Learning from Judicial Inquests into Health Care Incidents

Today the recommendations of the Inquest into the death of Heather Brenan have been made public.
I take particular interest in this inquest as we were in the Emergency Room only a few days before Heather Brenan arrived at Seven Oaks General Hospital (SOGH).  We had front row seats to the circumstances that existed at SOGH during January of 2012.  A few weeks after our experience I wrote a letter to management at SOGH.  I received a very thoughtful and reasonable response from the Chief Medical Officer.  At the hospital's request, I consented to have my letter shared with the staff at SOGH.

Here is an except from that letter written in February of 2012.

Events of Jan 12-13, 2012

My wife was taken by ambulance to Seven Oaks General Hospital Emergency Room after she was in a car accident at about 5:30 PM, Jan 12.  The injuries she sustained were not life threatening and when she called me to let me know, she suspected she may have a broken foot.  She arrived at the ER at about 6:00 or shortly after.  I arrived at about 7:00 as I had to find child care for our two children and drive to Seven Oaks, as we live in the Lockport area.  During this time she was in extreme pain and probably had some symptoms of shock.  My wife (Susan) as previously mentioned has a Congenital Heart Condition, Hypertrophic Obstructive Cardiomyopathy (HOCM).  As part of the treatment for this she has an AICD.  This information was conveyed to emergency services personnel and to the triage nurse upon arrival at Seven Oaks.

Susan saw a physician assistant at approximately 8:30 PM.  I believe the attending physician was Dr Van Dyk although we never actually saw him/her.  X rays were taken and the diagnosis was one broken toe and one dislocated toe.  The dislocated toe was reset and the toes were taped and we were sent home with a prescription for pain medication.  We left the hospital approx 10:00 – 10:30PM.

The next morning, Jan 13^th, we received a phone call from the SOGH emergency room.  The caller stated that the Susan’s x-ray had been reviewed by a radiologist and that they wanted us back at the hospital for a CT scan and that Susan would likely be referred to an orthopaedic surgeon as the foot is broken.  We were told to come into the hospital and let the triage nurse know that Dr Abbott had requested her to come in and to let him know that she was there. We proceeded to the hospital and arrived at 11:00 AM.  We notified the triage nurse and explained why we were there.  We waited for nearly 3 ½ hours.  Once we were taken to a treatment room…we received an apology from Dr Abbott as there had been a communication error and that Susan was supposed to be brought right in and not have to wait for hours.  We were waiting so long that we nearly missed the CT scan as the staff were heading home for the day.  We did get the CT Scan, which confirmed a diagnosis of a lisfranc fracture , and after that there was significant amount of discussion about the best course of action.  We ended up leaving the hospital at about 9:00 PM.  In the end, Susan was referred to Dr Chris Graham at HSC, where she had surgery on her foot.  As I stated earlier, the outcome of our experience was a good outcome.

Concerns:

• I was very upset at the condition my wife was in when she was dropped off by emergency services at the emergency room.  She was placed into a wheelchair, and placed in a corner by herself, and ignored.  She was in so much pain that she was in tears when I arrived.  From what my wife told me she received first class treatment from the paramedics at the accident site, but when she arrived at the hospital it seemed she was forgotten about.
• On several occasions, we reminded the staff of Susan’s heart condition.  We got the reaction we usually get when we explain this condition…a blank stare.  I am convinced no one had any idea what we were talking about or had any clue what HOCM is.  For a patient such as Susan she should have been put on a monitor.  Not once did anyone inquire anything about the condition or acknowledge our concern.
• The fact that the fracture was missed in our first visit is a concern, but I view this as a medical issue that I am not qualified to comment on.  From my understanding, a Lisfranc fracture can be difficult to detect.  I was pleased that the error was caught the next day.  Obviously the procedure works; as the error was found upon review.  I would think that a typical incident report would be done when these types of issues come up.  I am confident this can be managed in house.
• The communication in the emergency room seems to have failed as the information about my wife coming back to the Emergency Room should have been conveyed to reception at Emergency and Dr Abbott notified that we were there.  We assumed this happened but it did not.  When you ask a question of Emergency Room staff you feel like you are imposing and monopolizing someone’s valuable time.  You are expected to patiently wait and not ask questions.  
• We were somewhat frustrated by our experience at Seven Oaks but in the end Susan had the surgery she required and Dr Abbott did a good job of advocating for us.  However, when Susan received her follow up at HSC, we conveyed some of our experience at Seven Oaks to the staff at HSC.  The quote from them was…”that is why they call it Seven Jokes.”  I did not really appreciate that comment.  This is an off-hand remark that really does not matter; but is this the perception that is out there?  As a leader in that facility…that would concern me.

Opportunities

• You have a dedicated and hard working staff; that is very capable.  The concerns I have stated above (if you investigate them) will likely determine a root cause of a failing of a policy or process.  People make mistakes and have errors in judgement.  It should never fall to one person alone to make a system or process work.  
• Own the Waiting Room!  The treatment process (in some form) should begin as soon as you walk in the doors of the hospital.  My feeling is that just about anything could happen in the waiting room and chances are no one would notice what was going on until it was too late.  Waiting and delays are part of the process, but people’s condition can change significantly in the hours they have to wait.  Those who are in the waiting room need to be monitored and checked occasionally.  Perhaps even talk to them.  The feeling we got was that until you actually make it into a treatment room you were not really in the hospital…you had not yet penetrated the “system.”  The way the Emergency Room is constructed you cannot see the vast majority of the waiting room from the triage desk.  Compare this to the Emergency Room at Children’s Hospital, where you can see the entire waiting room from the triage desk.  If anything happens in that waiting room…it can be seen.
• The general public does not know “hospital-speak.”  We, as patients, do not know how to access the system nor the terminology to do so.  Critical information can be misinterpreted and misunderstood.  For those of us who have spent extended periods of time in hospitals we have had to learn how to navigate the system, and it is challenging, even for those who know how the system works.  There needs to be a better way for communication to happen between patients and medical professionals.  I cannot emphasize how critical this is.  When we brought my son into emergency on Oct 2, 2008, if we had not chosen our words carefully and asked the right questions our son would have died in the waiting room.  It is because our cardiologist prepared us ahead of time, and educated us, that we were able to communicate effectively and ensure that our son was seen immediately as opposed to waiting.

My purpose in sharing this letter is this. When you consider all of the cost and time of a judicial inquest, is it not more effective to listen to patients and caregivers and learning from their feedback?  

Patients are capable of providing valuable feedback that can lead to meaningful change and do it far more quickly.  As a result of my feedback to SOGH I was asked to participate in an process review of the Emergency Department processes at SOGH.  I was able to provide candid feedback, and more importantly learn about many of the challenges faced by staff in city Emergency Rooms.  I gained a new respect for many who work in our hospital ERs but was very disheartened to learn of all the challenges and shortcomings of our health care system.

I think judicial inquests do provide valuable information and important recommendations.  My concern is that it seems like an immense amount of effort to get to information and improvement that should be readily available.  It is reasonable that with an effective incident investigation and input from all stakeholders (including patients) to improvements can be made in weeks; not the years it takes for the judicial process.  Changes need to be made quicker and more efficiently.

I was fortunate enough to be able to engage the hospital and provide feedback through my letter, and my continued relationship with the hospital.  However, I am curious what Heather Brenan would have shared with the hospital about her care at SOGH?  Unfortunately, even with a judicial inquest. that is something we will never know.