My son was killed due to negligence and incompetence at our local hospital while in the care of three doctors and one nurse. I have complained to the College of Physicians and Surgeons and to the Ontario Nurse’s College regarding the providers. I suspect that the regional coroner tried to cover up for the doctors , and I have since complained about him to the college and to the chief coroner of Ontario who is currently investigating my son’s case. I have also requested an inquest.
My son, Joshua, was admitted to our local hospital E.R. on June 5, 2012 after taking an overdose of his prescription medications. Joshua had been diagnosed as bi-polar by a psychiatrist at the hospital a few years before and was under his care for medication. I would like to say that one of the drugs he was prescribed was Abilfy which can cause suicidal tendencies. I had asked the doctor to put him on Zeldox which was recommended by my brother who also suffers from mental disorder but he did not. His life at this time was going in a good direction. He was a fabulous writer and had articles published in a local newspaper. He was starting a new job and there was no indication of suicide.
He contacted his father and I shortly after he attempted suicide at approximately 2:30 am. We took him to the local hospital and arrived by about 4:00 am. He was admitted at once and the emerge doctor contacted Poison control for recommendations. This doctor followed Poison control recommendations and for the next 24 hours my son seemed to improve. Apparently when you ingest this much medication your ammonia levels rise and valproic acid levels are high from the medications themselves. The providers were told by Poison control to start him on L-carnitine, which is used to lower the levels in the blood. They were doing blood work every 3 hours and had to send it elsewhere for testing. His levels for the whole day were very high. All day on June 5 he seemed very groggy.
On June 6 at 10:30 am his levels were normalizing. At 2:40 pm the psychiatrist tried to assess him but could not get him to follow direction or give a sensible response. He said he would come back later to assess Josh. His care had been turned over to a new doctor and this doctor had been assessing him all day on June 6. At 3:15pm, just 35 minutes after the psychiatrist could not get any sense out of my son, the new doctor “medically cleared” him. How could this be? At 3:35 pm, 20 minutes later, the nurse questioned his decision and showed him the most recent blood work results from 1:00 pm that day which showed Josh’s levels to be rising. He still medically cleared him and sent him off to the Mental Health ward. They did not contact Poison Control with this information.
Upon Arriving at the mental health ward, the psychiatrist prescribed Haldol even though Poison Control told them not to. Apparently he did not consult their recommendations. At approximately 6:00 pm Poison Control contacted the hospital since they had not been contacted since earlier that day. When they learned that my son’s levels had started to rise again, they became very concerned and advised them to have the antidote ready and monitor Josh closely. The psychiatrist contacted the doctor who had “medically cleared” Josh and his was response was as follows, “I stand by my decision, patient is medically clear.” At this point the psychiatrist brought in yet another Internist to assess Josh.
By 8:00 pm my son was deteriorating quickly. He was incoherent, confused, and tried to leave the hospital. The new doctor sent him over to the medical ward. After being transferred to this ward they restarted the L-carnitine antidote for his rising ammonia levels. He was still not stable and at 10:45 the Internist prescribed Haldol again. Consequently from 8:00 until about midnight my son was in a very bad mental state. During this time he had a code blue. At about 12:30 am the hospital finally called me. I could hear ungodly screaming in the background which I was told was my son. She told me they were admitting him to the ICU. My other son and I rushed up to the hospital and about 2:00 am the doctor finally came in to talk to us. I asked what had happened and all she told me was that Josh’s levels started rising and they did not know why. I had no idea about the rising levels earlier in the day or that they had given him Haldol in spite of being told not to by Poison Control. I was also told that it had taken 7 – 8 people to hold him down when they moved him to ICU and he had to be physically and chemically restrained to protect him. I have asked in my complaints why I was not contacted as soon as my son was unable to speak for himself since there is an informed consent to treatment act which states that if a patient is incapable of speaking for themselves than the next of kin (me) should be contacted. I live about 5 minutes away from the hospital and they waited over 4 hours before contacting me. This is in clear violation of the act.
From the time he was in the ICU he had a high fever, he was sweating, had a high heart rate (over 130 the whole time up until his death), and he developed pink sputum. These are all signs of DVT (blood clot) but nothing was done to check for this. They gave him Heparin which is only effective in preventing blood clots and is useless after the clot has developed. By chemically and physically restraining him for over 4 days they increased the risk of blood clot. He should have been given surgical stockings and physio as well as heparin but he was not. They never did one test for the clot. They assume giving him heparin would take care of this. Again I stress I believe he had already developed this by the time they gave him Heparin.
I also questioned the use of physical restraints after he had been chemically restrained as well. Josh looked like he was in a coma and could not even move a tiny muscle so why did they leave the physical restraints on. There is also a Minimum physical restraints act in Ontario. It states that only the doctor can order this and they have to monitor and keep records of this and remove them as soon as possible. There are no records on monitoring this. In one of the doctor’s responses to me, she states “I am not saying Ms. Patey is not telling the truth but I do not recall the physical restraints and there are no records of this.” She was not aware of the picture we have. I sent her a picture and had everyone who visited Josh and witnessed the restraints sign an affidavit. She now miraculously claims that records have been found that they missed giving her at first and yes, he was restrained a couple of times. She claims that this was to stop him from pulling out any tubes etc. How in the world can anyone who is so sedated and physically paralyzed pull anything out? This is a ridiculous statement by her. She knows she violated the restraints act and has lied and tried to cover this up.
During his intubation they had trouble getting his breathing stable. The nurse even asked me if he had asthma. This is also a sign of a blood clot but still no one questioned this. He was intubated, physically and chemically restrained from June 7 at 12:30 am until June 11 at 8:00 am. 4 ½ days lying perfectly still.
On June 11 at about 8:00 am they extubated him and woke him. At 10:00 am he had to go to the bathroom and they sat him in a commode next to the bed. He promptly started turning blue and did a face plant on the bed. A code blue was called just as I was arriving in the ICU. They got him stabilized and I was told this was probably due to dizziness from laying in the bed for more than 4 days. According to the coroner, this was likely a sign of the blood clot. However again neither of the doctors involved in the code blue could figure this out. Who is practicing at this hospital? A layman, like me, would attribute this to dizziness, but a trained doctor should have more sense than this.
I stayed with him most of the day and ordered TV for him since he was an LA Kings fan and the final game was on that night. Thank goodness he at least got to see his team win the cup. This was the only good thing that happened to him. During the day he had an oxygen mask on and he kept pulling it away from his face and sucking in. The nurse assumed he was trying to remove it and put the restraints back on for a while. I believe he was doing this because again he was having trouble breathing and he was trying to suck in more air. I had a good talk with him and told him all about the last 5 days and what had happened. He had no recollection of anything from June 6 until June 11. Many family members visited with him that day and he seemed to be doing well. We all thought we were now on the road to recovery. Josh was sincerely sorry for what he tried to do and was looking forward to receiving the counseling he needed. I left the hospital after the game and told him I would see him around noon the next day. That same day, June 11, the doctor started prescribing Haldol again but I was not aware of this until after he died. At about 3:30 am on June 12, he started hallucinating and pulled out his catheter. He was getting very paranoid now.
I called the hospital at 9:00 am and was told about the incident in the night, but not to worry as he could void on his own. They did not tell me about the paranoia. When I arrived at noon the first thing he said to me was “Mom, you have to get me out of this hospital. I will go to another one.” I asked why and he said, “they don’t want me here. I heard them say 'He doesn’t belong here.'" I said, “Oh Josh, they would never say that.” He was acting very paranoid and started to tell me the details of his hallucination. I did not believe my son at the time but now I realize they wanted the bed in ICU and were trying to decide which patient they would move to free up the bed.
I was concerned about the paranoia, which I am now convinced was caused by the Haldol. At the time, however, I thought it was from being without any medication for so long and that it had to do with his bipolar condition somehow. I went to the nurse, the doctor was there with her, and I asked that a psychiatrist be brought in to assess him. They called the psychiatrist who was on call and he came to see us. I found out after reading his report that he was clearly concerned about the paranoia and assumed Josh was still on a Form 1 at the time and said he would continue this. A Form 1 means that a nurse must be with Josh 24 hours to watch him closely. Apparently the other psychiatrist had discontinued the Form 1 earlier in the week and the doctor did not consult with the new psychiatrist about this. Thus my son had no nurse assigned to him.
Josh and I continued to watch some TV and at about 3:00 pm a cleaning lady came in and started cleaning the room. She told us that he was moving to the medical floor. I was surprised since this was the first I heard of this. Apparently they definitely were in a hurry to get the bed since they had the room cleaned before we left. How sanitary is this? especially since they had no idea if my son had c-diff or any other contagious disease. I asked the nurse if we were moving and she said yes. I was still concerned since Josh had diarrhea, stomach cramps, still a fever and high heart rate (130) and was very paranoid. She said they would put a portable heart monitor on him and keep the antibiotics IV with him. She plunked him in a wheelchair. I noticed his feet were not on the foot rests and helped him to put them up. His legs were very stiff and he could not lift his feet by himself. Apparently I am the only one who noticed this. Again I found out later that this is another symptom of DVT (blood clot). Nobody bothered to ask or check him. At this time they still did not know exactly what was causing the high heart rate or fever. They were so sure it was some kind of infection although they had no idea what it was. The doctor was so sure it was aspirated pneumonia but an x-ray earlier in the week showed his lungs were clear. Why did she not even check for something else. I thought when you ruled out one thing you would check for something else as the cause of the symptoms.
We arrived at the medical ward about 3:30 pm. The nurse came and helped him to the bathroom and said she was going to get him into bed. They put him in a semi-private room at the end of the hall. This room was probably the farthest away from the nurse’s station that you can get. Never mind his physical symptoms, what about the paranoia? They didn’t seem to be concerned about what might happen because of this.
I left to go and arrange a phone and TV transfer. When I came back ten minutes later, 3:40 pm, Josh was jumping around in the bed. I asked what was wrong and he said “I think I’m having an anxiety attack. I think I am going to die.” He could not breathe. I pushed the call button. At this time I noticed feces on him and got some paper towels and water and washed him. I tried to calm him down. After about 5 minutes I pushed the button again as no one had answered the call the first time. After another couple of minutes I went into the hall to see the nurse coming. She said they had contacted her from ICU because he had dislodged one of the leads from the heart monitor and his heart rate was climbing (160). I believe this is the only reason she came and not because I pushed the button. She was very snarky and seemed annoyed with Josh. We both tried to settle him down and after a few minutes he started turning blue. At this point she left the room. I ran after her and said, ”Where are you going, my son’s turning blue.” She replied, “I know I am going to get oxygen.” She came back a few minutes later and called another nurse to assist her. She put the mask on him. I was with him holding his hand and the last thing he said to me was, “Mom, don’t let me go.” After this I watched his eyes roll back and I heard him defecate. It was not until then, that the nurse pushed the code blue and everyone came running. I was pushed aside and taken to a quiet room. They worked on him for almost an hour but to no avail. I know in my heart he was gone before she even pushed the code. Protocol states that they are supposed to push the code as soon as a patient starts to change color but she wasted at least another 5-10 minutes before pushing the code.
I believe if I had not been present I would never have known the truth about what happened with Josh. I am sure they would have told me they did everything they could, and I probably would have believed them. Only after I got his records, did I realize the extent of the harm done to him.
They were truly incompetent with my son’s care. If they had kept in contact with Poison Control and did what they told them to, I am certain my son would still be here with us today. They caused him to end up in ICU by not treating his rising levels and prescribing him Haldol. This is why I cannot accept what happened. They killed him and he deserves justice. I pray that we will be granted an inquest. By medically clearing him too soon, prescribing Haldol when they were warned not to by Poison Control and miss diagnosing the DVT they clearly killed him.
Two of these doctors are supposed to specialize in internal medicine. Why was DVT not considered? These doctors should be criminally charged with negligence causing bodily harm and death. They have no idea what this has done to the surviving family and friends. When they took my son’s life, they took mine as well. Life will never be the same.