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Thestar.com
> News | | May. 22, 2001. 01:32 AM | | |
| | `Something wrong' in death of Sanchia | | Daughter's death at Sick Kids to be subject of inquest | Sonia Verma and Harold Levy
STAFF REPORTERS |  | | PETER POWER/TORONTO STAR | | Stephanie Clarke with daughters Elizabeth and Ashley. |
The toughest moment for Stephanie Clarke came when she realized there was nothing left to do but pray. It was around 9 p.m. last Sept. 14 at the Hospital for Sick Children. The soft-spoken born-again Christian, whose unswerving faith had helped her in the past, prayed fervently for her daughter's life. In a nearby room, an emergency medical team struggled to revive 17-year-old Sanchia, whose vital signs were failing. The bright-eyed Scarborough girl, who loved to read books and listen to gospel music, had been sick for most of her life. But no matter how ill she got, she had always pulled through. ``If Sanchia was supposed to die young, she would have died long ago,'' Clarke said. Her thoughts were interrupted by Dr. Peter Kim, who had performed a routine operation on Sanchia's gallbladder earlier that day. This time Sanchia hadn't made it. ``I could barely speak,'' Clarke recalls, ``but I looked at him straight in the eye and said, `Something went wrong here.' '' ``I know,'' she remembers Kim replying. Medical errors at hospitals are not unique. But what some observers are focusing on is not the number of mistakes made at the Hospital for Sick Children - not even those that have cost lives - but how the prestigious institution has dealt with them. Over the past 20 years, various coroners' inquests have probed six deaths at the world-renowned facility, as well as the death of a recently discharged patient. Collectively, the inquest juries have issued more than 100 recommendations intended to prevent the same mistakes from recurring. Several recommendations - calling for better communication between doctors and nurses, closer monitoring of patients, and better support and education for new nurses - have been made more than once. Nonetheless, the hospital says it's not that simple to compare the deaths of Sanchia Bulgin and any of the other children who have died there unexpectedly. ``When we take a look at each one of those (deaths), you'll see that there's differences in all of them,'' the hospital's chief executive officer, Michael Strofolino, said in an interview shortly before announcing he'd be leaving Sick Kids when his contract expires next year. But on Dec. 8, Ontario's chief coroner, Dr. James Young, ordered an inquest into Sanchia's death, in part because circumstances surrounding it so closely resembled those in the death of 10-year-old Lisa Shore. She died Oct. 22, 1998, in the same ward - Ward 5A/B, the unit that cares for general surgery and orthopedic patients. A comparison of recommendations from the Shore inquest and an internal hospital report on the Bulgin death shows that similar mistakes were made in both cases: a lack of monitoring by nurses, errors in medication and poor communication. The inquest is set to begin tomorrow. Among those expected to testify are Sanchia's doctors and nurses, whom the hospital would not make available for media interviews. Sanchia's family will be represented by Frank Gomberg, the Toronto lawyer who represented Sharon Shore at last year's inquest probing her daughter's death. ``It's frustrating to think a similar death occurred less than two years after Lisa Shore's death, to go through the entire process again, to address the same issues,'' Gomberg said in an interview. ``The whole purpose of a coroner's inquest is to find out what went wrong so it doesn't happen again.'' But the hospital insists those recommendations that emerged from the Shore inquest have been implemented. ``They were implemented, or in the process of being implemented, before Sanchia died,'' Dr. Alan Goldbloom, the hospital's chief operating officer, said in an interview earlier this year. ``If that's true, why is my daughter dead?'' asks Clarke. What happened to Sanchia Bulgin last fall is not in dispute. She was supposed to go into the hospital to have gallstones removed, stay overnight and return home the next morning. The hospital's internal review committee interviewed the seven doctors and 11 nurses who dealt with Sanchia. Its preliminary report states the teenager died of internal bleeding after a series of medical errors. It lists five main problems:
Inadequate nursing clinical judgment: ``Nurses did not obtain complete vital signs or recognize the seriousness of changes in the observed vital signs, and thus did not identify developing shock in this patient nor a need to request help from the surgical house staff.''
Poor communication among nurses: ``Nurses failed to pass on key clinical findings to new nurses assuming care of Sanchia. . . . Documentation of clinical nursing observations and interventions was incomplete.''
Poor communication among physicians and surgeons.
Failure of the hematology and anesthesia departments to properly evaluate Sanchia before the surgery.
Lack of recognition of the severity of her illness. Diagnosed when she was 18 months old with sickle-cell anemia, a genetic disorder in which abnormal red cells hamper the blood's capacity to carry oxygen, Sanchia had spent most of her life in and out of the hospital. Each time she experienced a sickle-cell crisis, an infection that can cause permanent organ damage, Clarke would rush her to Sick Kids. Sanchia knew the hospital's corridors and its staff, and many came to love the girl with the sparkling smile. For most of her life, her visits numbered five or six a year. Her medical records filled an entire cabinet. When Sanchia was 6, a sickle-cell crisis resulted in permanent brain damage that left her without the use of her legs and her ability to speak. Clarke quit her job as an inventory accounting clerk to stay home and care for her daughter full time. Today, the 43-year-old with two surviving daughters still credits the hospital for having saved Sanchia's life in the past. ``I trusted the nurses at the hospital. Any time I wasn't at the hospital, I knew the nurses could cope with Sanchia even though she couldn't talk. They knew Sanchia inside out,'' Clarke said. So when Sanchia needed routine surgery to remove gallstones, Clarke didn't hesitate about where to take her. ``They should have known the different complications. If there was something they could not understand, at least there was a file so they could go back to years earlier for the information,'' she said. ``They couldn't have missed anything on Sanchia with a file like that.'' The medical errors that ultimately led to the girl's death began before she was admitted for surgery. ``Sanchia had complex medical problems and should not have gone to the operating room without a recent detailed medical evaluation,'' the hospital's report states. No blood work was done before Sanchia arrived at the hospital at 7:30 in the morning. None of Sanchia's four physicians - the surgeon Kim, a blood specialist, the attending pediatrician and her family doctor - spoke to one another, the report says. The surgery went relatively smoothly, it adds, but after Sanchia came out of the operating room, she was given two small doses of morphine - medication to which she had a sensitivity, details of which were noted on her chart. For 45 minutes, while staff waited for a room on Ward 5A/B, Sanchia's vital signs weren't recorded in the recovery room as required, her medical records show. When she was moved downstairs to the fifth floor, nurses were supposed to record her vital signs on a flow sheet. Many of the entries are missing, but copies of the flow sheet show that those that were recorded - indicating high heart and respiration rates - should have been a warning that something was very wrong. Sanchia was hooked up to a corimetric monitor, which is designed to sound an alarm if vital signs are flagging. When the alarm went off, nurses believed the monitor was malfunctioning, the hospital's internal report says. When Kim, her surgeon, did his rounds at 6 p.m. that evening, he never examined Sanchia. He didn't even enter her room, according to Clarke, who was sitting at her daughter's bedside. At 8 p.m., the night nurse realized there was a problem. ``I asked the nurse if she was okay and that nurse was very agitated. The nurse said, `I don't think it's the monitor. I think something is wrong with your daughter,' '' Clarke recalled. ``That's the first sign the nurse said something was wrong.'' The night nurse called for help, but Sanchia went into cardiac arrest and died. Clarke received a written apology from the hospital the next week. In a press release Nov. 9, nearly two months after her daughter died, Sick Kids took full responsibility for Sanchia's death. The acknowledgment came in marked contrast to the hospital's actions in the Shore case two years earlier. Lisa was found dead in her bed on Oct. 22, 1998, less than 12 hours after arriving at the emergency department with leg pain caused by a non-life-threatening condition. An inquest jury was told Lisa's nurses failed to monitor her for the possible deadly effects of morphine. It returned a verdict of homicide, a neutral term meaning the killing of one person by another. That finding prompted an ongoing investigation by the Toronto police homicide squad. It wasn't until after the coroner's jury returned its verdict in the Shore inquest that the hospital shouldered the blame for the girl's death. Sick Kids officials say the hospital has learned from its mistakes. ``We weren't very good in the Lisa Shore case,'' Strofolino said. ``We didn't handle the post-mistake appropriately with communication to the parents. We didn't handle our dealings with the coroner appropriately.'' It's an admission that cuts to the heart of the hospital's new strategy of dealing with medical errors. In the United States, some 400,000 patients are the victims of negligent mistakes or misdiagnoses every year, according to a Harvard University study. Many of those cases involve relatively minor injuries, but 90,000 result in death. Canadian incidents of medical error have never been tracked in a parallel way. Roughly 5,000 patients are treated every year at the Hospital for Sick Children, and between 150 and 200 die each year in its care. The hospital says it does not keep track of deaths that are directly due to medical errors. ``If I was to sit here and say to you that I believe that every one of those 5,000 patients we're treating without an error, that would be foolhardy and ridiculous,'' Strofolino said. The hospital will reduce future medical errors by altering its systems instead of blaming individual doctors or nurses for the mistakes, he said. This approach falls somewhere on the line that divides health-care experts and consumer advocates on how to right medical wrongs. Health-care experts say the best way to reduce errors is to assume that mistakes will be made and design systems that will catch them before they happen. Some advocates argue that the medical profession doesn't do enough to hold doctors and nurses accountable for mistakes, and that blame should be meted out on those involved to teach others a lesson. The hospital has set its own targets under a new nursing administration. Janet Rush took over as the hospital's chief of nursing in November, replacing Jean Reeder, who now works as a nursing consultant in the U.S. Rush ordered an external review of the hospital's nursing program systems that was completed in March by two senior nursing experts. Ontario's College of Nurses is also reviewing the hospital's nursing practices. Rush is still waiting for the results of those reviews. ``If the standards are not up to snuff by my estimation and the external reviewer, I mean business. That's what I'm hired to do,'' Rush said in an interview shortly after assuming her duties. The Bulgin inquest will be a crucial test of the hospital's claim that it has learned its lesson. The jury will hear from about 30 witnesses over a six- to eight-week period. ``These will include doctors and nurses directly involved in Sanchia's care, as well as other experts who can shed light on the care and events that led up to Sanchia's death,'' said Jeff Mainland, a spokesperson for the coroner's office. Deputy Chief Coroner James Cairns, who presided over the Shore inquest, personally conducted the coroner's investigation into Sanchia's death and will testify. The Sickle Cell Association of Ontario will also participate through its legal counsel. At a recent hearing, the chief coroner dismissed an application by Sharon Shore, Lisa's mother, to participate in the Bulgin inquest, noting that ``some of the Shore inquest recommendations that appear relevant to the Sanchia Bulgin case will be reviewed.'' In addition to those recommendations, Frank Gomberg said, he will ask Young to examine recommendations from other inquests over the years to determine if they were heeded.
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