Arnold Kilby 0

Justice For Terra Dawn Kilby

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My daughter bled to death 12 hours after being released from hospital. She underwent open abdominal surgery to remove a benign tumor and had a colon resection. This was done without the mandatory antibiotic prophylaxis plus numerous other issues that have been ignored. I have over 100 surgeons from outside of Canada (no one within will comment) specifying that the Standards of Care were not met and that there was indeed pre and post operative neglect.
Dear Mr. Kilby: Of course I will be happy to review your materials and give you an opinion. It is always disappointing to hear that other surgeons are not willing to take the time to offer opinions regarding cases that may have been mismanaged. ....... I would believe it to be a grave mistake to have NOT prepared a patient's bowel if there was any chance the bowel would need to be entered during the surgery. ......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?

Dear Mr Kilby......I think there are a lot of problems with this case and you have a strong case to proceed.....Bleeding from a stapled anastomosis that leads to hemorrhage shock and death seems a little unusual.  I see negligence in this case.

Dear Mr Kilby......I find it difficult to justify what appears to be a "whitewash" of the patient's 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.

Dear Mr Kilby....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.

Dear Mr Kilby....I have concerns that the nurses documented for Terra's 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 doesn't 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.

Mr Kilby....I am concerned about the description of the abdominal examination progressing from "rounded" to "large" The nutritional aspect is contributory ......supplemental nutrition should reasonably have been considered.

The Chief Coroners Office of Ontario has to be shown by the DIOC, Minster of Corrections and Community Safety, Ms Meilleur that this Office must ensure that they deal with issues brought forth to them in the matter of a death related to care at a hospital so that they can act to prevent future deaths under similar conditions. The were made fully away in 2007. Then low and behold three years later they shut down the medical department and team and brought in an outside expert! At least 5, maybe more deaths, may have been prevented if this Office seriously looked at my concerns that I brought forth to them three years prior to 2010!

The Chief Coroners Office of Ontario failed to:

1. Conduct a death investigation in a manner that is effective and accountable

2.  Conduct a high quality death investigation to ensure that no death will be overlooked, concealed or ignored. (By basing all of their decisions on a medical expert consultant whose report omitted numerous crucial factors)

3. To help improve public safety and prevent deaths in similar circumstances (there were 6 more deaths by the same department of this hospital during 2009 and up to Feb. 2010)  These death may have been prevented if my daughter's death was thoroughly investigated. But this office has refused a public inquest, refused my daughter's death go before the Patient Safety Death Panel, refused my request for an Eastern Ontario Coroner's Review and refused my request for a Chief Coroner's Review.

4.  Making sure their concerns and needs of grieving families are met as this office has refused repeatedly to answer specific questions and concerns I have had and relayed to them.  They have also refused to communicate with me telephone, faxes, e-mails and refused requests by the Ontario Ombudsman's Office to answer my questions.

They failed by:
5. Overlooking, concealing and ignoring crucial factors related to my daughter's care or lack of care which in turn did factor into her death

Too many unanswered questions? 
How about the enlarged abdomen at time of release?                                        

â      How about the foul, purulent oozing incision at time of release?  
â      How about the fact she had no colon cleansing prior to operation? 
â      How about the fact that she did not have the anti-biotic prophylaxis given at the time   of induction? 
â      How about the fact she received no anti-biotics what so ever at any time? 
â      How about the fact the she remained on a liquid diet for 8 days consisting of jello, juice, tea and  without any nutritional supplement? 
â      How can a wound heal without proper nutrition?
â      How about the fact her resting pulse rate was over 90
â      How about the fact that she was only receiving 687 calories per day for 8 days? 
â      How about the many gram negative bacilli seen? And not treated.
â      How about the low Absolute Lymphocyte (type of white cells)?  
â      How about the many PMN’s (polymorphonuclear Neutrophils) –This a hallmark of acute inflammatory process
â  How about the low hemacrit counts, low red blood cell counts and low haemaglobin counts?

The Ontario College of Physicians and Surgeons is not being truthful, not being accountable and have not treated myself, Terra's family, relatives and friends fairly.  They have placed the surgeon's reputation first, with very little regard to my daughter's death and thus they have failed all the citizens of Ontario.  Their right to self-regulate needs to be reviewed by the Ontario Government.

The hospital without admitting guilt, offered to create a Memorial Garden in my daughter's name. I think this shows that all of my concerns were genuine! Why else would they do it???

For full story see my blog: No Accountability or Transparency in Ontario
The hospital, the College of Physicians and Surgeons, the Chief Coroner's Office of Ontario, and the Provincial Liberal Party have all failed the citizens of Ontario. Patient Safety comes well behind their own selfish welfare and ambitions.

Please sign this petition and send an e-mail outlining your displeasure in the cover-up of my daughter's death to:
Politicians: Andrea Horwath
Tim Hudak
Dalton McGuinty
Deb Matthews Minister who oversees hospitals and the College of Phys & Surg
M. Meilleur Minister who oversees the Chief Coroner's Office of Ontario

I have found that Ontario’s Health Institutions which include the hospital, local coroner, Chief Coroner’s Office of Ontario, the Ontario College of Physicians and Surgeons will avoid, at all cost, to bring forth the truth when a death occurs which may question the care given by a member of the Medical Profession.  I strongly suggest to any patient and family members to question and research the medical conditions, treatments and test results.  Please do not merely accept the findings or comments made by any member of the medical profession with regard to an adverse event, including a death.  Be sure to obtain hospital records and thoroughly investigate the material provided within.  It takes a great deal of time, but only you can find the answers to the many questions you may have. 

Unfortunately, you are alone and cannot count on the Provincial Government to assist you.  I followed all the predetermined procedures that one would take, but found it to be time consuming and very discouraging.  At every step, you find questionable compassion toward your situation and deceitful action on the part of every player involved.  In Ontario, there are no institutions that really protect the rights of a patient.  However, the Health Professions Appeal and Review Board did find in my favour with my first appeal and I am sure that they will do so again with my second appeal of the College's inept decision.  The current Liberal government, at the time, is guilty of turning a blind eye to obvious imperfections in the accountability of these health care institutions. 

I only wanted to correct a situation within a specific hospital to ensure that a death such as my daughter’s would never occur again.  I mistakenly believed that the very institutions within Ontario, which are supposed to protect the public, would do their job. 

            But I was wrong!



Arnold Wayne Kilby

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