October 12, 2012

To whom it may concern:My son, Joshua, was admitted to Cambridge Memorial Hospital emergency on June 5, 2012 after taking an overdose of his prescription medications.  Joshua had been diagnosed as being 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 as well as just starting to work for the Velvet Rope Society.  There was no indication of suicide. 

He was hospitalized from June 5, 2012 until his death on June 12, 2012. His father took him to the emergency department at 4:00 am.  The hospital contacted poison control and was told to give him charcoal medication.  He was kept in emergency under a form 1 until June 6, 2012 when he was medically cleared by emerg dr. and sent to the mental health unit at the hospital.  I had been told the day before that they would send him to ICU but unfortunately he got bumped before this could happen.  Just before midnight on June 6. 2012 I received a call from the nurse to tell me “Joshua has gone bad”.  When I asked for an explanation, she said “do you hear the screaming in the background?  That’s Joshua.”  It was ungodly.  She told me they were rushing him to ICU.  I arrived at the hospital and after waiting to see the doctor for approximately 1/2 hour, she finally arrived.  I was told his ammonia levels had spiked earlier and his tongue went back.  While they were trying to attend to him he became violent and it took 7 – 8 people to restrain him.  They decided to keep him under full restraint and sedate him in ICU until they could stabilize him.  I spent every waking moment I could with him even though he was sedated.  My sister, who is a kinesiologist and works with cardiac patients, came to visit and questioned the nurses about his high heart rate, fever and trouble breathing.   They could not say what caused it except that there was an infection somewhere in his body.  I was never told what it was and they did not seem to be concerned.  On June 10, 2012 they told me they were going to bring him out of sedation the next morning.  I called the ICU at about 9:00 am and was told by his nurse that he was awake, a little angry and had been given a Popsicle.  I arrived at the door to ICU at 10:00 am only to hear over the speaker “code blue-ICU- room 5”.

They swept me away and everyone came running.  Within 10 minutes they had him stabilized again.  I was told what had happened. Apparently he wanted to use the commode.  The nurse helped him on to it.  At this point his colour changed and he did a face plant on to the bed in front of him.  At this point the code blue was called.  I stayed with him all day except for coffee.  He was very disoriented and puzzled as to why he was there.  Early in the afternoon he seemed to be getting more lucid and told me he had made a mistake and was very sorry.  He also indicated that he was looking forward to getting help with his bipolar problem.   At this time, I arranged for a TV to watch the hockey game, since the la kings were his favourite team.  I left at approximately 4:00 pm to go home for dinner and told him I would return at 8:00 pm to watch the game with him.  Between 4:00 pm and 7:00 pm he had visits from his step brother, father and step mother and seemed to be in good spirits.  I returned at 8:00.  My sister and her husband came to visit and then my other brother – in – law came to watch some of the game with us.  My son also told him how sorry he was.  I stayed until 11:30 pm and went home.  I was very happy and assumed we were on the road to recovery with josh.  I should mention that his heart rate was still high all day over 120 bpm.  The next morning I phoned ICU and was told he had a hallucination during the night and pulled out his catheter but not to worry as it was ok and he could void in a bucket.  I went to work since I had not been there much in the last week.  I returned to the hospital ICU at 12:00 pm.  My son seemed very agitated.  The first thing he said to me was that he wanted me to move him to another hospital.  I asked him why and he told me he overheard someone say “he doesn’t need or belong here”.  I thought he was imagining it of course and told him so.  Although now I believe he may have been telling the truth.  He seemed very paranoid and I went to talk to the doctor.  I also told the nurse that he wanted to use the commode again.  She said she would call someone from physiotherapy because they were concerned about him having another episode like the day before.  In the meantime I asked the doctor to send a psychiatrist and she said she would.  A psychiatrist came in and talked with both of us together and then Joshua alone for a while.  After he left I asked the nurse again to help josh to the bathroom since he had cramps.  She called the physiotherapist and they came and helped him. Shortly after a cleaning lady came in and started cleaning the room and she said they were moving him.  I asked the nurse and she said that they were moving my son to the medical unit on the fifth floor.  I wondered about this given his condition, but did not question this.  His heart rate was still over 120 bpm, he still had a fever, and he was still very paranoid and also had very bad diarrhea and stomach cramps.  The nurse came in with a wheel chair and plunked him down.  I found this a little disconcerting as earlier that day they had used a physiotherapist as they were afraid he would repeat what had happened the day before.  He could not lift his feet onto the supports and she said it was ok if he wanted to leave them free.  I was concerned about his feet dragging on the floor so I helped him put them on the supports.  Previously to this the nurse had given him some pills and put on a portable heart rate monitor.  A porter was called and we went upstairs.  Again, no nurse was in attendance even though he was still extremely paranoid.  It was around 3:30 pm when we got to the fifth floor. He was put in room 577 which is probably the farthest room away from the nurse’s station.  It was a semi-private room and there was a patient in the other bed with a visitor when we arrived.  When we got to the room, he had to go to the bathroom again.  The nurse helped him to the bathroom.  When he was finished she said she was going to get him into bed.  I left to go and arrange a phone and pick up something at Tim Horton’s.  On the way I mentioned to the nurses at the nurse’s station that they should watch him because of his paranoia.   They did not respond.   I was no more than ten minutes and when I returned to his room he was flipping out because he could not breathe.  He said, “Mom I think I am having a panic attack and I think I am dying.”   I tried for a minute to calm him down.  The lady visitor called out to see if we wanted her to push the call button and I said no and pushed it myself.  However, there was no response.  While I was waiting, I noticed he had quite a bit of feces on his backside and I decided to clean him up.  I had hoped this would help to calm him down.  It did not appear as if the nurse had in fact cleaned him up at all.  I found paper towels, went to the bathroom, wet them, came back and washed him.  He was still very agitated and was trying to pull out his IV.  I pushed the button again and after a few seconds went out into the hall looking for the nurse.  At this point she was finally coming.  She said she had been notified that his leads had been dislodged from the heart monitor. She did not seem to be too concerned about the situation.  There was no mention of my calls to her.  We went in and tried to get him to settle.  She made him lie down in the bed and another nurse came to help.  I was holding on to him and reassuring him.  All of a sudden the original nurse left the room and I noticed his colour was changing to blue and his eyes were rolling back.  I ran out into the hall to call her and told her about his colour and she said “I know.   I’m going to get oxygen.”  When she returned she put the oxygen on him.  The last thing my son said to me was “mom, don’t let me go”.  They then pushed me out of the way and pulled the curtains.  I heard one of them say “he’s passed out” and then I heard the code blue.   I knew in my heart he was already gone but didn’t want to believe it.  I was taken to another “quiet room” while they worked on him for almost an hour but to no avail.    I have since picked up all records from the hospital after three calls.  They were very reluctant to give me the records but I insisted.  I think it was all about numbers and they wanted the bed.  I believe he would still be alive if he had remained in ICU and had been tested for the blood clot.  I requested an autopsy and it was done in Hamilton.  I have also requested a copy of the autopsy.   The Cambridge coroner contacted me with cause of death which was pulmonary embolism.  He indicated that this was caused by a blood clot from the leg to the lung.  The clotting is apparently caused by lying still in the bed for so long.   My son was restrained and sedated for 4 days with only being turned slightly every few hours.  No machines on his legs.   I have since found out there is a way to test for this and manage the clot, but this was not even mentioned.  The bottom line is they were negligent in his care.  My sister who knows quite a bit about this has read some of the records and there are a lot of questionable things regarding his treatment.  I have also received all of his records from poison control.

 Further to this, I have since read some of the medicals records, for Josh.  When he was first sent from emergency to the Mental Health ward, he was medically cleared by the emerg doctor.  The hospital knew at 1:05 pm that his valprioc acid and ammonia levels were spiking again.  When poison control contacted them about 4 hours later, they were advised and poison control then indicated that they had not been made aware of this.  Poison control then advised that they were quite concerned about complications and made some recommendations as to how to proceed.  However, when the emerg doctor was contacted he said that he stood by his decision that the patient was medically clear.  A second doctor was called in and all that he ordered was close monitoring.  Around midnight my son’s oxygen levels dropped to around 58% and a code blue was called and he was then transferred to ICU.

As far as I can tell, they did not take any precautions other than giving him Heparin even though two of the ingested medications put him at risk for developing blood clots as well as having a BMI in the obese range and 4 days of immobilization with full restraints.  They did a chest x-ray the first day in ICU with no indication of any blood clots and the chest was clear.  After that there were no further tests or ultrasounds to determine whether any clots had developed.  On the day before he died his oxygen levels were dropping off and on, he was having trouble breathing, his heart rate stayed above 120 bpm and his blood pressure was quite low.   He also had a pinkish tinge to his sputum and an ongoing fever without any clear indication as to where a possible infection might be.  All of these things are known to be symptoms of a possible pulmonary embolism developing.  However, at no time were any tests conducted to ensure that this was not the case.  Further to this, my son was also quite paranoid which when coupled with a high resting heart rate could easily have led to a cardiac arrest.  Finally, he was having major stomach cramps and diarrhea. 

On the morning my son died,  the psychiatrist interviewed both my son and me and according to his report, he indicated that he was going to stay with the Form 1 as Josh’s behaviours were not stable.  However, there was no nurse assigned to watch my son once he was transferred up to the fifth floor.

The primary nurse after they moved him to the fifth floor medical unit, omitted some information in her statement.  I pushed the call button twice with approximately 5 minutes in between and she never mentioned this delay in response in her report.  There were other people in the room (next bed) who were aware of this. Also she stated that she cleaned him but I was the one who found him with feces on his backside and cleaned him up.  I am also wondering why she had to go find oxygen when there is supposed to be oxygen on the wall in every room.  These things all delayed the time for my son to receive appropriate care when time was critical to his survival.

As far as I am concerned, limited bed space in the ICU may have been the determining factor in my son’s early release from ICU and transfer to a floor where he was not being appropriately monitored.   He was not ready to move.  Had they have done the appropriate tests and taken the proper precautions, I feel that my son would be here today. 

June 26/12

I have been thinking about this some more and I realize that if the first emerg doctor had listened to Poison control recommendations on Wed June 6 my son probably would not have coded and ended up sedated and restrained.  Therefore I think this negligence caused my son to develop a blood clot.  Why did they wait so many hours to notify Poison control of his ammonia levels spiking and why did they not restart the antidote therapy until so much later?  Had I known about this I would have got him moved to another hospital since they obviously did not know how to take care of him properly.  They caused my son’s blood clot and ultimately his death.  I also think by moving him in a wheel chair they hastened the pulmonary embolism.  I am especially concerned about the horror by son must have endured both times. 



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