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

Eleventh Anniversary of Terra's Death--July 21, 2017

Post updated, August, 2017

PATIENT OMBUDSMAN'S FINAL LETTER:


Ms Muamba, Ms Elliott                          copy:  MPP Steve Clark, Administrative Assistant Jiggens.

Patient Ombudsman
Every experience matters

July 11, 2017
Arnold W. Kilby 888 County Rd 2 Lansdowne Ontario KOE ILO

Dear Mr. Kilby:

Re: File #0148


I am writing to confirm that our office's review of your complaint is complete and the file is closed on the basis of the information I provided to you in my letter of June 2, 2017.

In that previous correspondence, I provided a summary of the information our office received during the review and our attempts to facilitate resolutions of concerns deemed to be within the mandate of the Patient Ombudsman. As is part of our process, I invited you to contact me once you have reviewed the information.

AWK -- IN YOUR REPORT, THERE WAS NOT ONE NEGATIVE COMMENT OR SUGGESTION WITH REGARD TO THE HOSPITAL'S ROLE OF "PUTTING PATIENT'S FIRST, BEING COMPLETELY TRANSPARENT AND ACCOUNTABLE, NOR ANY WRONG DOING BY HRH. THEIR ACTIONS OR LACK THERE OF, REMAIN SQUEAKY CLEAN!

You responded to my June 2 letter by emails dated June 14 and 18, 2017. In your emails you declined my invitation for a discussion of the information contained in the June 2 letter as you indicated that in your view no useful purpose would be served in having the discussion.

AWK-- AND I STILL MAINTAIN THIS OPINION!

I appreciate that you are disappointed that our office could not review and address questions related to the medical or clinical care and decisions by regulated health professionals involved in your daughter's care in July 2006. 


AWK -- DISAPPOINTED IS NOT THE WORD I WOULD USE--- "DISGUSTED AND BETRAYED" ARE MORE APPROPRIATE WORDS.

In our meeting of September 22, 2016 and in subsequent communication, I clearly made you aware of the scope of our office's review of your concerns. This fact was confirmed in my letter to you dated January 18, 2017.


AWK -- THE SCOPE OF YOUR REVIEW MAKES IT IMPOSSIBLE FOR YOU TO TRULY REPRESENT AN ONTARIO CITIZEN! LEGISLATION NEED TO EXPAND YOUR SCOPE, OTHERWISE YOUR OFFICE IS A COMPLETE WASTE OF TAX PAYER'S DOLLARS!

I can confirm that our office carefully examined the information you provided as well as the information received from HRRH and we did so fairly and without taking sides. As an impartial, fact-gathering, oversight agency, when we indicate that a complaint with our office is resolved, we mean that it's resolved to the point that we are satisfied that no further action is warranted. Sometimes, this doesn't always mean that everyone who contact us will be satisfied.

AWK -- WHICH EFFECTIVELY MEANS THIS HOSPITAL WILL NOT LOOK INTO THE SURGEON'S NON USE OF PRE AND POST OPERATIVE ADMINISTERING OF ANTI-BIOTICS AND DOES NOT CARE HOW MANY OF DR. KLEIN'S PATIENTS DIE DUE TO NEGLIGENT CARE.   
 AWK -- QUOTE FROM DR KLEIN WHEN NURSE QUESTION HIM AS TO WHETHER TERRA SHOULD BE ON ANTIBIOTICS ----"THE BODY WILL HEAL ITSELF!"

I CERTAIN HOPE YOU OR ANY OF YOUR RELATIVES AND FRIENDS DO NOT GO UNDER THE KNIFE OF THIS SURGEON. BUT HOW DO YOU FEEL FOR THOSE ONTARIO CITIZENS WHO WILL DO SO, AND SUFFER ADVERSE EVENTS INCLUDING DEATH?    
AWK -- YOUR HAVE BEEN GIVEN THE FACTS, ONTARIO CITIZENS HAVE NOT!


I thank you for your commitment in bringing your concerns to the Patient Ombudsman's office. Although many of your concerns were outside the scope of our mandate, we do believe every experience can help us find ways to tackle system-wide issues, which can lead to better care for everyone.


AWK -- YOU CAN'T POSSIBLY TACKLE SYSTEM WIDE ISSUES WHEN SO MANY OF MY CONCERNS ARE OUTSIDE YOUR SCOPE. UPON LOOKING AT THE ISSUES AND MEDICAL SUPPORT INFORMATION.  YOU CERTAINLY SHOULD HAVE REALIZED THE FAILINGS OF THE OTHER INSTITUTIONS/INDIVIDUALS WHO I HAVE SOUGHT OUT. THERE IS NO WAY YOUR INVESTIGATION AND EXPERIENCES LEAD TO BETTER CARE FOR EVERYONE!


REGARDLESS OF THE RESTRICTED MANDATE YOU HAVE, FURTHER DEATHS BY THIS SURGEON AND CONTINUED COVER-UP BY THE HOSPITAL AND OTHER INSTITUTIONS/INDIVIDUALS, MAY IN A SMALL WAY, MAKE YOU ACCOUNTABLE FOR THE FURTHER ADVERSE EVENTS WHICH WILL UNDOUBTEDLY OCCUR!

WHEN MISS ELLIOTT SUBMITS HER YEARLY REPORT, SHE SHOULD INCLUDE TERRA'S CASE TO SUBSTANTIATE WHY THE PATIENT OMBUDSMAN'S ROLE SHOULD BE ENHANCED AND TO POINT OUT THE FAILINGS OF THE OTHER PARTIES I HAVE DEALT WITH.


Marie-Claire Muamba -- Investigator
Patient Ombudsman                                                      Ombudsman des patients
Box 130, 77 Wellesley St. West, Toronto, Ontario M7A IN3

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The reply from the Patient Ombudsman's Office

Dear Relatives, Friends and Ontario Citizens.

LET TAKE A QUICK REVIEW OF MY FAILED ATTEMPTS AT ACHIEVING ACCOUNTABILITY, TRANSPARENCY AND THE TRUTH. 
Confirmation bias = seeking or interpreting information that (one thinks) will support one's favored hypothesis or diagnosis. Ego bias = biasing probability estimates in a self-serving way. When you look at the PATIENT OMBUDSMAN'S REPORT, I think one might feel the above is relevant.

1. Humber River Regional Hospital IN 2010, "With the help of the Coroner's Office, the program was shut down while an external review was done by a well-known expert." (according to this power point display which mentions 5 deaths within 30 days of operation of patients) --this was referencing bariatric deaths--one can only wonder about other general surgeries conducted by Dr. Klein. Government funded through our tax dollars and FAILED!

HRH must take some accountability as they employ the nurses and grant the surgeon hospital operating privileges! They should be putting their patients first and not doing everything they can to conceal negligence. We already know how corrupt the CPSO is. HRH should have reported this negligence upon completion of their so-called thorough, in-depth internal review.
There must be something written in legislation that mandates they do so and should they not, then the hospital administrators should be held accountable! AND the PATIENT OMBUDSMAN SHOULD BE REPORTING THIS TO THE MINISTER OF HEALTH FOR ACTION.

2. The College of Physicians and Surgeons of Ontario -- 3 decisions "Physicians have been granted the privilege of self regulation. Society allows physicians to regulate themselves in return for the covenant that this regulation will occur in the public interest."FAILED!

3. The Health Professions Review and Appeal Board --- 3 meetings plus two attempts at a Reconsideration. Totally ignored College's conflicting statements to the actual operation records. Government funded through our tax dollars and FAILED!

4. The Chief Coroner's Office of Ontario "We speak for the dead to protect the living'

The Office of the Chief Coroner for Ontario serves the living through high quality death investigations and inquests to ensure that no death will be overlooked, concealed or ignored. The findings are used to generate recommendations to help improve public safety and prevent deaths in similar circumstances. THEY DID ALL THEY COULD TO CONCEAL THE CONTRIBUTING FACTORS INTO MY DAUGHTER'S DEATH FIRSTLY TO PROTECT THE SURGEON/HOSPITAL'S REPUTATION AND THEN TO COVER THEIR OWN ASSES! Government funded through our tax dollars and FAILED!

5. The Death Investigative Oversight Council -- twice The DIOC waiting TWO YEARS before they handled my complaint against the Chief Coroner and only started after both Dr. McCallum and Dr. Lauwers left. WHY?   And then they say they can not investigate the medical aspects of my complaint. Government funded through our tax dollars and FAILED!

6. The Minister and Ministry of Health "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." THIS MINISTRY AND THE THREE MINISTERS HAVE NOT ADHERED TO THE ABOVE AND THUS FAILED ALL ONTARIO CITIZENS!  FAILED!

7. The Minister and Ministry of Corrections   FAILED!

8. The Ontario Provincial Police --stated that Breach of Trust by a Public Official is not within their jurisdiction to investigate???? It is contained within the Criminal Code of Canada and Ontario. Government funded through our tax dollars and FAILED!   And the response letter I received was from Inspector Bradley McCallum---??Gee my complaint was against the Previous Chief Coroner, Andrew McCallum???

9. Ontario Independent Police Review Director  Government funded through our tax dollars and FAILED!

10 The Ontario Ombudsman's Office ---so many times I can't count ---P Dube totally ignored the contradiction within the College's third decision which HPARB had dismissed at well. Government funded through our tax dollars and FAILED!

11. Next up: Patient Ombudsman -- Am I confident this institution will do anything---NO GEE, I got this prediction correct! Government funded through our tax dollars and FAILED!

12. Forget about accessing the Freedom Of Information --- waste of time and money   FAILED!

13.  All Liberal and NDP MPPs and the majority of the Conservative MPPs  FAILED!

Not a single institution/person above could find a single systemic or patient care issue??

HPARB, THE OMBUDSMAN'S OFFICE, THE HEALTH MINISTER MUST BE INCREDIBLY DUMB OR THEY PARTICIPATED WILLINGLY IN CONCEALING THE TRUTH THUS JEOPARDIZING THE CITIZENS OF ONTARIO TO FURTHER MEDICAL HARM BY THIS SURGEON.

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

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!!!
Procedure One Desc. “Laparoscopic Colon Resection Attempted For Mesenteric Mass”
The second Procedure Desc. indicates the laparotomy.

LET US LOOK AT THE MEDICAL FACTS:

A. How about the fact that she did not have the anti-biotic prophylaxis given at the time of induction?
Prophylactic Antibiotics The need of prophylactic antibiotics is indisputable in colorectal surgery in order to reduce the rate of postoperative infectious complications.

 B. How about the enlarged abdomen? Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem.

 C. How about the foul, purulent oozing incision? Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence

D. How about the fact she had no colon cleansing? The colon contains bacteria and waste products that can cause infection if they leak into the abdomen during surgery. Therefore, a number of precautions are taken to reduce this risk. First, oral antibiotics may be prescribed several days before the operation. Secondly, the colon is emptied as much as possible to reduce the risk for infection during surgery.

E. How about the fact she received no anti-biotics what so ever? It is no wonder that the colon tissue died and separated causing internal bleeding leading to death. Have you ever been prescribe antibiotics for an: ear infection? eye infection? bladder infection? throat infection? chest infection? for a cut? etc, etc, etc, Yet my daughter received nothing??? 

F. How about the fact the she remained on a liquid diet for 8 days consisting of jello, juice, tea and both without any nutritional supplement?

How can a wound heal without proper nutrition?
Terra’s diet from July 11th/06 to & including lunch on July 19th/06 The clear-liquid diet is used for one or two days or until you are able to drink or eat other things. It cannot meet daily nutritional needs, but it helps keep fluids in your body as you recover and become able to eat a regular diet. 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.

G. How about the fact her resting pulse rate was over 90 Resting heart rates that are consistently high (Pulse Rates >90) (tachycardia) may indicate a problem, and you should consult a health care provider 34/38 of Terra’s recorded pulse rates were above 90 during her stay

H. How about the fact that she was only receiving 687 calories per day for 8 days? A healthy individual on a safe weight losing diet should not have fewer than  1200 calories per day. A healthy individual on a safe weight losing diet should not have fewer than  1200 calories per day.

I. How about the many gram negative bacilli seen? And not 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.

J. How about the low Absolute Lymphocyte (type of white cells)?

K. How about the many PMN’s (polymorphonuclear Neutrophils) –? hallmark of acute inflammatory process. PMN’s are the hallmark of acute inflammation PMN’s are rapidly recruited to tissues upon injury or infection

L. How about the below the standard scores for red blood cell count, hemoglobin counts and hemacrit counts?

HOW THE HELL CAN ALL OF THOSE NAMES ABOVE TOTALLY IGNORE SO MANY ISSUES UNLESS THERE IS A CONSPIRACY TO COVER UP NEGLIGENCE?

Ms Muamba

--you mentioned in your letter posted further down that I had multiple meetings with HRRH---May I remind you that at my ONE meeting in May of 2008 with the 5 administrators, I was told by Scott Jerrit (hospital administrator) that they found nothing wrong in their investigation??? -----  Gee, what about the failure to administer the antibiotic prophylaxis???  What else have they hidden from me?? They did not address one single issue I brought up at this meeting.  My brother and his wife and their son, a Bay Street lawyer attended this meeting.  Dr. Barkin only tried to defend the hospital's record of in-hospital deaths which at the time of Terra's death was the second highest in ALL OF CANADA!

The ONLY meeting assessment written by Terra's Aunt who attending this meeting: HRRH’s Communication Efforts?

 “The general attitude of senior staff at HRRH (we met five senior staff members, including Dr Jack Barkin, Chief of Staff, at our meeting of May 15, 2008) appears to be one of complete haplessness: as they have been cleared (by the College of Physicians/Surgeons) of not meeting standards in Terra’s post-operative care, they have expressed a lack of interest in further discussion and have given us the impression that they consider Terra’s death to be a fluke/bad luck/ “just one of those things” / a medical mishap for which there is no explanation and show absolutely no inclination to conduct their own inquiry.

Their truculence to say anything at all, indicates to us that any discussion initiated by them may be taken as an admission of culpability. Is it not incumbent upon hospitals, when these types of totally unexpected deaths occurs, to conduct an investigation, to shed some light on the situation (in Terra’s case, the cause of death was DIC) as some measure of solace to relatives, and also to educate other medical professionals and to advance the body of knowledge on the subject - in other words, perform a public service?

Our family expected HRRH would provide this kind of service to us - that they would tell us what happened/may/could have happened. On the contrary, we have had to conduct our own research, much of it via the internet, via journals, but it can be accessed only by subscribing and paying a fee.

This state of affairs should be unthinkable in our province. Our family knows the CAUSE of Terra’s death - what should be investigated are connections between the events of Terra’s hospital stay and their connections to the onset of DIC. This is the heart of the matter. Terra’s father, has done a meticulous job, researching medical records, organizing documents etc. while at the same coping with his overwhelming grief. He deserves credit for this.”

“It is common knowledge that on very rare occasions, a patient, even a young healthy patient dies after surgery. However, until every detail of the surgery/post-operative period in HRRH have been examined by specialists in the field, we are not prepared to accept the fact that Terra’s death has no explanation.”

Note: Terra's Colon Resection broke down (necrosis of the tissue--what caused this tissue to die?) and she bled to death. We had been told that she had DIC which the Chief Coroner later retracted.

AS WELL,---NO correspondence were ever responded to my concerns. It was two years after Terra's death that Ms. Collin via a phone call admitted that there was no record of Terra not receiving the antibiotic prophylaxis---TWO YEARS & they supposed conducted an internal review???

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MPP STEVE CLARK   --I AM DONE!

--perhaps you might ask to be included in the dinner mentioned below to give you the opportunity to question this report.

STEVE, what is your impression of this report if it was about one of your own adult children?

Note—Ms. Elliott discharged herself from my complaint due to the close friendship between herself and the CEO of Humber River Hospital.

Tremendous effort to support HRH, a piss poor effort for Terra and the citizens of Ontario!

Ms. Collins (CEO of Humber River Hospital) and Ms. Elliott (Ontario Patient Ombudsman) should take Patient Ombudsman, Marie-Claire Muamba out for a congratulatory dinner recognizing her for producing this indifferent, sterile, partisan and whitewashed report.

READ THIS REPORT to form your own opinion.—“swept under the carpet, glossed over, explained away, dodged, masked, buried, screened, camouflaged, concealed, suppressed, disguised, hushed up, veiled, kept under wraps, buttoned lip, kept mum, kept the cat in the bag, etc.”

I have failed my daughter, and all the citizens of Ontario as have all the other institutions/parties I have contacted. One only has to look at the medical evidence to see how negligence continues to be covered up. This newly created Patient Ombudsman’s Office is just another waste of tax dollars to merely create a political fantasy of another institution that, in actuality; does not place Ontario citizens high on the integrity priority list. Another institution lacking teeth, not to mention ethical integrity!

AWKilby
Discussing this report would be an obvious complete waste of time. So many have ears but are unable to listen.

Unfortunately, I am unable to copy this report here.

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THE "TERRA DAWN CONSPIRACY" --"a conspiracy to manipulate the results"

My ten year struggle resulting in failure to bring about the truth, protect Ontario citizens and open up true transparency and accountability.

Will the Patient Ombudsman's Office be another failed institution??

Regardless of the friendship between Ms Elliott and Ms Collins, I feel she should be fully engaged in the investigation as this is far too important to disqualify herself!

I met with the Patient Ombudsman, Christine Elliott, my MPP, Steve Clark and a patient ombudsman investigator, Marie-Claire Muamba with regard to HRH and Dr. Klein. This occurred several months ago, September 22/2016. I was told not to post anything until they had been in touch with HRH. This has occurred.

Marie, I am a little hesitant with regard to the coming phone call today, January 11, 2017, as I have had so many from so many investigators who merely want to inform me that there is nothing to be done! All these phone calls do is raise my blood pressure and anger me. They ignore the evidence and do a lame job of trying to explain why the find nothing to my concerns, which of course, is absolutely ludicrous! 

HRH has an opportunity to bring forth the truth after concealing it for over ten years.

The patients of Humber River Hospital should have the assurance that should an adverse event occur, this hospital will not conceal the truth by remaining silent. I and all of whom are aware of Terra Dawns's hospitalization and death would certainly not go to this hospital nor recommend Humber River Hospital to anyone. 

The problem is most Ontario citizens are completely unaware!

Should they not, the Ontario Citizens should be able to access a public document from the Patient Ombudsman's Office indicating HRH's lack of transparency and accountability and their excuse to hide behind the "Excellent Care Act" and conceal the truth with regard to a surgeon's negligence which resulted in many more deaths after Terra Dawn Kilby.

Also: If the phone call has to do with what I want from HRH. l doubt they will do the following.. They will not want to put anything on record.

For example-- a written response to some of the following questions. There are many more questions!

 HOW'S THIS FOR HUMBER RIVER HOSPITALS COMMITMENT TO TRANSPARENCY AND ACCOUNTABILITY TO IT PATIENTS AND FAMILY OF THE PATIENTS?

Barb Collins, now the CEO, has for ten years refused to comment on questions like those below: 

1. Is it hospital policy and the standard of care for a Humber River Hospital and its Surgeon to change to an open abdominal surgery to perform a colon resection and removal of a tumor after attempting a colon resection laparascopically without administering the mandatory antibiotic prophylaxis???

2. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide the patient with antibiotics when the abdominal incision became so infected that all staples had to be removed, considering the patient did not receive the mandatory antibiotic prophylaxis at the time of surgery???

3. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide antibiotics to the patient when test results indicated the "presence of many gram negative bacilli" considering the patient had not received any antibiotics whatsoever???

4. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon not to provide supplemental nutrition after five days of the patient only receiving a liquid diet and where records indicate the patient was not tolerating current diet???

5. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to keep a patient on a liquid diet for nine days without nutritional supplementation??

6. Is it hospital policy and the standard of care for a Humber River Hospital and its Surgeon not to ensure the patient had a solid bowel movement after consuming her only two solid meals just prior to discharge??

7. Is it hospital policy and the standard of care for Humber River Hospital and its Surgeon to not see the patient the day of discharge??

8. Is it hospital policy and the standard of care for Humber River Hospital to take over two years to substantiate my assertion that the mandatory antibiotic prophylaxis was not administered even though the surgeon kept telling the COO that he had done so???? And this was only done so during a phone call I had with Ms Collins.

9. Would HRH not consider all of the above to be negligence on the part of the surgeon and perhaps the hospital???

PLUS SO MANY MORE QUESTIONS WHICH HRH CAN EASILY SEE BY STUDYING THE HOSPITAL RECORDS.

January 10, 2017 -- phone call with Patient Ombudsman, Marie Claire Muamba.  It went well but after I reflected on it, I became disappointed.  E-mail from Ms Muamba the next day:

Hi Arnold, 

As you would recall, during our conversation yesterday, I confirmed with you the issues in your complaint that are under review by the Patient Ombudsman and the issues that are outside our mandate, specifically the issues related to the professional decision of a regulated health professional, such as a surgeon  or a nurse. For these issues, an individual needs to go to the appropriate regulatory body.

Along these same lines and as discussed, the questions you propose in your previous email are related to dispensation of medication. This issue is not part of what our office is able to review.

I hope you understand. I am sending you a letter confirming the specific concerns in your complaint that our office is able to review. Thank you.

Since when does the Hospital not be held somewhat accountable for the actions of a surgeon who they have granted hospital privileges to???? --especially one who has numerous death associated with his operations! 

 

E-mail sent January 18th, 2017 to Patient Ombudsman Investigator:

 

Ms Muamba,


Ms Collins, knowing that my complaints with regard to Terra's care or lack thereof has been ongoing for ten plus years, one would feel compelled to reopen my file when the Excellent Care For All came it effect.

Keep in mind, I met with five HRRH administrators in May of 2008 whereby they didn't respond to a single question/concern of mine.  This was before I actually had the hospital records.  Once studying the records,  I often sent my new concerns to Ms. Collins.

Excellent Care For All 

1. Have practices in place for handling patient complaints as part of the organization's overall patient relations process. As part of these practices, health care organizations are be required to:

• have processes in place for reviewing and resolving complaints made by patients and caregivers

• record, monitor, and analyze key information about each complaint, including the name of the person who made the complaint (except in the case of an anonymous complaint), the date the complaint was made, the subject matter, whether the complaint was resolved, and if so, when and how the complaint was resolved

• inform the person who made the complaint of its review status, within five days of the date the complaint was made and whenever the person who made the complaint reasonably requests further information

Public Hospital Act 

  Remember this is after Terra's death--considering this surgeon has multiple deaths, and the fact that his department was temporarily shut down due to multiple deaths in 2009 up to Feb of 2010, the CEO and COO should have realized there was a serious problem present.  Let's not forget the death of Crystal Rose in Dec of 2012.  Perhaps, HRH's lack of action led to these deaths and continue to do so.

Duty where serious problem exists        CEO and COO were well aware of a serious problem! But ignored it for years. (3) If an officer of the medical staff who is responsible under subsection (1) or (2) becomes aware that, in his or her opinion a serious problem exists in the diagnosis, care or treatment of a patient, the officer shall forthwith discuss the condition, diagnosis, care and treatment of the patient with the attending physician.  2006, c. 4, s. 52 (12).

Relieving attending physician

(3.1) If changes in diagnosis, care or treatment satisfactory to the officer are not made promptly, he or she shall,

(a) assume forthwith the duty of investigating, diagnosing, prescribing for and treating the patient; and

(b) notify the attending physician, the administrator and, if possible, the patient that the member of the medical staff who was in attendance will cease forthwith to have any hospital privileges as the attending physician for the patient.  2006, c. 4, s. 52 (12).

Term of appointment   

Considering hospital privileges are appointed yearly, the CEO and COO had plenty of opportunities to refuse Dr. Klein hospital privileges

(2) Every physician appointed to the medical staff of a hospital shall be appointed for a period of not more than one year.  R.S.O. 1990, c. P.40, s. 37 (2)

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THERE IS NOT ONE SINGLE INSTITUTION CREATED AND THEN FUNDED BY TAX DOLLARS THAT TRULY REPRESENT A CITIZEN WHEN IT COMES TO MAKING OUR HEALTH CARE SYSTEM ACCOUNTABLE AND TRANSPARENT.   F***KING UNBELIEVABLE!

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“THE TERRA DAWN CONSPIRACY”

--the action of plotting or conspiring and/or a secret plan by a group to do something unlawful or harmful.      
                                                        
Reader of this post, if you know of anyone who has unfortunately suffered the loss of a loved one in the past ten or so years, please invite them to read this post.  In particular, if they have had dealings with any of those mentioned below:  Should you wish to send your comments to those whose e-mail addresses I have include, I encourage you to do so.

Also, should any loved one enter an Ontario hospital, stay with them 24/7 and keep copious notes on anything you feel is abnormal.

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What could possibly be gained by covering up the negligent investigation into a hospital/surgeon related death?   If the truth was known, then all hospital deaths investigated by the Chief Coroner’s Office, in particular by past Deputy Chief Coroner of Death Investigations, Dr. Burt Lauwers, would be called into question.  Much the same as what happen when Dr. Charles Smith, the Chief Coroner’s Pathologist whose so-called expert testimony removed children from their caregivers and sent people unjustly to prison.  

BUT in this case, it may be more serious in that more deaths had occurred by my daughter’s surgeon after her death.(bled out 12 hours after discharge)  Had Dr. Lauwers implemented a “thorough” death investigation and looked into my concerns pointed out to him on numerous occasions, these deaths may not have happened.  Dr. Lauwers was employed at the CCO for seven years.  One must wonder how many other families have been treated the same by Dr. Lauwers?  The inquiry, led by Justice Stephen Goudge and concluding in October 2008, found that Smith "actively misled" his superiors, "made false and misleading statements" in court and exaggerated his expertise in trials. 

THESE WORDS ABOVE WOULD CERTAINLY APPLY TO THOSE WHO SUPPOSEDLY INVESTIGATED MY DAUGHTER'S DEATH!

Is he in the same class as Dr. Charles Smith? – You decide!  Remember, the coroner’s office temporarily shut down the hospital department in 2010 due to five or six deaths and brought in an expert to review this department.  Terra’s surgeon is a part of this team.  This was done in secret!! You will not find this publicly reported anywhere by neither the hospital nor the CCO?

What other deaths may have been prevented in other cases examined by Dr. Lauwers??  Who really knows?? That is why there is a conspiracy to keep the truth hidden from the public!  If the truth is exposed with regard to my daughter’s death investigation, the door would be wide open for others to question the CCO’s past actions or lack thereof!  Patients of Ross Memorial Hospital --BEWARE --should an adverse event occur in your hospital, the truth will be conceal as Bert Lauwers is the President and CEO.

More than 99% of the families of loved one who have died while in hospital believe what they have been told by the hospital and the CCO.  When one questions the CCO, they do whatever they can to silence the family of the deceased.  The less than one per cent who raise issues are considered as paranoid, trouble makers and are very dangerous to the maintaining the status quo.

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I SENT TO THE OPP HEADQUARTERS IN ORILLIA A REQUEST FOR AN INVESTIGATION INTO BREACH OF TRUST BY A PUBLIC OFFICIAL WITH RESPECT TO FORMER CHIEF CORONER, ANDREW MCCALLUM, FORMER DEPUTY CHIEF CORONER OF DEATH INVESTIGATIONS AND THE PRESENT CHIEF CORONER, DIRK HUYER.

Criminal Code of Canada

I BELIEVE PAST CORONER, DR ANDREW MCCALLUM, PAST DEPUTY CHIEF CORONER DR BERT LAUWERS AND THE PRESENT CHIEF CORONER SHOULD BE CHARGED WITH "BREACH OF TRUST"

122. Every official who, in connection with the duties of his office, commits fraud or a breach of trust is guilty of an indictable offence and liable to imprisonment for a term not exceeding five years, whether or not the fraud or breach of trust would be an offence if it were committed in relation to a private person.

* R.S., c. C-34, s. 111.
Breach of Trust By Public Official
Accused intended to use his/her public office for purpose other than public good.
Interpretation of the Offence

The purpose of this offence is to ensure that the public retains "the confidence of the public in those who exercise state power"
The offence is a codification of the common law offence of "misconduct in office"
 
Misconduct of officers executing process
128. Every peace officer or coroner who, being entrusted with the execution of a process, willfully
* (a) misconducts himself in the execution of the process, or
* (b) makes a false return to the process,
is guilty of an indictable offence and liable to imprisonment for a term not exceeding two years.
* R.S., c. C-34, s. 117.
 
Actus Reus
A "breach of trust" can include "any breach of the appropriate standard of responsibility and conduct demanded of the accused by the nature of his office as a senior civil servant of the Crown."
 
Mens Rea
The mens rea requires a prohibited act that is done intentionally or recklessly, with the knowledge or willfully blind to the facts making up the offence.
There must also be a "subjective foresight of the consequences" (that their actions will result in a benefit).
There is no need for intent to act dishonestly.
The accused need not be aware that he was breaching trust, it only requires that a reasonable person would conclude that there was a breach of trust.
Pleadings Breach of public trust is a straight indictable offence. The defence has an election under s. 536.
The prohibited act must cause a personal benefit to the accused and must be contrary to the duties imposed upon them.
The breach does not need to be in respect of trust property.
The offence does not capture mere nonfeasance or neglect of duties.
There must be a marked departure from the standard expected from the official.
 

But the Ontario Provincial Police will not investigate!  Read their reply to my request:

Will those who should be charged with Breach of Trust by a Public Official choose to commit perjury??  Or will they tell the truth which of course would prove "Breach of Trust"?

What do you think Dr. Bert Lauwers, Dr. Andrew McCallum, Dr. Dirk Huyer, Dr. Laz Klein, Dr. Brian Taylor, Ms Angela Bates, Dr. Rueben Devlin, Ms Barb Collins, and Mr. Paul Dube???   I would love to have the above sworn in by a court of law to tell the truth!

What is the penalty for perjury in Ontario, Canada? 

Perjury (and all criminal offences) are covered by the Criminal Code of Canada, which is federal legislation, and the same in all Provinces.
Perjury specifically is covered by sections 131, 132. 136 is related, and has to do with giving contradictory evidence.

Misleading Justice

Perjury

• 131 (1) Subject to subsection (3), every one commits perjury who, with intent to mislead, makes before a person who is authorized by law to permit it to be made before him a false statement under oath or solemn affirmation, by affidavit, solemn declaration or deposition or orally, knowing that the statement is false.
  

Punishment

132 Every one who commits perjury is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.

• R.S., 1985, c. C-46, s. 132;
• R.S., 1985, c. 27 (1st Supp.), s. 17;
• 1998, c. 35, s. 119.

Witness giving contradictory evidence

• 136 (1) Every one who, being a witness in a judicial proceeding, gives evidence with respect to any matter of fact or knowledge and who subsequently, in a judicial proceeding, gives evidence that is contrary to his previous evidence is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years, whether or not the prior or later evidence or either is true, but no person shall be convicted under this section unless the court, judge or provincial court judge, as the case may be, is satisfied beyond a reasonable doubt that the accused, in giving evidence in either of the judicial proceedings, intended to mislead.      ************************************************************
  

OPP Commisioner Hawkes

OIPR Director McNeilly

SO, I THEN PUT IN A REQUEST TO THE OIPRD AGAINST THE OPP FOR NOT INVESTIGATING MY COMPLAINT.  THEIR RESPONSE IS ALSO A BUNCH OF BULL.  If either the above actually read what I had sent to the OPP, they should have been able to clearly see that a thorough death investigation was not done.

 

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

The Chief Coroner's Office, Humber River Hospital, the College of Physicians and Surgeons, the Health Professions Appeal and Review Board, the Death Investigative Oversight Council, the Minister of Health and unfortunately the Ombudsman’s Office of Ontario all believe it is perfectly within the accepted Standard of Care, as opposed to my over 100 surgeons’ opinions, to:

--have open abdominal surgery without the mandatory antibiotic prophylaxis –note: no open surgery is ever done without this being administered unless it is emergency surgery and this is not the case.        
                                                                                                                               
--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

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                      
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.

--not having either of the above, still apparently there was no need for antibiotics when test results indicated the "presence of many gram negative bacilli" (in same catagory as C Difficile)
                                                                                                                                                    
 The very last phone call I had with Dr. Lauwers (before I received the letter from him stating that he would not accept any further phone calls from me) I asked him point blank "what about the gram negative bacillia not being treated?"   And his response was, the expert didn't comment on it so it was not significant!  Bullshit—the expert omitted lots!

PLUS MANY OTHER ISSUES WHEN ONE LOOKS AT TERRA’S HOSPITAL RECORDS.
A VERY DANGEROUS PRECEDENCE HAS BEEN SET BY ALL OF THE ABOVE AS THIS DECISION CAN NOW BE USED TO JUSTIFY SIMILAR COMPLAINTS.

 The Curtain of Concealment must be opened!

 Institutions/parties involved in this Conspiracy and which have failed Terra Dawn Kilby and all Ontario Citizens

1. Laz Klein     --Terra’s Surgeon who performed open abdominal surgery to remove a tumor and performed a colon resection without the mandatory antibiotic prophylaxis.  Plus numerous other issues of neglected care.  Has numerous deaths but they won’t appear anywhere on the CPSO’s public records.                                                                         surgery@misgroup.ca        lklein@hrrh.on.ca   l.klein@utoronto.ca  
2. Humber River Hospital -- past CEO Rueben Devlin and past COO and current CEO Barb Collins--put patient safety well behind protecting the surgeon and covered up this negligent surgeon resulting in many more deaths.  bcollins@hrh.ca

3.  Chief Coroner’s Office -- Andrew McCallum, Dr. Bert Lauwers and present Chief Coroner, Dr. Dirk Huyer for conducting and/or knowing supporting a flawed death investigation for the purpose of protecting the surgeon and covering up neglect.  Then doing whatever they could to protect their own Breach of Trust by a Public Official.  You may wish to comment directly to Dr. Andrew McCallum, head of Ornge

Dirk.Huyer@ontario.ca   

  They both have blocked me.   blauwers@rmh.org    amccallum@ornge.ca                                                                     This Office has declined multiple requests:

1. My request for a public inquest –note: a public inquest has never been granted if it involves a death associated with hospital/surgeon care!
2. MPP Runciman's, now Canadian Senator, request to reconsider the public inquest
3. My request for Terra's death to go before the Patient Safety Death Panel
4. My request for an Eastern Ontario Coroner's Review since Terra passed in Kingston –Oh, by the way, according to legislation it is the Eastern Ontario’s responsibility to deny or accept this request but I received a letter from Dr. Lauwers.
5. My request to initiate the Chief Coroner's Review Process
6. Refused the Ombudsman Office request to meet with me and respond to my concerns
7. Refused the OPP Detective's request to meet with me and respond to my concerns. “We will not meet with him nor answer his questions.”

Dr. Huyer meeting with me, and would not speak about the past Chief Coroner nor the Past Deputy Chief Coroner.  He insisted there may have been some patient care issues that should be dealt with by the CPSO and the Hospital. 
He stated “None of my concerns had anything to do with Terra’s death”   Bullshit!

Coroner’s Act 

whereby all three named above failed in their duties:  “Breach of Trust”  I think so.

--Coroners shall exercise their duties and responsibilities without fear, favour, prejudice, bias or partiality towards any person.
--Coroners shall proceed in the public interest to carry out diligently, and with all due dispatch, their duties and responsibilities as set out in the Coroners Act, 1990.
--Coroners shall have due regard for the fact that they are performing a public duty and that their actions and decisions affect the public interest as well as the interests of private individuals.
--Coroners shall not conduct themselves in a manner which might tend to bring their office into disrepute or affect public confidence in that office.
 *******************************************************

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

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

“We Speak For the Dead to Protect the Living”    Those that died after my daughter certainly would agree this office failed them, their families and all Ontario Citizens.

Dr. Bert Lauwers’ expert fail to comment on the majority of the items below:

How about 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.),                                                                                                                                                                                                                       And How about the fact her resting pulse rate was over 90?        (is the last number shown)             

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

Terra was released 0800 large 88

How about the fact she had no colon cleansing?  

How about the fact that she did not have the anti-biotic prophylaxis given at the time of induction?                                                                                                

From the College’s own opinion provider:   Dr. Taylor from London. “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case.”

How about the fact she received no anti-biotics whatsoever? 

How about the fact the she remained on a liquid diet for 8 days consisting of jello, juice, tea and both without any nutritional supplement? 

How can a wound heal without proper nutrition?

From the College’s own opinion provider:   Dr. Taylor from London.
“Dr. Taylor noted that the patient's serum albumin was only 10 at Kingston General, something that "does not happen overnight", but indicates profound protein loss and poor protein intake.”

How about the fact she was only receiving 687 calories per day for 8 days? <1200 is a starvation diet

How about the many gram negative bacilli seen? And not treated.

How about the low Absolute Lymphocyte (type of white cells)? 

**ABS LYMPH#   All 5 tests are well below normal range
Absolute Lymphocytes Count Ref. 1.5 - 4.0
July 18 0.9
Day 6 0.7
Day 4 0.5
Day 3 0.8
Day 2 1.0

How about the many PMN’s (polymorphonuclear Neutrophils) –   hallmark of acute inflammatory process – a sign of infection.

How about the above normal temperatures?

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
                                                                                                 
Temperatures 23 out 38 recorded temperatures were not in the normal range

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)

How about the low hemacrit, red blood cell count and haemoglobin? –a sign of anemia

*HCT Hematocrit Count   All 5 tests are below normal range
July 18 0.35 Ref. 0.36 to 0.48
Day 6 0.35
Day 4 0.32
Day 3 0.32
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.

**HB Hemoglobin  ALL BELOW THE STANDARD
July 18 119 Ref. 120-160
Day 6 117
Day 4 107
Day 3 106
Day 2 111                                                                         
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
               
**RBC Red Blood Count  1 test at well low of normal range & other 4 below normal range
July 18 4.20 Ref. 4.20-5.40
Day 6 4.16
Day 4 3.80               
Day 3 3.78               
Day 2 3.95
Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body.

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.

 *************************************
Dr. Bert Lauwers, Dr. Andrew McCallum and present Chief Coroner Dirk Huyer all say that none of the above contributed to Terra’s death in any way.  Again---BULLSHIT

JUST A FEW COMMENTS FROM MY QUALIFIED SURGEONS WHO LOOKED AT THE MEDICAL RECORDS:MAKES ONE WONDER HOW EXPERT THE CCO'S EXPERT REALLY WAS, OR WAS THERE ANOTHER REASON FOR SO MANY OMISSIONS BY HIM.

Hello again, Mr. Kilby:
I have reviewed what you have sent to me via the attachments to your last email In your original email to me, you alluded to the fact that your daughter underwent her elective surgery without mechanical or antibiotic bowel preparation. As I mentioned to you previously, that is an ongoing issue in surgical discussions and decision making, but personally, I would believe it to be a grave mistake to have NOT prepared a patient's bowel if there was any chance the bowel would need to be entered during the surgery. 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

******
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

*****
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,
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

*****
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

*****
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

*****
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

*****
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.

*****
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

*****
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

*****
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 my 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

*****
Dear Father: I am not an authority on laproscopic surgery or mesenteric cysts. I practiced cardiac surgery.
Having said that I recognize that there were serious complications, and probably unnecessary complications, with your daughter’s care. From what I have read I believe that the standard of care was not met which caused your daughters demise.

My recommendation is that you try to find a laporscopic surgeon who is familiar with the procedure your daughter underwent. In addition you should determine the medical history -morbidity and mortality results -of the surgical team who cared for your daughter.
I am not familiar with the Canadian system but in the U.S. a lawyer would be hired to investigate this case which appears to be or at least border on malpractice.
I wish you solace and good luck in resolving this matter.
Steven J. Phillips, MD

*****
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 th rough 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

*****
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.

1. 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.

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
*****
Chief Corner’s expert states: “There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigations. Discharge on July 20, 2006 was therefore clinically appropriate.”
From my own unnamed source within Canada. Releasing name would mean reprimand and discipline by the Omnipotent College and I promised to never do so and I am a man of honour.

Mr Kilby
I am going to respectfully disagree with the coroner. If you take a look at the chart, it seems to me that nurses and doctors are talking about two different patients. Doctors are talking about a stable patient who is afebril, and her wound is healing, and their plan is to discharge the patient within 1-2 days. On the other hand, nurses are talking about a patient who has a fluctuating vital signs [particularly her Temperature], patient is refusing food while she is stating to nurses that she is hungry, and she tells nurses that she does not have pain but nurses are giving her pain medications anyway, and finally patient's abdomen is going from flat to round and large. Don't you think, these people either did not know what they were talking about or something serious was happening to patient. Maybe the thing that was happening was not septic shock but it was ileus, maybe it was not ileus but it was leaking from perforated site. Something was definitely wrong. It is easy to conclude that both nursing and medical care provided to patient was inadequate and below the standard of care. The definition of negligent malpractice in law is " failure to meet the standard of practice by health care professionals" and " omission of act that the fiduciary relationship of a nurses and physician with their patient, obligate them to do for their patients"
Two omissions here : a) timely prescription of antibiotics, and b) reporting and recording abnormal findings by nurses.

I have to tell you that it is a major problem that you could not find not even one nursing progress note, very big problem, huge. How is nurses did not even write one nursing note during 9 days of her hospitalization!!!!!!! Physician notes are not consistent with the nursing notes, for example on July 16 nurses noted:
July 16 Chest assessment
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
Abdominal assessment
July 16th 0530 rounded 1130 rounded 1130 rounded 1615 rounded 1310 rounded 2100 rounded 2000 large
On July 16, the attending physician did visit the patient but the fellow wrote:
July 16, 2006 (This note was written by the clinical fellow)
AVSS (afcbrile, vital signs stable) c/o nausea, no vomiting
wound packed incisional pain
I/P (impression plan): stable, blood work

How a patient who has a large abdomen, can not tolerate food, and has decreased air entry be stable?
Fellow wrote vital signs stable, no I disagree look at the vital signs, and they were fluctuating even in 24 hours and throughout her hospitalization. That is why Meditech , an electronic documentation, provides vital sign graphs so physician can see the trend of the patient’s vital signs throughout their hospitalization.

Dear Mr. Kilby I am puzzled by Narcan to be ordered for because we use Narcan only in case of overdose. I consulted with the hospital pharmacist , just to make sure , and he also agreed with me that Narcan in her MAR sheet seems a lit bit suspicious. From your e-mail , I understand that she was on PCA pump therefore there was no need for Narcan. Yet Narcan was ordered!
XXXXXXXXX

*****
Dear Mr Kilby:
I have read the sad account of your daughter's illness and Other 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

*****
Dear Mr. Kilby,
I just read through the attachment, and I recall reading your prior email.
My personal opinion based only on what you have provided 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
*****
Dear Mr. Kilby:
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
**************************************************
I believe there is a case of "Breach of Trust by a Public Official" to be made with regard to those who head up the following institutions:

4. Death Investigation Oversight Council --took two years to look into my complaint saying they had to wait due to my ongoing dealing with HPARB.  (Complaints against the Chief Coroner are to be handled immediately) My complaint vs the Chief Coroner was different, yes containing the same medical issues.  DIOC conducted the investigation only after the Chief Coroner and Past Chief Coroner had left Office and yes, I was still dealing with HPARB at the time.
The also said they could not look into the medical issues I was present.  Why else would I have a complaint against these two if it didn’t???     A few years later contacted them again when their role was expanded – same result – do not deal with medical issues associated with the death investigation!

5.  College of Physicians and Surgeons of Ontario -- a completely unaccountable institution whose covenant granted to them by the citizens of Ontario has been repeated broken for decades and that being to put citizens first. Their only role is to protect their members!  

"Physicians have been granted the privilege of self-regulation. Society allows physicians to regulate themselves in return for the covenant that this regulation will occur in the public interest."

"Meeting these responsibilities requires efficient and appropriate governance and a reliable system of accountability. Fulfillment of this duty is essential to self-regulation."

ANGELA BATES HAS NO IDEA WHAT THE ABOVE MEANS!  

 abates@cpso.on.ca  She is no longer with the CPSO  but is now working for Retirement Homes Regulatory Authority.  It appears one gets reward by this government when one covers up negligence probably causing death and protecting the very same surgeon responsible for more deaths after my daughter's.   angela.bates@rhra.ca

THREE DECISIONS AND THREE APPEALS TO THE HEALTH PROFESSIONS REVIEW AND APPEAL BOARD.
The Colleges’ third decision -- The contradictory CPSO's opinion/decision with their own expert as well as the factual documentation within Terra's medical records and Dr. Klein own description of the procedure.

6.  Heath Professions Appeal and Review Board --in particular their third decision which totally ignored the contradiction of the College’s assertion that Dr. Klein did not know a colon resection had to be performed and only found out when he converted to open surgery. Surgical Records state he attempted a laparoscopic colon resection prior to converting to open surgery, plus his own description and other pieces of factual information discrediting and contradicting the College’s third decision.  CPSO NEVER ATTENDED ONE OF THE THREE APPEAL MEETINGS!

             Past Chair Linda Lamoureux     linda.lamoureux@ontario.ca

              Present Janice Vauthier   janice.vauthier@ontario.ca

7.  Ontario Ombudsman --- over the years on numerous occasions with a multitude of ombudsman investigators -- they have failed with regard to numerous issues involving the Chief Coroner’s Office, the DIOC, and HPARB.   I met with Mr. Dube, the Ontario Ombudsman on August 2nd, 2016.  Even though the medical evidence undoubted shows the contradictions, he maintained that HPARB conducted the Third Review according to the principals of natural justice and procedural fairness and supported their decision.  WHAT????
He even suggested the College may have wanted to use the word “omitted” instead of what they did use –“neglected”  Who is he supposed to be working for?

When the Ombudsman’s Office reviews Board decisions, we consider issues such as whether the Board:
* complied with governing legislation;                                                                 
 *followed proper processes; 
*made its decision based on the evidence before it; and                                        
 * provided adequate reasons in support of its decision.
pdube@ombudsman.on.ca    bfinlay@ombudsman.on.ca

I maintain HPARB’s actions:  "were not carried out in accordance with the principals of natural justice and lacked procedural fairness."

8.  The Entire Liberal caucus over the past ten years and in particular, the two Premiers, and the Ministers of Health and Ministers of Corrections. They have allowed the CPSO to continue to abuse the citizens of Ontario and have allowed the institutions that are supposed to provide complainants with an avenue to achieve transparency and accountability to fail repeatedly.   They are all simply a mirage.  When you actually avail their services, they completely disappear!
                                                                                             
9.  The Ontario Provincial Police --I put a request into the Orillia OPP Headquarters to investigate the Chief Coroner’s Office for “Breach of Trust By a Public Official”   The letter I received back from Inspector Bradley McCallum (note, the Chief Coroner who I am complaining about is Dr. Andrew McCallum) stated “Please be advised the concerns you raise are not matters for the OPP to address.”                                                 Ok, then who does?                                                                                                                     
So, I sent an e-mail off to the RCMP.  They responded they have no jurisdiction but suggested I contact the Office of the Ontario Independent Police Review Director!    Funny how the OPP can on three occasions on complaints given to them from the OCC will investigate me.  Firstly, by having an OPP Detective with a uniformed officer visited my home one week before the anniversary of Terra’s death.  This was an intimidation technique employed by Dr. Lauwers and Dr. McCallum to shut me up. No charges, not even close.  Then secondly, on two other occasions I was invited to the Brockville OPP station to be video-taped and answer questions.   No charges, not even close.  Again, an intimidation tactic employed by the OCC!                                                                                                                                                                                                                                      
 Undecided as to how I feel about---10.  The Ontario Patient Ombudsman – Ms. Christine Elliott  -- presently sent in a complaint with regard to HRH’s silence and lack of accountability and transparency.  But it is under the Minister of Health, so who knows if the conspiracy will continue?  I await this avenue to be completed.

11.  The Ontario Independent Police Review Director – Mr. Jerry McNeilly – presently sent in a complaint to question the OPP’s refusal to investigate my complaint suggesting they investigate Dr. Bert Lauwers and Dr. Andrew McCallum and Dr. Dirk Huyer for Breach of Trust of a Public Official.  Got the reply back.

12.  Dr. Bert Lauwers’ latest attempt to silence me is by threatening a defamation suit against me if I don’t remove my postings on Facebook, Linked and my Blog. When all you report is the truth/facts, there is no possibility for slander/libel actions!   You may wish to comment directly to Dr. Lauwers who is now President and CEO of Ross Memorial Hospital in Lindsay.  He has blocked me.     blauwers@rmh.org

PROBLEM – the CCO, the DIOC, and Ontario Provincial Police fall under the jurisdiction of the Ministry of Corrections as did my request under Freedom of Information.    And, Humber River Hospital, HPARB and the Patient Ombudsman fall under the jurisdiction of the Ministry of Health.   So, in effect we have six institutions under the thumb of the Liberals who will do what they are told to do in order to keep the factors and circumstances of Terra’s death unknown!




Freedom of Information request:   “I would like access to all records pertaining to deaths investigated by the Chief Coroner's Office and/or Coroner for Humber River Regional Hospital, Finch Street Site.  Only the deaths whereby Dr. Laz Klein was the surgeon.  Included in this request should be all informtion to the temporary shut down of this Hospital Department in 2010 due to numerous deaths which occurred between 2009 and February of 2010 and an external expert brought in to evaluate.  I do not require the names of the deceased.”  A waste of my time --  Even the space where the number of deaths would have appeared was blackened out?  Why is this kept secret?

READERS, DO YOU FEEL THERE IS A “TERRA DAWN CONSPIRACY”  If so, contact your MPP and media (i.e.  CTV’s W5, CBC’s Go Public, TVO, Newspapers etc. to expose this)  

          A PUBLIC INQUIRY SHOULD BE CONDUCTED INTO ALL OF THE ABOVE WITH RESPECT TO THE TRANSPARENCY AND ACCOUNTABILITY INTO DEATHS THAT OCCUR WITHIN ONTARIO’S HEALTH CARE SYSTEM.

It appears Incompetence is rewarded by appointment to other government institutions!
ONTARIO CITIZENS MUST REMOVE THE LIBERALS IN THE NEXT ELECTION.  THE NDP HAVE BEEN USELESS AS WELL!  And their Liberal appointees must be removed.
The next government must remove those who have conspired and abused the roles appointed to them. 

 A complete flushing of this fecal material must be done!

******************************************************************
TIME LINE

--July 11/06--Terra was operated on.  It was supposed to be day surgery but had changed to major abdominal surgery to remove a tumor but then a colon resection was done.

--July 20/06--Terra was released from hospital at approximately noon.

--July 20/06--Terra died on the way to Kingston General Hospital, was revived at an ambulance sub-station on Hw 15 at approximately 11:30 pm.  Bled out due to colon resection breaking down.

--July 21/06--Terra is pronounced dead at Kingston General in early hours of morning (2:00am)

--Aug /06 -- Autopsy performed, cause of death DIC, however a defect discovered on bowel not there prior to operation, cause unknown.  Orally, Dr Hinton, investigating coroner told me over the phone that the defect was definitely not there prior to the operation and that my daughter should not be dead! The Colon resection broke down. 

--Feb of 2007 -- received autopsy report

--Sometime after Feb 2007, Kingston Coroner told me that the Ontario Chief Coroner's Office was looking into Terra's death

--May of 2007 -- put complaint into College of Physicians.  It should be noted that the caseworker for the College, Sandra Keough suggested that since my complaint was so lengthy that it should be shorten to be more precise.  So, she rewrote it and asked me to agree to this.  At this point, I unfortunately thought her intentions were sincere and helpful.  Thank God, I submitted my original complaint to HPARB for the first appeal.

It should also be noted that Sandra Keough’s significant other is Dr. John Lindsay, an associate professor at the University of Toronto’s Faculty of Medicine.  I found this out much later for the second appeal at HPARB.  My daughter’s surgeon is also an associate professor at the University of Toronto’s Faculty of Medicine.   CONFLICT OF INTEREST???

--July of 2007 -- met with Eastern Ontario Coroner to discuss Ontario Chief Coroner's finding. --It was suggested that I was entitled to get Hospital records by Dr. McCallum on three occasions

--Late Aug of 2007 --Terra's family doctor started requesting the medical records with no success

--Early Dec of 2007 --I demanded them and they were sent to the family doctor with a note that she would destroy them after she looked at them or send them back and no one else was to see them even me????   --I called hospital immediately and was told I could have them

--Dec 2007 --I started going through medical records and found many alarming items.

--Prior to Jan 16/08-- When College of Physicians and Surgeons were meeting to look into my complaint; I called and informed them of what I had found in the medical records.   I was told the investigating committee would definitely go through all medical records, as one of my complaints was that Terra was released too soon and not given appropriate care.

--Early in 2008 and for remainder of year, sent out over 3,000 e-mails to qualified surgeons throughout the world.
No Canadian surgeon would respond.  But I did get over 100 responses and many want the medical records.  I receive numerous responses outline their concerns which completely contradicted the expert opinion of Dr. Lauwer’s expert and the CPSO’s independent opinion provider.

--March 10/08 -- Received decision from College,--- they saw nothing wrong.
It took the College from May of 2007 to March of 2008 to render its first decision.
             
  -- March 13, 2008 -- I then appealed to the Health Professions Appeal and Review Board

--May 15, 2008 – met with 5 Humber River Regional Hospital officials for one and a half hours whereby they sat silent except for Dr. Barkin defend the high in-hospital mortality rate.

--Nov 12/08 –Spoke to Dr Hinton, Kingston Coroner.  He was not willing to meet with me and said he could be of no further assistance.  

--Dec 1/08 – Received letter from Mr. McGuinty stating that he will take my situation under consideration.  Suggested I keep working with the Ministry of Health and Long Term Care.

--Dec 15,  2008 – met with Dr. Lauwers at the OCC -- Dr. Lauwer  stated that although the investigating pathologist disagreed with him, the OCC took out the DIC aspect of the coroner’s report.  The colon resection broke down.
I asked about a public inquest and he told me to submit it, --  at the time I didn’t know that he had do intention of granting it.  A public inquest has never been granted if it deals with a hospital death!

-- January 8, 2009 –sent in formal request for a public inquest which was later denied.

-- March 4, 2009 – letter from Dr. Lauwers’ denying my request for a public inquest.

-- March 13, 2009  -- letter from Chief Coroner, Andrew McCallum refusing my request to review Dr. Lauwers’ decision to hold a public inquest

--Monday, September 14, 2009 had my first review with HPARB with regard to College’s first decision.  HPARB decision I received in the spring of 2010 and it stated the College’s decision was “unreasonable.”
                        
--October 21, 2009  -- Dr. Lauwer’s letter denying my request for an Eastern Ontario Coroner’s Review which by the way only the Eastern Ontario Coroner has the authority to do so, not Dr. Lauwers.

--August 24/10 –sent my second complaint into the College dealing with what I had discovered within the hospital records.   Since HPARB sent the College’s first decision back sometime in the spring of 2010, the College said they would combine the two.

--Feb.  23, 2011 –submitted my complaint to the DIOC regarding Dr. Lauwers and Dr. McCallum

--July 29, 2011—College of Physicians and Surgeons render their second decision.
It should be noted that this took over 400 days since the HPARB sent back the original decision. 
Of course, I immediately appealed this second decision to HPARB

-- April 5, 2012 – letter from Chief Coroner Andrew McCallum denying my request for a Chief Coroner’ Review

--June 7, 2012  HPARB’s Second Decision

DECISION

       “Pursuant to section 35(1) of the Health Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act, 1991, the Board returns the decision to the Committee and requires it to further consider and clarify its decision concerning the use of preoperative antibiotics and the standard of practice.

--January 14, 2013—received the third decision by the College of Physicians and Surgeons.

--I, of course, have appealed this third decision and will attend my third HPARB meeting on Wednesday, June 5 at 1:00 pm, 2013.

--Early August 2013 received HPARB’s third decision.  The medical records completely contradict the CPSO’s third decision.    I immediately asked for a reconsideration of the decision.  This was denied.

--August 28, 2013 – DIOC sent their decision – do not deal with medical aspect of my complaint – two years after I first submitted it, and after both Dr. Lauwers and Dr. McCallum left the OCC

--November, 30, 2013 -- since the DIOC role had been expanded, I resubmitted my complaint

--Dec 12, 2014 –reply from DIOC with same result

--January 12, 2015 --  received second denial from Janice Vauthier with respect to my request for reconsideration

--April 5, 2016 – received reply back from OPP stating an investigation of Breach of Trust by Official was not an issue they deal with.   Immediately wrote to the RCMP and received reply to get in touch with the OIRPD

--August 2, 2016 – met with Ontario Ombudsman, P Dube with regard to my complaint vs HPARB.  Waste of Time as he supported the contradictory medical records to that of the CPSO’s decision!

--Early August, 2016-- Sent in package to Ontario Patient Ombudsman regarding HRH

--Early August, 2016 – sent my complaint vs the OPP to the Ontario Independent Police Review Director

--August 24th, 2016 --   reply to my e-mail request was no!  How's that for transparency?  Alan Shanoff a Toronto Sun columnist who had previously written two articles dealing with Terrra and the CPSO had requested of me to see if he could attend my meeting with the Patient Ombudsman as an observer.  This meeting may be held on September 22nd if my MPP Steve Clark is available to attend,  -- waiting to hear from him before I confirm.

--September 22, 2016 -- Met with Patient Ombudsman, Christine Elliott, MPP Steve Clark and investigator, Marie Claire Muamba.   Meeting went well.  Christine is not taking part as she is friends with Barb Collins, the CEO of Humber River Hospital.

--January 10, 2017 -- phone call with Patient Ombudsman, Marie Claire Muamba.  It went well but after I reflected on it, I became disappointed.  E-mail from Ms Muamba the next day:

Hi Arnold, 

As you would recall, during our conversation yesterday, I confirmed with you the issues in your complaint that are under review by the Patient Ombudsman and the issues that are outside our mandate, specifically the issues related to the professional decision of a regulated health professional, such as a surgeon  or a nurse. For these issues, an individual needs to go to the appropriate regulatory body.

Along these same lines and as discussed, the questions you propose in your previous email are related to dispensation of medication. This issue is not part of what our office is able to review.

I hope you understand. I am sending you a letter confirming the specific concerns in your complaint that our office is able to review. Thank you.

Since when does the Hospital not be held somewhat accountable for the actions of a surgeon who they have granted hospital privileges to???? --especially one who has numerous death associated with his operations!  

 

THERE IS NOT ONE SINGLE INSTITUTION CREATED AND THEN FUNDED BY TAX DOLLARS THAT TRULY REPRESENT A CITIZEN WHEN IT COMES TO MAKING OUR HEALTH CARE SYSTEM ACCOUNTABLE AND TRANSPARENT.   F***KING UNBELIEVABLE!

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

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 therefor 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.  --     especially considering the numerous deaths which occurred after my daughter's death and the one in Dec of 2012.  Who really knows the real total being concealed by all?

Why is it all the institutions/individuals mentioned above know the truth and yet Ontario citizens are kept from it?  

You can bet your ASS that none of the above would allow a member of their own family, relatives and friends to be operated on by this surgeon or even use this hospital!!   

Don't you deserve the same choice?   

Please contact your MPP and express your concerns -- express your concerns to all the MPP's, expecially the Liberals and NDP!






 blauwers@gmail.com; amccallum@gmail.com; pdube@ombudsman.on.ca; Barb Collins; christine.elliott@patientombudsman.ca; dirk huyer(regional coroner); dirk huyer(regional coroner);

Brandy and Terra Kilby