what's new Site Search Hospital CEO CEOa CEOb Home Trust? MOH etc Latest Medical and Health NewsKPMG Consulting LP has been commissioned by the Ontario Ministry of Health and Long Term Care to conduct a review of the complaints and discipline process of the College of Physicians and Surgeons of Ontario. The review was commissioned in response to public expressions of concern and the Minister is seeking assurances that the College's processes have the accountability necessary to respond to the public's interests and respond to its concerns. This review will look at all phases of the complaints and discipline process from receipt of the complaint to the disposition/resolution of the case.
This was submitted February 2000
Please circle the most appropriate response to each question and print your comments clearly. Please try to make your written comments focused and brief. It will make it easier for us to analyze and compare your experiences with the other people who are providing input. However, if you do not have enough room to answer the question in the space provided, use the back of the paper or add more paper.
1. Briefly describe the nature of your complaint(s) to the College.
A. I was unable to obtain any explanation, while she was unattended after being pronounced dead, how my wife regained consciousness and required another 30 minutes "treatment" before she could successfully be pronounced dead a second time.
B. Why two autopsy reports were completed on the day of her death. One for distribution verifying the death certificate's cause of death and another using fictitious clinical evidence to justify why there was no evidence of the medical condition that was diagnosed as causing her death.
C. Why I was subjected to many statements, which I perceived, and still do, as lies by the involved "medical professionals". It is difficult to accept statements as true when they do not agree with my observations which are corroborated by the written hospital record and other factual evidence.
D. Many other significant points that I will not mention for the sake of brevity.
2. Please list the following dates: (day/month/year)
Date of your initial telephone or written complaint to the College 23 June 1986
Date of the final decision from the College 8 September 1989
a) Do you feel that the time it took to resolve your complaint was justifiable?
b) Did you receive information from the College that explained the steps in the complaints process and where to file appeals if you weren't satisfied with the decision of the College?
Yes, but for the appeal process only.
c) Do you feel that the steps of the complaint process were appropriate
d) If not, what could have been changed/improved?
The steps would have been adequate if the College demonstrated some respect for the legislation that gave them the great privilege of self regulation. The College's apparent lack of honesty, truthfulness and fair play made it evident that self regulation and self serving was a synonymous expression if used to describe them.
3. When a final decision was made, did you feel that the College adequately explained the reasons for that decision?
Please explain. Refer to survey question 1.
A. Question 15's answer a., b., c., d., e. provides a fair description of an inadequate reason.
B. There was absolutely no attempt to even acknowledge that this was a concern of mine. Based on its appearance, the only purpose of the autopsy was to ensure that my wife followed doctors orders that she was dead and to symbolically punish her for her initial non compliance by desecrating her body. I cannot see how there can be any medical benefit for an autopsy that presents dubious observations/findings and relates them to patently false clinical events.
C. An excerpt from the College's decision; "It is inevitable that when a number of health professionals are dealing with complicated problems that certain inconsistencies will arise in the recording of events, and these inconsistencies may give rise to concern on the part of family members. It is not the responsibility of the Committee to explain each of these inconsistencies to the satisfaction of the complainant"
I take it that using false clinical information in an autopsy report is acceptable, not lies, just an inconsistency.
A physician, wrote the College to indicate why it was difficult to make a good initial diagnosis; "She was admitted to *** on 7 February 1986 after presenting to the Emergency Department complaining of recurring chest pain. An electrocardiogram recorded during the presence of pain was normal however symptoms were relieved by sublingual nitroglycerin. ........... It remained clinically unclear at the time as to whether or not the pain was symptomatic of recurring cardiac ischemia." Even I, with limited medical knowledge, would agree that the doctors would have a problem with these "facts" . The difficulty that I have is that the emergency room doctor and my wife told me that she had not experienced any chest pain in the emergency department. The hospital record verifies that while she had a normal ECG while pain free no medications were administered. Obviously there was no pain that was relieved by nitroglycerine or ECG taken in the presence of pain. Is this an example of an acceptable inconsistency and not a blatant lie.
Two years prior, to this, I was prescribed nitroglycerine and cautioned that in the event that my chest pain occurred as a result of low blood pressure, nitroglycerine would not relieve the pain but could make the pain worse and possibly, but unlikely, result in death. This advise has been confirmed by other physicians, pharmacists and literature. On the morning of my wife's demise she was given nitroglycerine, by nurses, after stating she was dizzy and had chest pain. She suffered, almost immediately, a hypotensive seizure. My wife regained consciousness when the intern appeared and she stated that she had chest pain. The nurses record at this time that her blood pressure is too low to measure. The doctor administers another nitroclycerine which precipitates another hypotensive seizure and the events to her final demise. With no explanation the College finds no fault. They were aware that I had been prescribed nitroclycerine. I do not know whether it is a lie or an "inconsistency" on the part of the College. They obviously knew it would be an item that might cause me concern as it apparently led to my wife's death and if I followed their advice it could be lethal to me. I assume they obtained the result that they desired.
If part of the College's mandate is to protect the public then, especially when they recognize that an
"inconsistency" causes concern, they should provide an explanation without being asked . This is the first of a number of events that has led me to have concern that my life could be in jeopardy from the medical establishment. While most doctors are competent and ethical, how can one recognize the incompetent unethical before harm is done?
4. Overall, how would you rate the College's ability to communicate with you throughout the complaints and discipline process?
Extremely Poor ( I perceived that its capability of communication could be extremely good.)
5. Did you feel that your need for confidentiality was respected throughout the complaints process?
If not, please explain (i.e. how was it not respected?).
The College asked me to authorize them to obtain records that they were not legally or morally entitled. I offered to allow a neutral professional to examine the records and in the extremely unlikely event that there was some pertinent information I would authorize the disclosure, of pertinent excerpts, to the College. The College did not respond to my offer but made an unsuccessful attempt to request the records directly from the custodian. They knew full well that it would require the custodian to break the law if the College's request was granted. This along with the College cavalierly, unlawfully editing other medical records clearly illustrates the College's lack of respect for the law and confidentiality.
6. Did you feel that the College acted fairly to you and the physician during the complaints and discipline process (i.e. did you feel that each party had equal information and opportunity to participate)?
I was never convinced that the College was acting with any empathy towards my concerns. In a letter, to me from the College, they stated that "It appears that a personal interview would be of value ........"
After months of attempting to arrange for an interview at a time convenient for the College, I was informed that they would only deal with written submissions from me. This effectively hampered me from providing timely clarifications of my concerns that I thought would be covered in the interview.
I was continually pressed to provide fast responses while the "physicians" were allowed to provide their comments at their leisure, if and when they wanted to respond. It was obvious that no explanation was required by the "physicians" when their responses did not agree with the written record.
7. Did the College's complaint and discipline process address any systemic issues in the health care system that arose in this case (i.e. lack of latest equipment; shortage of staff; common, but out-of-date, medical procedures being utilized, etc.)?
a. I was informed, by a nurse, that my wife's IV was not consistently working because the hospital's IV stands were not high enough. This was not worthy of any response
b. After my wife suffered cardiac arrest, the hospital record indicates that the on duty intern wasted much time in a futile attempt to contact her cardiologist. The cardiology ward staff and the hospital switchboard were not aware of any changes to the duty roster. The cardiologist decided that he could go skiing without telling anyone. The College concluded that the scheduling was a hospital problem. The only evidence that I could see of this was that the hospital's doctor in charge of the cardiology floor was aware of the scheduling responsibility change and that this doctor neglected to tell anyone. The fact that my wife's cardiologist and the doctor in charge of the floor were one and the same person did not appear to have any significance.
c. The hospital staff, doctors and nurses, were apparently not aware that when communicating to someone with a hearing impairment that they might not successfully communicate with that person if they did not face them, even when the conversation is in close proximity; and also that verbal conversations, if the speaker(s) faced them, could be effectively understood at a distance and sound level below what would be required with a person with normal hearing.
A sample only, for brevity.
8. Did you feel that the complaints and discipline process was conducted ethically (i.e. moral, just, fair) and addressed any ethical issues that were part of your case?
If there is no apparent effort to provide justice, and many perceived efforts to thwart justice,
how can a process be perceived as just
9. Did you feel that the process for resolving the complaint reflected the responsibility of the College to protect the public's interest?
If not, why not?
If there is a real threat that will harm the public then action must be taken to correct the threat.
If the threat is not real, but only perceived as a threat, then reasonable explanations must be provided.
Anything less cannot be interpreted as protecting the public's interest.
10.Do you think that the complaints and discipline process reflects current public expectations and social values?
If not, why not?
While recognising that universal perfection is desirable, it is not attainable.
Current public expectations and social values require that there is at least an attempt to appear that there is some respect for them and the laws intended to protect them.
11.Do you feel that there is any need for changes in the legislation governing the College complaints and discipline process?
Legislation is required to establish a responsible, accountable, unbiased and just body to administer any regulatory process.
If an organization, administering a law, is not perceived as being accountable, just or respectful of the public it is intended to protect, then, no matter how good the legislative act in place might be, it cannot accomplish its purpose.
12 i) Did you take, or did you consult a lawyer about taking, a court action regarding the events which gave rise to the complaint?
ii) If so, did you consult the lawyer before approaching the College, during the period in which the College was dealing with your complaint, or after you received the decision of the College?
iii) Did you take a civil action seeking damages? If so, what was the outcome of this action?
When I was unable to get any reasonable response from the doctors or the hospital I consulted a local lawyer. He recommended that I use the complaints process with the College. After nearly nine months dealing with the College I did not see anything resembling concern from them. I panicked and obtained a lawyer to initiate a civil action that I eventually saw as unproductive of even obtaining answers. I reluctantly withdrew the civil action insisting that the hospital and doctors pay their own legal costs. After some theatrical reluctance, this was accepted by the hospital and doctors as long as I signed a waiver relinquishing all further claims on my part. This I refused to do on principal. It was agreed, with some reluctance (comedic reluctance) that I would drop the action and no legal costs would be attributed to me. This included my lawyer's fees and court costs as well. I am not aware if there were any court costs, but rightly or wrongly I believe there must have been some. Even though I was aware of the high compassion that is normally exhibited by the legal profession, especially the lawyers retained by the Medical Protection Association, it did nothing to convince me that I obtained anything resembling justice or that I would have if I had continued.
13. i) Did you appeal the decision of the College to the Health Professions Review Board?
No I appealed to the Health Disciplines Board.
If so, what was the outcome?
Unsatisfactory, the Board decided in favour of the College.
ii) If so, after you received the results of the appeal, did you appeal to a higher court?
No I persisted in insisting to the Board that they did not comply with the legislation governing them and the College.
If so, what was the outcome?
The Board, now acknowledging that the College had altered the hospital records in their possession in contravention of the Act, decided that their original decision was null and void as they found that they had no jurisdiction to hear my appeal until the College complied with the Act. ie "The Committee is required by Section 58 of the Act to either see or make every reasonable effort to see all documents and things that relate to the complaint." The Board further verbally admonished the College that a complainant might suspect that proper consideration had not been given to all the evidence, by the Committee, but that this could only be a suspicion if all the evidence was before the Committee as the Committee's deliberations would be in private. A similar admonition was incorporated in the Board's written decision.
When I resubmitted my complaint to the College there was now an even greater display of arrogance on the part of all concerned. There was no attempt to make the investigation even appear as sincere. Even though the College received my letter on October 5, 1988 the first letter on record to indicate that they attempted to contact one of the doctors was January 5, 1989. Sincerity, when the legislated time frame for handling complaints was 120 days?
One would think that after having been caught once deleting evidence from the record before the Committee they would now scrupulously, visually at least, comply with the Act's and the Board's directive. On looking at the record that was before the Committee it was evident that they withheld evidence that I provided them as well as an apparent symbolic withholding of a portion of the hospital record that I had provided to the Board and that the Board in turn provided the College along with their admonition to use all the evidence. I brought it to the attention of the Board and subsequent Ministers of Health this breach. There has been a reluctance to recognize my observation even verbally.
Was this to show:
a. The College is a law unto themselves;
b. They do not even have to give the appearance of compliance;
c. They can disregard laws and directives pertaining to them with impunity?
Obviously my complaint was rejected and College's decision was upheld by the Health Disciplines Board. Only a naive idiot would attempt to take it to a higher court after this display of confident arrogance.
14. Would you recommend any other changes to the complaints and discipline process?
Anything that would make the Health Professions accountable and would protect the public.
15. Is there anything else about your case, that you wish to share, that wasn't covered in the questions above?
The closest explanation for my wife being declared dead twice is as follows:
a. Following two hypotensive seizures she was, by IV, given a mixture of epinephrine and isuprel.
A further drop in blood pressure and cardiac arrhythmia occurred until she was pronounced dead and the IV was turned off and she was abandoned. When she was accidentally observed regaining consciousness and attempting to get off the gurney she was restrained and she now was exhibiting normal sinus rhythm and increasing blood pressure. The IV mixture was restarted and she was again faced with a lowering of blood pressure and cardiac arrhythmia. This progressed to the point when she was declared dead the second time. The doctor, who again pronounced her dead the second time, was at my last Board appeal. He stated that epinephrine and isuprel were powerful medications and that he did not turn off the IV immediately, the second time he declared her dead, as he had the first time he declared her dead.
b. At the 3rd Board hearing, the doctor representing the College stated that she was given "appropriate pharmacologic resuscitation". Appropriate for what, he did not elaborate on.
c. The College's comments on the pathologists and the autopsy observed that a very possible cause of death was cardiac arrhythmia.
d. Apparently knowing that I would again obtain the record that was before the College's Complaints Committee they saw fit to include a photo copy of a monograph relating to epinephrine. As this did not appear to be a normal procedure, I assume that it was put there in case I was confused by the meaning of the above "appropriate pharmacologic resuscitation" comment. This monograph clearly stated that a previous medication that she had been given could lower blood pressure and that epinephrine should not be used as its action would be reversed and cause a further drop in blood pressure to the point of possible cardiac arrest. When a copy of the monograph for isuprel was studied, there was a bold notation that the simultaneous administration of epinephrine and isuprel was contraindicated as serious cardiac arrhythmia would result.
e. As my wife reacted, apparently exactly, as should have been expected to the "powerful medication" and "appropriate pharmacologic resuscitation" I no longer feel that the statements have any ambiguity. A lack of clarification does not increase my confidence in the protection from harm provided by the College.
f. Following this I have had a number of troubling personal encounters. Following labour day, five years ago, my GP instructed me to go to the hospital where my wife's life was terminated. Without immediate medical intervention I would be dead before the end of the week and it would not be a pretty death. Instead of going to the hospital I made what appeared to me a more logical move. I went and made funeral arrangements. Was this the cause of my miraculous cure? I wrote the hospital, months later, that I did not go to their facility as I thought a slight chance of maintaining life by avoiding them was better than a perceived zero chance of survival with them. Their response was no indication that they would have my best interests in mind. No suggestion that I apparently misinterpreted their previous reassurances. The answer was short and sweet, that their earlier response to my concerns was appropriate. I agree that if it was their intention that they wanted me to believe that I would not survive their care, then it was appropriate. There has been no explanation for the misdiagnosis. Similar other incidents make me wonder. It would be unreasonable to think that this would be a terror tactic to put me in the hospital for "appropriate" treatment?
16. Is there anything else that you think we should know before writing our report on the complaints and discipline process?
There is much more, I believe I have given sufficient to illustrate my concern.
I have attached some letters to put my survey response in context and to show
that the problem is still current.
Thank you for completing the survey. Our report will be submitted to the Ministry of Health.
It is their decision whether or not to make the report public and when.
Hospital CEO CEOa CEOb Home Trust? MOH etc