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Son David Scott: "All I know is that she should not have died that night. (DAVID GONZCOL/The Gazette)

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• Pointe-Claire

Woman's death in Lakeshore General ER raises questions

Patient, 80, hospitalized after fall in seniors' home

AARON DERFEL
The Gazette
Wednesday, June 18, 2008

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Son David Scott: "All I know is that she should not have died that night. (DAVID GONZCOL/The Gazette)

On the frigid morning of Feb. 19, Catherine Fox was wheeled
by stretcher into the emergency room of Lakeshore General Hospital.

She was fully conscious, but the 80-year-old great-grandmother had
taken a bad fall two days earlier in her bedroom in an extended-care
seniors residence in Kirkland. She had banged her face against a
dresser and required stitches for a cut near one eyebrow.

Despite the relatively minor nature of her injury, she spent four
days in the overcrowded ER, growing more agitated as she shared
space with a howling Alzheimer's patient.

She was given a sedative to help her fall asleep, but she never
regain consciousness and was pronounced dead on the morning of Feb.
22.

Nearly four months later, her family still hasn't been provided
with a clear explanation about how Fox ended up dying in an ER when
she was simply in need of some stitches.

Beyond the particular circumstances of her death, Fox's case raises
questions about patients who continue to languish for days in
Montreal-area ERs, and about the increasing use of nurses from
private agencies to fill shifts in short-staffed hospitals.

The complaints commissioner of the West Island Health and Social
Services Centre has investigated Fox's case, concluding that her
follow-up care in the ER was "not conducted properly." What's more,
a nurse hired by the Lakeshore from a private agency to fill an
overnight shift in the ER was not adequately trained, the
commissioner noted.

"My mother wasn't going to live another 10 years - there's no two
ways about it," said David Scott, Fox's son, who filed the complaint
with the hospital.

"She was not a healthy person. But all I know is that she should
not have died that night, and I don't think she would have died that
night had adequate care been given."

Fox, who suffered from COPD (chronic obstructive pulmonary
disease), had been a patient of the Lakeshore before. She had even
spent five-day stretches in its ER.

Still, despite the fact all her medical files were at the
Lakeshore, on Feb. 18, the morning she suffered her injury, she was
rushed by ambulance to Verdun Hospital's ER instead. Once doctors
realized all her files were at the Lakeshore, she was transferred to
the Pointe Claire hospital the next morning.

Fox's cut was closed at Verdun Hospital. Normally, after a cut is
stitched, a patient is sent home. But given that she was elderly,
had taken a fall and had COPD, doctors felt she should be kept in a
hospital for observation. So off she went to the Lakeshore.

According to hospital policy, Fox should have been admitted to a
quiet room in one of the hospital wards soon after her arrival in
the Lakeshore ER. The hospital didn't have any beds available, so
Fox was confined to the ER, deprived of privacy.

On the evening of Feb. 20, doctors gave Fox a partial dose of
Ativan, a sedative, to calm her and help her sleep, as she was
beginning to suffer from delirium. It was her third day in the ER
and fourth day away from home.

"Now, we warned the hospital at the time that they had to be very
careful what they gave her as far as sedatives go because she was a
COPD patient on a lot of medications and she was also very frail,"
Scott recounted.

Ativan, which relieves anxiety and encourages sleep, is known to
lower the breathing rate in patients with COPD. Careful attention
must be paid to such patients to ensure their respiratory rate stays
within the normal range of 12 to 16 breaths a minute.

What's more, it's advisable to take the patient's oxygen saturation
value in their finger, using a device called a pulse oximeter, to
measure how much oxygen the blood is carrying. A value below 90 per
cent is cause for concern.

In an ER, nurses are expected to check a patient's vital signs
every four hours. That includes the respiratory rate, although pulse
oximeters are not always available to verify the oxygen saturation
level.

In Fox's case, her son said, her respiratory rate and oxygen
saturation levels were not checked for 81/2 hours after she was
given the Ativan.

Sometime in the early morning of Feb. 21, Fox lost consciousness.
About 8:30 a.m., her oxygen saturation was taken and she was found
to be hypoxic - a condition of severely low oxygen concentration.

Fox never regained consciousness. She was pronounced dead about 24
hours later.

For Scott, a volunteer medical first-responder in Russell, Ont.,
something didn't add up. He was by his mother's side the last day of
her life. A couple of hours before her death, he asked to see her
medical chart. He sat down with a doctor, peered at the chart, and
discovered Fox's oxygen saturation was never checked overnight on
Feb. 21.

"I said, 'You guys dropped the ball, in my opinion,' " Scott
recounted.

Since no explanations were forthcoming, Scott filed a complaint
with the hospital ombudsperson, Diane Joly, two days later. He
received a response on May 7.

"The inquiry proved that on the night of Feb. 21, the follow-up of
your mother was not conducted properly," Joly wrote to Scott.

"We have identified the employee in question and measures were
taken so he does not work any more in the emergency room, without an
adequate training. (sic)

"We are sincerely sorry for your loss and thank you for taking the
time to write to us, as this is an opportunity for us to improve the
quality of care."

The response left Scott more baffled and angry than ever. The cause
of his mother's death was not given. Joly did not go into detail
about how or why his mother's follow-up was not conducted properly.
Joly didn't even mention whether the employee in question was a
doctor or a nurse, although The Gazette has confirmed it was a nurse
working for a private agency.

Scott said Joly's explanation is upsetting because it suggests one
person is to blame, but he believes the hospital itself and its ER
procedures are at fault. That's why he has filed a new complaint
with the provincial ombudsman, the Protecteur du citoyen.

"I don't think pinning the blame on one single person is the final
answer," Scott said.

"You're putting people's lives at the risk of one person having a
bad day, or one single person dropping the ball. I mean, you're
dealing with people's lives here."

Louis Pascale Cyr, the Lakeshore's spokesperson, said the hospital
intends to sit down with Scott soon to go over the case in more
detail.

But he denied the hospital was at fault.

"There was no medical error per se, although I understand how
someone could come to that conclusion by reading (Joly's) letter,"
Cyr said.

"To have a medical error there needs to be a fault, there needs to
be a consequence and there needs to be a link between these two," he
added. "And when that happens, we need to say it to the person, or
in this case, the family. There's a (provincial) law that says that
and it's pretty clear."

Asked whether Fox's vital signs were checked regularly in the early
morning of Feb. 21, Cyr replied:

"When we looked at the follow-up that was done, including the vital
signs, we thought everything was not done totally to the maximum of
what could have been done. That being said, enough was done that we
could come to the conclusion there was no link between that and the
passing away of the patient."

The Gazette asked Clifford Albert, an experienced ER physician who
works at Jean Talon Hospital, to comment on the case. Albert
responded that without knowing the cause of death or how much Ativan
was given, it would be hard to tell what, if anything, went wrong.

But he did say all ER patients should have their respiratory rate
checked every four hours, especially those with COPD.

More troubling for Albert, however, is the fact Fox languished in
two ERs for a total of five days.

"That's the main problem there," Albert said. "As a COPD patient,
she should have been admitted to a floor."

In this regard, the Lakeshore is like nearly every Montreal
hospital that is struggling with ER overcrowding.

Cyr said the Lakeshore is working hard to reduce the number of
patients staying more than 48 hours in its ER.

"Spending four days in the ER is certainly not something we believe
is optimal care," Cyr added.

Both Scott and his sister, Carole Tetley, said they're not
considering legal action against the Lakeshore. All they want is to
make sure their mother didn't die in vain.

"What I would like to see done is have more attention paid to
elderly patients," Tetley said.

"The older patient is sort of pushed to the back because they're
not a top priority. This needs to be looked at."