses to answer the question from the grieving family? As well, I’m sure the attorneys and committee members are aware of the dismal record of investigations by the Ontario College of Physicians and Surgeons. The Chief Coroner’s Office has the authority through holding pubic inquests, utilizing the Patient Safety Death Committee and having Regional Coroner investigations to obtain these answers.
Would you consider the Chief Coroner's Independent Expert Opinion Provider as doing a thorough death investigation?
If the COO was conducting a death investigation into one of your family members, would you not expect MORE?
THEY DID NOT EXPECT ME TO CONDUCT MY OWN THOROUGH DEATH INVESTIGATION BY CONSULTING OVER 100 QUALIFIED SURGEONS OUTSIDE OF ONTARIO, CANADA. THE CCO DID NOT APPRECIATE THAT I THOROUGHLY RESEARCH THE RECORDS AND THUS WENT INTO BUILDING A BRICK WALL AND WENT INTO DEFENSE MODE--- WHY?
*********************************************************************************
From the Chief Coroner’s independent expert are in quotations--selections in red are contradictory to the actually hospital records and/or medical fact. I have inserted in capital letters the concerns omitted by this expert.
ONE MUST ASK WHY THE EXPERT DID NOT COMMENT ON THE OBVIOUS?????
WHY, WHEN I BROUGHT ALL OF THESE ISSUES TO THE COO THEY DID NO FURTHER INVESTIGATIONS??
DO YOU SMELL A COVER-UP???
********************************************************************************
November 17, 2008
Dr. A.E. Lauwers,CCFP, FCFP
Associate Deputy Chief Coroner Office of the Chief Coroner
26 Grenville Street Toronto, Ontario M7A 2G9
Dear Dr. Lauwers:
RE: Terra Kilby
Deceased: July 20,2006 OCCFileNo.: 2006-11425
"As you requested, I have reviewed the file on the above person and provide my report. In reaching my opinion, I have reviewed the following materials":
1. The hospital record from Humber River Regional Hospital related to admissions from March 3 to March 4, 2006 and July 11 to July 20, 2006.
2. The Coroner's investigation statement (statement number 2006-054-8).
3. The report of postmortem examination by Dr. Caroline G. Rowlands dated March 22, 2007.
4. A compact disk containing images taken at autopsy and provided to me by Dr. Rowlands.
"In summary, the deceased presented to Humber River Regional Hospital on March 3rd with abdominal pain. She was found to have a large mesenteric cyst. There were no acute issues, and she was therefore discharged for further investigation as an out-patient. She was assessed by Dr. Klein and underwent further investigation. A decision was reached to resect the mesenteric cyst. On July 11th she underwent attempted laparoscopic resection of the cyst, but because of intraoperative concerns the procedure was converted to laparotomy."
NO ACUTE ISSUES??? --WHAT RECORDS WAS THIS EXPERT LOOKING AT?
THIS WAS DONE WITHOUT THE MANDATORY ANTIBIOTIC PROPHYLAXIS BEING ADMINISTERED
Anastomosis Breakdown
(dehiscence) separation or leaking of the sutured colon. This breakdown usually leads to an infection inside the abdomen. ---Test results indicated the presence of many gram negative bacilli!
There are numerous causes of dehiscence, but generally they fall into three broad categories:
(1) a major necrotizing wound infection is responsible; Autopsy indicated necrosis of the tissue surrounding the colon resection.
(2) there is a mechanical problem, such as inadequate wound closure or defective suture material; I don’t believe this was the case.
(3) tissue quality is poor, such as in a debilitated (weakened,fatigued,weary) patient. Why no concern over test/lab results, nursing observations? Why no colon cleansing? Why no anti-biotic prophylaxis?
Although the exact mechanism leading to anastomotic dehiscence remains largely unknown, several factors such as blood flow, bacterial contamination, anastomotic technique, emergency operation, anastomosis in an unprepared bowel and inexperienced surgeon have been implicated. AS IN TERRA’S CASE!
"Removal required right hemicolectomy with resection of the associated mesentery that contained the cyst. On the second postoperative day, the patient did have a low-grade fever but this resolved by the following day."
Resolved by the following day? --- which would be day three July 13 (99.5°F),
LOOK AT DAY FOUR JULY 14TH, LOOKS A LOT LIKE DAY TWO JULY 12TH--July 14 (100.8°F) (100.3°F) (100.4°F)
July 15 (99.4°F) (99.4°F)
July 18 (99.4°F)
July 19 (99.4°F) (99°F)
Temperatures 23 out 38 recorded temperatures were not in the normal range
* Scientists today know that normal is actually 98.2 plus or minus 0.6, that is to say anything in the range of 97.6° to 98.8° should be considered normal." 36.4 to 37.1 °C
Terra’s abnormal readings are highlighted in bold below:
July 11
1630 36°C (96.8°F)
1730 37°C (98.6°F)
2000 37.1°C (98.9°F)
July 12
0000 38°C (100.4°F)
0400 37.5°C (99.5°F)
0800 37.3°C (99.1°F)
1300 37.1°C (98.8°F)
1605 37.2°C (99°F)
2000 38.1°C (100.6°F)
July 13
0820 37.5°C (99.5°F)
1130 36.9°C (98.4°F)
1650 36.8°C (98.2°F)
2015 36.2°C (97.2°F)
July 14
0500 38.2°C (100.8°F)
0815 36.3°C (97.3°F)
1200 36.3°C (97.3°F)
1550 37.9°C (100.3°F)
1857 38°C (100.4°F)
2000 36.7°C (98°F)
July 15
0530 36. °C (98.2°F)
0910 37°C (98.2°F)
1800 37.3°C (99.4°F)
2108 37.3°C (99.4°F)
July 16
0530 36.5°C (97.7°F)
0835 36.8°C (98.2°F)
1130 36.3°C (97.3°F)
2000 37.1°C (98.8°F)
July 17
0800 36.2°C (97.2°F)
1400 37°C (98.6°F)
2000 36.6°C (97.9°F)
July 18
0600 36.4°C (97.5°F)
1000 36.2°C (97.2°F)
1625 36.4°C (97.5°F) 2000 37.3°C (99.4°F)
July 19
0925 36.7°C (98°F)
1600 37.3°C (99.4°F)
1957 37.2°C (99°F)
July 20
0800 36.3°C (97°F) Terra discharged at noon.
"However on the fourth postoperative day it was noted that she had a wound infection. The skin was opened and the infection appeared to be confined to the subcutaneous space and not extend below the fascia. She then had some diarrhea and cultures for Clostridium difficile were negative."
NO MENTION OF 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)
No mention of the many Gram Negative Bacilli Seen and how it should be treated?
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.
"This seemed to settle and she was discharged home on the ninth postoperative day. Arrangements were made for Home Care visiting nurses to manage the abdominal wound with the intent that it would heal by secondary intention. The records indicate that on the evening of discharge she collapsed at her parent's home and was returned to hospital by ambulance but died in the emergency room despite resuscitation efforts. A Coroner's investigation was undertaken and a forensic autopsy carried out. The pathologist concluded that the patient died from hemorrhagic shock secondary to acute intraperitoneal bleeding. It was noted that on arrival in the emergency room on the evening of death, the patient had a marked coagulopathy. The pathologist concluded that a clear source for the bleeding was not identified and that the underlying coagulopathy could have been a contributing factor."
"You have requested that I review the quality of care that this patient received and I have done so. In preparing this report, I have given consideration to the concerns that the patient's family expressed specific to the quality of medical care provided."
"I believe that the initial assessment and care plan on March 3rd and 4th was entirely appropriate."
NO ANTIBIOTICS GIVEN AT ANY TIME? THIS IS APPROPRIATE?
"Dr. Klein subsequently carried out an appropriate investigation and reached a management plan that reflects a good standard of care. The operative procedure was carried out according to the appropriate standard and good decision making is evident. The postoperative care was appropriate. Specifically, treatment of a superficial wound infection is opening of the wound and allowing drainage. Subsequently allowing the wound to heal by secondary intention is the correct management. The use of antibiotics in the absence of systemic sepsis is not necessary, and does not improve the outcome. Unnecessary use of antibiotics does have risks including increasing the probability of development of antibiotic resistant infections including Clostridium difficile"
THIS MAY BE TRUE IF SHE HAD BEEN GIVEN THE ANTIBIOTIC PROPHYLAXIS PRIOR TO THE OPERATION!
"There were no clinical indications for a CT scan or other investigation."
THERE WERE MANY SIGNS
Breathing It should be noted that Terra’s breathing to the most part indicated concern. (see hospital records)
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 nomally 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
-- ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE
No mention as to 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
Description of Terra’s Abdomen Resting Pulse Rates Nursing Records well 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.
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
Terra was released 0800 large 88
AS WELL AS:
No mention of low hemacrit, red blood cells & hemoglobin indicates anemia (iron deficiency)
**HCT Hematocrit Count
July 18 0.35 Ref. 0.36 to 0.48
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
**RBC Red Blood Count
July 18 4.20 Ref. 4.20-5.40
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.
**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
No mention of high pulse rate? 34/38 above 90
Does not comment on 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
Does not mention 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 cells
No mention of the 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 hrs 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 18th 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
July 19th 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.
"It is not unusual for patients to be discharged without having had a solid bowel movement CERTAINLY NOT AFTER HAVE A COLON RESECTION!, and there certainly are care paths for bowel resection that do not even require passage of flatus. There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits."
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!!!!!
Nutritional Deficiency From Terra’s hospital records.
July 12 nutrition—probably inadequate
July 13 not tolerating current diet
not tolerating current diet, nauseated
July 14 ate about half of what was served
July 16 not tolerating current diet, nausea, save tray to try and eat later
July 17 not tolerating current diet,
And no nutritional supplementation to ensure her nutritional needs were met.
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
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
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.
3. LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE! Supports a healthy immune system, energy metabolism and protein synthesis
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.
5. LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE!
Blood coagulation is dependant on calcium.
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.
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.
8. LACKING 93% OF TOTAL DAILY FIBRE INTAKE!
9. LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE!
protects against infection, and enhances the immune system;
10. LACKING 82.7% OF TOTAL DAILY ZINC INTAKE!
protects against infection, and enhances the immune system; Zinc is also required in wound healing.
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.
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
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
14. LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE!
Necessary for red blood cell formation, anti-body production, cell respiration, and growth
Necessary for red blood cell formation, anti-body production, cell respiration, and growth
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
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.
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
18. LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE INTAKE!
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.
"Therefore there was no indication for supplements of things like vitamin K and calcium."
"Postoperatively, the hemoglobin, white cell count and platelet count remained within expected ranges. Culture from the infected wound grew the expected bowel related organisms. Samples of the loose stool for Clostridium difficile were negative. The last hemoglobin measurement that I can identify was on July 18 \ There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigation. Discharge on July 20, 2006 was therefore clinically appropriate."
**HB Hemoglobin
July 18 119 Ref. 120-160
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
"I concur with the pathologist that the cause of death was hemorrhagic shock. It is my opinion that the coagulopamy was a dilutional coagulopathy as a result of the hemorrhage, rather than a cause of the hemorrhage. I believe that the bleeding came from one of the staple lines on the anastomosis."
"Following removal of the right colon, the bowel was reconstructed using mechanical staplers and a technique known as a functional end-to-end anastomosis. This is the predominant technique in use today for joining two ends of bowel together. This was properly done by Dr. Klein. One of the risks of any anastomosis is bleeding or leak from the anastomosis. This can occur very early postoperatively, or be delayed. When it is delayed it is not uncommon for this to happen 6 to 10 days postoperatively. This complication happens in spite of proper surgical technique. Its incidence varies based on numerous factors, but is generally quoted to be in the order of 1 -5% of all bowel resections."
"I believe that the defect occurred because of ischemic necrosis at the intersecting staple lines created by the functional end to end anastomosis. This led to an open edge of bowel that subsequently bled. This led to hemorrhagic shock, subsequent dilutional coagulopathy and the patient ultimately expired from these events."
"While the patient suffered the most devastating complication of an operation, and specifically one of the common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care that she received."
THERE WERE FAR TOO MANY ISSUES NOT COMMENTED ON, DELIBERATELY, AND THE COO OFFICE FAILED TO FURTHER INVESTIGATE MY CONCERNS SENT TO THEM!
If you have any further questions, I would be happy to discuss this at any time
UNSIGNED
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NOTE: All of the Chief Coroner’s decisions were based on this expert’s opinion
This expert’s investigation is severely lacking! Far too many omissions!!
SOME RESPONSIBILITY TO DEATHS AFTER MY DAUGHTER ALSO LIES WITH THE FOLLOWING WHO HAVE IGNORED MY PLEAS FOR ASSISTANCE:
ROBERT W. RUNCIMAN, MPP
CONSTITUENCY OFFICE:
Leeds-Grenville.
Suite 101 Brockville, Ontario K6V 5J9
Tel. (613) 342-9522 Toll Free: 1-800-267-4408 Fax (613) 342-2501
July 9, 2009
Dr. Andrew McCallum
Chief Coroner of Ontario
26 Grenville Street
Toronto, Ontario M7A 2G9
Dear Dr. McCallum: I was recently visited by a constituent, Mr. Arnold Kilby, to discuss his concerns surrounding the circumstances of his daughter's death in July of 2006. I understand that you are personally familiar with Mr. Kilby and his concerns and that your office rejected the need for an inquest into his daughter's death.
Mr. Kilby, understandably, is quite passionate about determining the real cause(s) of his daughter's death and insuring that, if mistakes were made, that they not be repeated and jeopardize other lives. During his visit, Mr. Kilby laid out a very persuasive case, raising legitimate questions that, apparently, have never been answered. As a layman I can't speak to many of the issues he raised, but two jumped out at me as very legitimate causes for concern in the way his daughter was dealt with.
The first was the decision to operate without purging the colon for fear of infection; and the second was the nursing charts indicating a persistent "foul odour" at his daughter's incision, an odour that was still present upon her release from hospital and should indicate, to the least trained eye, that infection is present.
After reviewing Mr., Kilby's extensive file, I believe his daughter's death merits reconsideration from your office with respect to the death meriting an inquest. There remains far too many unanswered questions surrounding Terra Kilby's untimely passing, questions that only your office can secure answers to.
I urge you to give every possible consideration to calling an inquest into Terra's death.
Kind regards.
Sincerely,
Robert W. Runciman, MPP Leeds Grenville
IT SHOULD BE NOTED THAT DR. McCALLUM REFUSED MR. RUNCIMAN'S REQUEST.
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17/10/2015 This e-mail is asking the MPP's to question the Health Minister and sent to the Health Minister, Dr. Hoskins
IT IS NOW OCTOBER AND I HAVE NOT RECEIVED A REPLY TO THIS E-MAIL SENT SEPT 2, 2015
Will it take another year for you to respond to my comments below (over a year late!:
1. Who forced you to respond? AFTER A YEAR!!!!
2. Can you tell me exactly how many times I have tried to communicate
my concerns to both you and the previous Health Minister and the
Ministry over as you say "numerous" years? Perhaps you can send me a
copy of all of these responses that you say the Ministry has provided.
Prior to sending these to me, do they actually respond directly to my
concerns or are they merely a "whitewash" response to my communications.
3. You mention in your letter that I have received numerous responses from Ms Matthews and the Ministry. I can count on one hand the number of responses! What number to you consider numerous?
4. In your response letter you mention the newly legislative Office of the Patient Ombudsman and mention that he/she would handle concerns dealing with hospitals, long term care facilities and community care centers.
So, that means he/she has nothing to do with HPARB?
5. Who oversees HPARB?
When I can prove that HPARB totally ignored the factual evidence contained within the Operation Record concerning my daughter, who do I turn to in order to correct this?
Why is it not YOU?
6. You mention that I should continue to correspond the CPSO regarding their decision which was supported by HPARB on the third appeal. YOU HAVE GOT TO BE SERIOUS! Most of the citizens of Ontario who have dealt with the CPSO would find your suggestion to be absolutely ABSURD as would most MPP's, perhaps not the Liberals!
If you actually took the time to investigate my concerns supported with facts.
7. --would like to respond to how a surgeon can convert from minimal evasive surgery to open abdominal surgery without administering the mandatory antibioitic prophylaxis?
8. --for the College to actually state that this was neglected by the surgeon on two decisions but when sent back for the third time came up with the unsubstantiated opinion that the surgeon did not know he had to do a colon resection to remove the tumor? Note-- the operative records states under procedure one that he attempted a colon resection before convert to open surgery!
9. --for the surgeon having to remove all abdominal staples due to an infection that remained untreated with antibiotics
3. You mention in your letter that I have received numerous responses from Ms Matthews and the Ministry. I can count on one hand the number of responses! What number to you consider numerous?
4. In your response letter you mention the newly legislative Office of the Patient Ombudsman and mention that he/she would handle concerns dealing with hospitals, long term care facilities and community care centers.
So, that means he/she has nothing to do with HPARB?
5. Who oversees HPARB?
When I can prove that HPARB totally ignored the factual evidence contained within the Operation Record concerning my daughter, who do I turn to in order to correct this?
Why is it not YOU?
6. You mention that I should continue to correspond the CPSO regarding their decision which was supported by HPARB on the third appeal. YOU HAVE GOT TO BE SERIOUS! Most of the citizens of Ontario who have dealt with the CPSO would find your suggestion to be absolutely ABSURD as would most MPP's, perhaps not the Liberals!
If you actually took the time to investigate my concerns supported with facts.
7. --would like to respond to how a surgeon can convert from minimal evasive surgery to open abdominal surgery without administering the mandatory antibioitic prophylaxis?
8. --for the College to actually state that this was neglected by the surgeon on two decisions but when sent back for the third time came up with the unsubstantiated opinion that the surgeon did not know he had to do a colon resection to remove the tumor? Note-- the operative records states under procedure one that he attempted a colon resection before convert to open surgery!
9. --for the surgeon having to remove all abdominal staples due to an infection that remained untreated with antibiotics
10. --when test results came back stating the presence of "many gram negative bacilli", still no antibiotic treatment???
11. --could you explain why the CPSO find nothing wrong with the fact that an open abdominal
11. --could you explain why the CPSO find nothing wrong with the fact that an open abdominal
surgery took place and at not time during the
hospital stay did the patient receive antibiotics????
NOW, IF THIS IS NOT A COVER-UP FIRSTLY TO PROTECT THE SURGEON AND HOSPITAL AND THEN TO GO ALL OUT TO COVER UP THEIR OWN NEGLIGENCE IN INVESTIGATING MY CONCERNS ADDRESS TO THE CPSO!!
AND THIS IS ONLY ONE ISSUE OF PATIENT DEATH BY THIS SURGEON WHO BY THE WAY HAS AT LEAST 5 DEATHS.
CCO TEMPORARILY CLOSE THIS SURGEONS DEPARTMENT DUE TO SEVERAL DEATH DURING 2009 TO FEB OF 2010, AND HAD AN EXPERT BROUGHT IN TO ANALYZE THE OPERATING PROCEDURE. THIS WAS DONE WITHOUT PUBLIC KNOWLEDGE.
KEEP IN MIND THAT I HAVE BEEN CONTINUALLY CONTACTING THE CCO WITH REGARD TO MY DAUGHTER'S DEATH AND THEIR OWN INEPT DEATH INVESTIGATION!
NOW, IF THIS IS NOT A COVER-UP FIRSTLY TO PROTECT THE SURGEON AND HOSPITAL AND THEN TO GO ALL OUT TO COVER UP THEIR OWN NEGLIGENCE IN INVESTIGATING MY CONCERNS ADDRESS TO THE CPSO!!
AND THIS IS ONLY ONE ISSUE OF PATIENT DEATH BY THIS SURGEON WHO BY THE WAY HAS AT LEAST 5 DEATHS.
CCO TEMPORARILY CLOSE THIS SURGEONS DEPARTMENT DUE TO SEVERAL DEATH DURING 2009 TO FEB OF 2010, AND HAD AN EXPERT BROUGHT IN TO ANALYZE THE OPERATING PROCEDURE. THIS WAS DONE WITHOUT PUBLIC KNOWLEDGE.
KEEP IN MIND THAT I HAVE BEEN CONTINUALLY CONTACTING THE CCO WITH REGARD TO MY DAUGHTER'S DEATH AND THEIR OWN INEPT DEATH INVESTIGATION!
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11/09/2015 This e-mail concerns the two institutions he is suppose to oversee!
Mr Hoskins, Minister of Health
Now 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."
YOU, SIR, ARE FAILING IN YOUR DUTY MENTIONED ABOVE!
It is clear who you are accountable to --- the CPSO, not the Ontario Citizens
Now 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."
YOU, SIR, ARE FAILING IN YOUR DUTY MENTIONED ABOVE!
It is clear who you are accountable to --- the CPSO, not the Ontario Citizens
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A PRIMER ON THE LAW OF DEFAMATION IN ONTARIO
"Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words)
Proving a Claim in Libel and/or Slander
"the statement must be false!"
Defences to Actions in Libel and Slander
TRUTH--
"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefore there was nothing false about the statement, meaning therefore, that the statement was not defamatory."
FAIR COMMENT--
"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."
QUALIFIED PRIVILEGE--
"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate.
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THE LIBERAL GOVERNMENT FOR THE PAST NINE YEARS HAVE DONE ABSOLUTELY NOTHING!
"Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words)
Proving a Claim in Libel and/or Slander
"the statement must be false!"
Defences to Actions in Libel and Slander
TRUTH--
"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefore there was nothing false about the statement, meaning therefore, that the statement was not defamatory."
FAIR COMMENT--
"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."
QUALIFIED PRIVILEGE--
"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate.
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THE LIBERAL GOVERNMENT FOR THE PAST NINE YEARS HAVE DONE ABSOLUTELY NOTHING!
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| Where the Provincial Liberals bury their heads when it comes to reforming the CPSO and improving transparency and accountability within Ontario's Health Care System The similarities are amazing especially their stubbornness!  |
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