A Cautionary Tale

"If misleading information about gross medical error was provided by a hospital chief of staff, a caution -- even one delivered in person -- does not reasonably address the impact of such conduct on others involved in health-care delivery, and the erosion of public trust in the profession.
Lawyer Taivi Lobu, Health Professions Appeal and Review Board, dissenting board member

"It is disheartening to see that people responsible for the administration of a hospital were involved in misleading the family in this very sad case."
Barb MacFarlane, malpractice lawyer, Toronto

"We believe the changes ... will make our care safer in the future and improve our disclosure process when errors do occur."
Grand River Hospital, Kitchener, Ontario

Google Maps   An Ontario doctor has been censured by regulators for misleading family members about the role of "gross medication error" in a patient's death, an almost unprecedented case of alleged secrecy around medical error leading to disciplinary action. The physician, chief of staff for Grand River Hospital in Waterloo, Ont., had insisted that an excessive dose of the narcotic painkiller dilaudid played no role in the elderly man's death, a day after he was admitted to hospital.

An unidentified [in respect of privacy concerns] 85-year-old patient was admitted in June 2010 to Grand River Hospital in Kitchener, Ontario, with a suspected case of bowel obstruction. One to two milligrams of dilaudid to be administered by subcutaneous injection [hypodermic] into the epidermis every three hours was prescribed. Instead the correct drug was erroneously administered directly by IV, altering the drug's potency to the extent that it caused the man's death.

The man's condition became deleteriously impacted as his breathing became depressed; he contracted pneumonia and the following day he was dead. The hospital's chief of staff, Dr. Ashok Sharma, an emergency physician, along with other hospital officials informed the family that the error in administering the drug was irrelevant to their family member's death. The dose that assumed 'excessive' proportions when administered by IV, was merely incidental, they claimed.

The family thought otherwise, and expressed their doubt by handing material from the patient's charts to the coroner. And since this was the official conclusion of the hospital itself, the coroner initially simply accepted the hospital version. He changed his mind on contact by the family and reversed his findings on the death. His final statement affirmed that overdose of the opiate in fact was likely to have been the source of the death.

A subsequent appeal board hearing chided the hospital and rebuked the chief of staff, upholding an official caution from the College of Physicians and Surgeons. A dissenting board member felt the rebuke was inadequate to the situation, feeling the college should have given the case a more intense level of professional censure, resulting in an open disciplinary hearing, rather than the private caution.

Dr. Sharma himself is a member of the College of Physicians and Surgeons' discipline committee, and as such engages in overseeing hearings for other physicians whose professional conduct may come under scrutiny, as his has done. Studies estimate that up to 23,000 Canadians die on an annual basis as a result of preventable medical errors committed at acute-care hospitals. It would appear that a minuscule number of those cases are ever internally reported, much less publicly disclosed.

In this particular case, the family had appealed the college's response, inadequate to their way of thinking in response to the coroner's investigation resulting in a statement that death likely resulted from "narcotic overdose". The chief of staff was ordered to appear for a verbal caution which held that he should have been fully transparent in his interaction with the family and the significance of the "very large" dose of dilaudid administered to an elderly, dehydrated man whose reaction to powerful opioids killed him.

In response to the family's appeal, feeling that under the circumstances a rebuke was inadequate to the cause of their loss, the majority on the three-person appeal board supported the college's cautious response. But did state that had the College of Physicians and Surgeons taken more robust action to reflect the seriousness of the chief of staff's "evasive and vague" response to the family, it would have been fully justified.

If patients and their families cannot place their full trust in the professional veracity of a doctor whom their hospital has entrusted as chief of staff, who can they trust? Well in this case, a coroner whose own professionalism was quite evident, in assigning responsibility for an unfortunate death which was attributed where it rightfully belonged.