As Ottawa Plans to Increase Health Funding, Families Say System Doesn’t Learn from Mistakes | globalnews.ca


When Diane Breen died unexpectedly after her visit to the Nova Scotia emergency room, her family was left grieving, both by her loss and by the sense that no lessons were learned from the tragedy.

Kim and Jennifer DeWolfe say their 74-year-old mother spent eight hours waiting on February 28 last year at Aberdeen Hospital in New Glasgow, NS, before she was briefly seen by a doctor for a urinary tract infection.

His charts said that Breen, a runner with no health problems, told medical staff about a week of chills and cold sweats, but was discharged home anyway with a prescription for antibiotics.

Within hours, he died from sepsis, the body’s extreme reaction to infection.

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Her daughters requested a quality review of their care, but instead of learning what happened, they found themselves embroiled in an opaque process that experts say is typical of the frustrating experiences shared by families across Canada.

“What maybe could have saved my mom was a doctor who saw her on the admission, or a nurse who cleared a blood test, or a sepsis screening,” Jennifer DeWolfe, 49, said in a recent interview.

“I’m pretty sure the necessary steps will not be taken to change the way things work.”

Kimberley DeWolfe (from left to right), Jennifer DeWolfe, Mark DeWolfe and his mother, Diane Breen, are shown in a family photo. For Diane Breen’s daughters, the enduring tragedy of their mother’s death after an eight-hour wait in a Nova Scotia emergency room is not knowing what lessons they learned.

THE CANADIAN PRESS/HO-Jennifer DeWolfe

Earlier this week, the announced the federal government it would add $46 billion in new spending over ten years to the country’s health care systems. But families like the DeWolfes, along with some teachers and patient safety advocates, say Canada’s patchwork of quality review systems needs deep reform to ensure the money is well spent.

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Dr. Rob Robson, a primary care physician and patient safety advocate, said in a recent interview that “you’ll almost always find multiple factors coming together to cause a patient to get injured or die.”

A 2019 report from the Canadian Institute for Patient Safety said that patient deaths from preventable causes, ranging from long waiting times to misdiagnosis, are the third leading cause of death in Canada, after cancer and heart disease.

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However, Robson said that internal reviews generally exclude patients and their families, adding that they are too secretive and contribute to diminishing public confidence in the health system.

Robson said that in Nova Scotia, for example, the law allows authorities to prevent detailed information about patient deaths from being released to families. The opacity of the quality review process creates a “straitjacket where there is no sharing of what was discussed in the review committees,” she said.

Kim DeWolfe said that after two meetings with the committee to review the care her mother received, “we still didn’t know anything more about how my mother died that night.”

“This is nonsense,” Robson said. “Explain to me how it makes sense for us to spend time, effort, and money to find out what happened, why it happened, and how, and we’re not going to tell you.”

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DeWolfe’s frustration is shared by Cathy Pitre, who says her husband Luc Pitre, 53, could have been diagnosed faster for a stroke that left him partially blind and on a feeding tube at Campbellton, NB, hospital. .

She says her partner was “shaky” and had abnormal blood pressure and high blood sugar while waiting six hours in the hospital emergency room on January 4. Pitre received x-rays and was sent home with a request to return the next day for an examination. CT scan He came back on January 5th and the CT scan was done. However, Pitre said the diagnosis of her stroke only occurred on January 6, during an MRI.

The 49-year-old woman requested a quality review, but after five weeks she says neither she nor her husband were asked to participate in the process or told what was learned.

“We put our lives in the hands of these competent people and we have to trust them, but when something goes wrong, we are not allowed to know what happens,” he said.

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Vitalite Health Network of New Brunswick said it could not comment on Luc Pitre’s case. The network said it would “make any necessary improvements, if necessary,” adding that Cathy Pitre would be informed when “the review process is complete.”

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However, Carolyn Canfield, who teaches medical and nursing students about patient safety at UBC, said in a recent interview that by keeping families out of the quality review process, key facts can be left out, It hurts everyone involved.

“Healthcare professionals who don’t have the opportunity to learn from family and survivors… are deprived of their engagement with the patient, leading to burnout and isolation,” said the educator and advocate for 73 years, whose publication of husband -Surgical death occurred due to a series of breakdowns in basic care.


Click to play video: 'Nova Scotia introduces measures to improve emergency care'


Nova Scotia introduces measures to improve emergency care


He said that maintaining the status quo will hamper Canada’s progress towards health care reform.

“All of this poor care that exists in our system is a waste… It doesn’t deliver the results that make care valuable and erodes the quality of learning,” he said.

Canfield said that while hospitals fear families will use more information to pursue costly legal action, the evidence suggests just the opposite.

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He cited a University of Michigan study indicating that medical malpractice claims at its health centers between 1995 and 2007 dropped from seven claims per 100,000 patients to about 4.5 claims per 100,000 patients after its hospitals introduced methods to fully reveal to the families what had gone wrong.

The DeWolfe sisters said they would gladly waive their rights to sue in exchange for the truth.

Meanwhile, without accountability, money alone won’t solve crises, Jen DeWolfe said.

“My mother did not die for lack of doctors, in my opinion,” he said. “It’s because operationally, they’re not learning from mistakes.”

This report by The Canadian Press was first published on February 9, 2023.

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