Hopefully, the Liberals will be OUT! They have ignored my daughters death through medical negligence for almost 8 years now. Should you feel the urge to support me, please contact Chief Coroner Dr. Dirk Huyer. I will be meeting with him this June 26 re: the death of my daughter almost eight years ago due to medical negligence and the cover-up by the Chief Coroners Office. Please urge him to bring forth the truth!!!! [email protected] *************************************************** This is my opening and closing statement when I meet with Dr. Huyer Dr. Huyer and all those present; It is clearly evident to those who do not possess a pre-biased opinion and if they can merely look at the hospital facts surrounding the death investigation completed by the Chief Coroner’s Office of Ontario; they would conclude all decisions made by past Deputy Chief Coroner of Death Investigations, Dr. Bert Lauwers and Chief Coroner, Dr. Andrew McCallum were erroneous and extremely acute misjudgments. I maintain that while conducting the investigation into my daughter’s death they purposely ignored, overlooked, and concealed factors related to my daughter’s death. Answering the mandated investigation questions is not their only important role to the citizens of Ontario. They failed to: Conduct a death investigation in a manner that is effective and accountable. Conduct a high quality death investigation to ensure that no death will be overlooked, concealed or ignored. (Done so by basing all of their decisions upon a medical expert consultant whose report omitted numerous crucial factors) To help improve public (patient) safety and prevent deaths in similar circumstances by denying my request for my daughter’s death to go before the Patient Safety Death Committee and denying my daughter’s death be looked into by the Eastern Ontario Coroner through a review. As well, the Chief Coroner refused to assemble a team to conduct a Chief Coroner’s Review of Dr. Lauwers’ death investigation and, of course, my original request for a public inquest and MPP Bob Runciman, now Canadian Senator, request supporting a public inquest. Make sure the concerns and needs of grieving families are met as this office has refused repeatedly to answer specific questions and concerns I have relayed to them. They have also refused to communicate with me via telephone, faxes, e-mails. Also, refusing requests from the Ombudsman and an OPP detective to meet with me and answer my concerns and questions. They failed by: Overlooking, concealing and ignoring crucial factors related to my daughter’s care or lack of care which in turn did factor into her death Considering the numerous patients deaths under Dr. Laz Klein’s care after the death of Terra Dawn Kilby in July of 2006, the secretive, temporary closure of the HRRH bariatric surgery department in 2010, and continued deaths, (the death of Crystal Rose in December of 2012), the non-responsive manner exhibited by Dr. Lauwers and Dr. McCallum, and their intimidation attempts to silence me; their interference in the investigation by one of my experts at London Bridge Hospital in England; this all speaks that the Chief Coroner’s Office of Ontario did not “Speak for the Dead To Protect the Living”and actually abused the authority given to them by the people of Ontario! They spoke first to protect the surgeon/hospital and then to protect themselves. If we are being completely honest; we all know there is no way a Canadian surgeon, let alone an Ontario surgeon, would dare speak against a fellow member of the College of Physicians and Surgeons. This is the case with regard to Dr. McCallum and Dr. Lauwers’ investigation into my daughter’s death as they too are members of the College! So, I went outside of Canada to Surgeons around the world for their expert opinion based upon the medical facts contained within Terra’s hospital records. I have over one hundred qualified surgeons who state that administering antibiotic prophylaxis is a Standard of Care prior to open abdominal surgery to remove a tumor and perform a colon resection. (Actually, all open surgeries required this) The following are merely a few excerpts from responses dealing with other issues. “The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op; the etiology of that distention needs to be sought prior to discharge.” Maurice Lyons, MD FACS “Obviously she had a wound infection. John Reza Mehran, MD FACS “It sounds like your daughter did not receive the appropriate standard of care. . It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected.” Allan Stewart MD FACS …. There must have been some kind of contamination either during or after surgery most likely coming from the bowel itself based on the gram negatives you describe.” God Bless. Cristy Smith MD FACS “Anti-biotic prophylaxis should be given at time of surgery according to practice guideline in US and in China as well while performing trans abdominal colon resection based on evidence-based colorectal surgery, I think. In my opinion, your daughter died from postoperative infection or sepsis.” Regards Wan-Jin Shao Chief Consultant, Colorectal Surgeon, Clinical Professor Department of Colorectal Surgery Nanjing University of Chinese Medicine Hospital. American Society of Colorectal Surgeons(ASCRS )member …“What troubles me from the material you sent is the experts/ coroners opinions as to the cause of death. … If she died of intra peritoneal bleeding, that could have come from either a disrupted anastomosis or from larger blood vessels ligated during the resection of the mesenteric cyst and her right colon. If indeed her abdomen was distending, and her pulse rate rising over an observable period of time, then the really important issue was why was she not rushed back into the operating room when it was clear that an intra-abdominal catastrophe was occurring? … Anastomotic disruption following a RIGHT colon resection is quite rare actually, and the range stated in the experts report probably reflects the overall leakage rate from ALL colon anastomoses. Such leakage/disruption is much more common in lower (or distal) anastomoses, closer to the rectum. If her anastomosis did disrupt, as alluded to, then it is usually a TECHNICAL ERROR on the part of the operating surgeon, especially because of the young age and apparently excellent former health of the patient. If there is sufficient proof of the above, then an investigation of the surgeons performance both in this case and others might lead to systemic issues which deserve correction. The main thrust of such investigations should be prevention of similar outcomes, with a willingness to confront all the causative factors, including surgeons performances.” … It is inconceivable to me that the autopsy report would not contain more detail than what you have given me regarding the status of her ileal-to-colonic anastomosis, since that would be the area that would demonstrate what (if any) disruption of the bowel occurred. Since there was no rectal bleeding prior to discharge, what bleeding she was having would have been intra-abdominal, and if those counts were falling in the hours prior to discharge, that also should have sent up red flags of warning to anyone who was paying attention. Yours sincerely, Mark Helbraun, MD, FASCRS Member of the 2010-2011 International Council of Coloproctology 35 years experience Academic Colon & Rectal Spec. Holy Name Hospital, Teaneck, NJ Hackensack University Medical Center, Hackensack “I think there are a lot of problems with this case and you have a strong case to proceed. … Your daughter needed pre-op antibiotics, post-op antibiotics, and antibiotics when a wound infection occurred. I think that she needed to have a bowel movement prior to discharge. …Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual. I see negligence in this case” Thanks Ron Hill, MD, FACS 8. Based only on the information you have provided I find it difficult to justify what appears to be a whitewash of the patients cause of death. The points you have raised are--in my opinion--legitimate reasons to question the validity of classifying her death as natural and would support your complaint of inadequate investigation. She unmistakably died of surgical complications that were arguably survivable with less flawed management. Benson B.Roe, MD,FACS, Professor Emeritus. Department of Surgery, University of California at San Francisco Medical Center I recognize that there were serious complications, and probably unnecessary complications, with your daughter’s care. From what I have read I believe that the standard of care was not met which caused your daughters demise. … this case which appears to be, or at least border on malpractice. Steven J. Phillips, MD FACS As I review the file that you attached, there are several concerns that come to mind. …I think most surgeons would proceed with a mechanical bowel prep prior to an operation where possible right hemicolectomy was possible. However, there is very good evidence that mandates that patients receive broad spectrum IV antibiotics prior to having colon surgery, especially if they havent received a bowel prep. If this wasnt done, this is not in line with the standard of care in the US. Also, I have concerns that the nurses documented for Terras abdominal exam that her abdomen was large for the last several days of her stay in the hospital. More importantly, they document for a number of days prior to her discharge that there was a foul smelling odor and that the wound was oozing copious amount of purulent discharge during this entire time,as well, is very concerning. This doesnt happen with a superficial wound infection. These things happen when there is an anastomotic breakdown and leakage through the wound and possibly into the peritoneal cavity. David A Lanning, MD, PhD FACS Surgeon-in-Chief, Childrens Hospital of Richmond Virginia Commonwealth University Medical Center PO Box 980015 There are several items here that in combination raise concern a. I am concerned about the description of the abdominal examination progressing from rounded to large”… that should raise concerns that might require imaging of the abdomen but certainly resolution prior to discharge. b. The nutritional aspect is contributory … supplemental nutrition should reasonably have been considered. c. Such a bleeding complication after such surgery is certainly a possibility but should be exceedingly rare. If, as you suggest, your daughters complications were part of a series of such problems then, indeed, a system or operator issue is suggested which satisfies the stated requirement for a complete investigation. Matthew M. Cooper, MD FACS ******************************************************************* There are really two issues that must be addressed: The totally inept death investigation by the Chief Coroner’s Office of Terra Dawn Kilby! and how to prevent this office from abusing the authority it has been given by the people of Ontario? --this must be exposed publicly to ensure that it will not occur again! We, the people of Ontario need to be reassured that this Office should remain operating as is “To Speak For the Dead to Protect the Living”. ************************************************************************************** Should this not occur within this Office, Legislation must be enacted in one of the following two ways: All personnel employed by the Chief Coroner’s Office MUST not have any affiliation whatsoever with the any College of Physicians and Surgeons, nor any Ontario Hospital nor any Ontario University Faculty of Medicine. Should this fail; Legislation must be passed to employ in the executive positions only those who comply with the above even if it means these people come from outside of Ontario and outside of Canada. This is to ensure true transparency and accountability through the Office of the Chief Coroner for the present and future citizens of Ontario. ************************************************************************************** With all due respect: As the present Chief Coroner of Ontario, you, Dr. Huyer have the opportunity to make Darcy McGee’s statement and this office’s Motto relevant once more. That is; if you choose to represent the people of Ontario, not the College of Physicians and Surgeons of Ontario, even should it mean discrediting those who came before you. To allow this faulty death investigation to remain as is, merely adds your name to those from this Office who have chosen to participate in this cover- up. The death investigation must be set straight by clearly indicating the many omissions and relevant facts that were purposely overlooked which should have been investigated during the initial investigation. HOW TO ACHIEVE THIS: 7 years late, but a Public Inquest be granted. Secondly, initiate a Chief Coroner’s review of Dr. Lauwer’s death investigation. To make it quite clear the two named parties involved did not conduct a thorough death investigation due to their fraudulent actions. Of course, this Office wouldn’t dare do this! ************************************************************************************** Arnold Kilby Terra Dawn Kilby An Angel In Our Lives April 22/78 to July 21/06 anangelinourlives-awk.blogspot.ca/
Posted on: Thu, 12 Jun 2014 21:27:26 +0000