The Vancouver Sun, Wednesday, May 22, 2002, front page
Woman’s illness, injuries went untreated: coroner
She died after routine hip surgery
by Glenn Bohn
Esther Elsa Winckler went into Chilliwack General Hospital for routine hip surgery but died there 15 days later, after life-threatening complications from the surgery and a serious head injury went undiagnosed and untreated.
Now, more than two years after her death, a coroner’s report documents a series of omissions and mistakes by doctors and nurses at the hospital.
Among Coroner Margaret Turner’s findings:
- Winckler had a post-operative heart problem called congestive heart failure, which occurs when the heart is unable to circulate enough blood through the body. But the problem went undiagnosed and untreated, although Winckler had the classic symptoms caused by that heart problem, including low blood pressure and fluid in the lungs.
- The patient’s health was unstable after the operation, but she was transferred to an “understaffed” area of the hospital instead of remaining in the surgery unit, where there were more nurses to watch patients.
- A serious head injury believed to have been sustained in two falls from her hospital bed went undiagnosed, despite obvious signs like slurred speech, dilated pupils and bruising on one side of Winckler’s head.
- The patient didn’t have a bowel movement during the last 15 days of her life. Bowel function is commonly assessed after surgeries and should return two or three days after an operation, but the coroner found that bowel care records weren’t kept and she couldn’t determine whether Winckler had an adequate diet to promote bowel movements, because proper records about her diet weren’t kept for six days.
“Higher standards” would have given the 77-year-old woman a better opportunity to recover, the coroner’s report suggests.
continued p. A9 Doctor, nurses told ‘to go back to Medicine 101’
“Throughout Ms. Winckler’s hospital stay, there were several elements of the health care provided to her that illustrated a gap between the standards being recommended in the field of geriatrics and those in use at Chilliwack General Hospital,” Turner wrote in her judgment of inquiry, dated May 6, 2002.
The Vancouver Sun obtained the report Tuesday from the dead woman’s family.
An autopsy found that Winckler had the undiagnosed head injury, plus three fractured ribs that also were not diagnosed or treated, but died from the post-operative complications, which led to decreased blood flow and depleted oxygen levels in her brain and bowels. Not enough oxygen reached the organs, which damaged and killed their tissues.
Turner, a nurse, ruled the death was “accidental,” which coroners define as a death caused by injuries that were not natural. She urged that the case be reviewed “for educational purposes” by Chilliwack hospital, the College of Physicians and Surgeons of B.C. and the Registered Nurses Association of B.C.
“Medicine is not black and white,” Turner said in an interview. “When you look back on it, it may be easier to see and learn from this particular case, where treatment may have been quicker.”
Catherine Winckler, the patient’s daughter, said the findings substantiate the family’s belief that Esther Winckler should not have died from the hip surgery. “To our mind, they are remarkable recommendations in that they, without finding blame, basically tell the nurses and doctors to go back to Medicine 101,” the daughter said. “Learn how to keep charts, learn how to report falls, learn how to give out pain medication, learn what dehydration, malnutrition, brain damage, and senility look like.”
Dr. Alex Bartel, who said he became the hospital’s chief of medical staff shortly after Winckler’s death, said he could not comment until medical and legal staff had reviewed the coroner’s report.
Bartel responded with one word – “Yes” – when asked if it was unusual for someone to go into Chilliwack hospital for hip surgery and die from complications. When asked what the hospital wanted to say to the Winckler family, Bartel said: “Of course, I’m sorry … I regret they’ve had an unfortunate experience.”
Although Winckler was 77 years old, the daughter said her mother was still in relatively good health. She lived with her husband, Lawrence, at the Cultus Lake cabin they had turned into their retirement home. She died much younger than her siblings: a sister died at age 96; a second sister is still alive at 94;a brother is now 89.
Raised on a family farm in Manitoba, Winckler obtained a university degree in home economics and began her career at a grain research laboratory in Winnipeg. She moved to B.C. in the 1950s, taught home economics at Kitsilano high school in Vancouver and pioneered a home economics course for immigrants and native Indians who were seeking jobs in hospitals and private homes. Winckler and her husband, a retired businessman, raised a son and a daughter.
Catherine Winckler says her mother spoke out and wrote letters on women’s equality issues during much of her adult life. After retirement, at Cultus Lake, her mother became involved in local issues like water quality and fire safety.
She was “a wonderful feisty senior,” the daughter said.
But when the daughter and her father visited Winckler in hospital the day before she died, they found her in an old wheelchair, trying to remove a leather restraining strap around her swollen stomach. There were scabs on her face and blood in her nose. And the elderly woman wasn’t wearing any clothes. She was beside a bed that was farthest away from the nursing station, behind a cloth screen where she couldn’t be seen.
Catherine Winckler said she didn’t recognize her mother at first.
The Winckler family says it not suing anyone, but has instead chosen to try to bring attention to the case, so changes can be made.
The family said Esther Winckler’s experience is a bellwether case that illustrates the plight of seniors in the health care system.
“It is our sincere hope,” son Ron Winckler said, “that we will have the opportunity to sit down with the new Fraser Valley Regional Health Authority and hospital administrators to find out what, if anything, has changed in the past two years as a result of the outcome of this very sad case that saw us lose our mother prematurely.”
Daughter hopes her mother’s story will be heard
by Glenn Bohn
One year after Esther Winckler died, her daughter Catherine created a Web site called Esther’s Voice.
Winckler asked the questions she wanted the medical system to answer. The Web site is the public place she chose to post her sad journal of her mother’s last 15 days in the hospital.
That’s where anyone with a computer can see her requests for investigations by the College of Physicians and Surgeons of B.C. and the Registered Nurses Association of B.C. That’s where she posted a tasteful photograph of “Mum,” someone who had always shunned the camera.
Catherine Winckler, who requested an autopsy after her mother’s unexpected death two years ago at Chilliwack General Hospital, said she hoped her mother’s story would be heard, and that some sense would be made from the seemingly senseless.
She was struck by something a coroner said at the beginning of an investigation that wouldn’t lead to a final report until two years later.
“The coroner said they were there, not to act for doctors, the nurses, the hospital, the police, or even the family,” she wrote.
“They were there to be Esther’s voice – to hear the story that she had to tell us in death, the story she was incapable of telling us over her 15-day stay at Chilliwack General.
“And so we have called this Web site Esther’s Voice as a place where family and her many friends across Canada can find out what happened to this wonderful feisty and articulate senior … and more important, to ensure that it doesn’t happen again.”
Catherine Winckler is a partner at Fleming Design, a Vancouver graphic design firm.
She’s a copy writer, whose words appear in advertisements, Web sites and brochures.
Winckler said she didn’t want to create another vitriolic Web site that incited hatred against doctors. She wanted to make sure the same thing didn’t happen to another senior.
“I treated it like it was business,” she said in an interview in the company board room. “If I had a client who came to me with a story like this, what would I do?”
Knowing the tricks of the trade, she “meta-tagged” or computer-coded the Web site so that anyone doing Internet searches on key words like “Chilliwack General Hospital” would see a link to Esther’s Voice.
The hospital doesn’t have its own official Web site. So when someone uses a search engine and keyboards in the official name to find out something out about the hospital, they see something titled “Esther’s Voice – Chilliwack General Hospital Malpractice.” With the popular Google search engine, Esther’s Voice [www.esthersvoice.com] is the third Web site listed, after mentions of the hospital on Fraser Valley Health Region and B.C. Cancer Agency Web sites.
Note: On Page A8 of the same edition of The Vancouver Sun, the Journal kept by Catherine Winckler was reprinted. This journal is readable on the Esther’s Voice website under “Daughter’s Journal.”
The Vancouver Sun, Thursday, May 23, 2002 p. A4
Chilliwack hospital will study report on patient’s death
Committee to review coroner’s findings on ‘accidental’ death of surgery patient
by Glenn Bohn
Chilliwack General Hospital is setting up a multi-disciplinary committee to review a coroner’s report into a patient who died in the hospital two years ago, a Fraser Health Authority official says.
“We’re very concerned about the family’s reaction, and the coroner’s concerns as well,” Helen Carkner said Wednesday.
Esther Winckler, 77, went into the hospital for routine hip surgery. She died 15 days later of complications from the surgery and a head injury sustained in a fall from her bed – medical problems that went undiagnosed, and untreated.
The report by coroner Margaret Turner, a nurse, ruled the death was “accidental,” in that Winckler died of injuries that were not natural.
She urged that the case be reviewed “for educational purposes” by Chilliwack hospital, the College of Physicians and Surgeons of B.C. and the Registered Nurses Association of B.C.
Catherine Winckler, the dead woman’s daughter is not suing anyone, but has instead chosen to bring attention to the case, so changes can be made.
The dead woman’s son, Ron Winckler, said the family also hopes to sit down with the health authority and hospital administrators to find out what has changed in the past two years.
Carkner didn’t offer a date for the meeting, but said health officials have agreed to meet the family.
“Of course, the hospital would like to speak to them as well,” she said.
The Vancouver Sun, Thursday, December 2, 2004, page B7
Woman’s legacy lives on in care for patients
HEALTH Family turns her death into positive changes in hospitals
by Glenn Bohn
CHILLIWACK Esther Winckler’s life ended in tragedy four years ago, when the 77- year-old went into Chilliwack General Hospital for routine hip surgery and died 15 days later.
She had life-threatening complications from the surgery and a serious head injury that went undiagnosed and untreated. But instead of filing a lawsuit, her family decided to advocate improvements that would help other elderly people in hospitals.
That triggered a host of patient care reforms outlined in the December edition of Nursing BC, a magazine published by the Registered Nurses Association of B.C. For example, more than 1,500 nurses in B.C. are now part of a network of nurses who have upgraded the skills they need to diagnose and care for the elderly.
The patient’s daughter Catherine Winckler, who created a website titled Esther’s Voice to try to ensure another senior won’t suffer the same fate, says the health care system has listened. “Once we took it outside a case of blame and litigation, it gave us the ability to speak and allowed people to have a dialogue,” she said in an interview Tuesday.
In May 2002, the day a coroner’s report documented a series of omissions and mistakes by doctors and nurses at Chilliwack General Hospital, The Vancouver Sun published a three-page story about the premature death.
Some of corner Margaret Turner’s findings:
- The patient’s health was unstable after her operation, but she was transferred to an “understaffed” area of the hospital instead of staying in a surgery unit where there were more nurses;
- A serious head injury believed to have been sustained in two falls from her hospital bed went undiagnosed, despite obvious signs like slurred speech, dilated pupils and bruising on one side of Winckler’s head;
- The patient didn’t have a bowel movement for the last 15 days of her life, although bowel function is supposed to be watched after surgeries and records are supposed to be kept.
Catherine Winckler said the first organization to respond to The Sun’s story was the registered nurses association, which assured Winckler that nurses wanted to find out what went wrong.
Phyllis Hunt, a geriatric clinical specialist with the Fraser Health Authority, and colleague Marcia Carr, another specialist in the same field, began using Esther Winckler’s death as a teaching tool after getting B.C. health ministry funding to conduct seminars for nurses around the province.
“I remember when the news story came out,” Hunt said. “For those of us who work with older people and the challenges of caring for them when they’re acutely ill, it was devastating.”
There are now 11 clinical nurse specialists in B.C. senior care experts who work in all five health authority regions of B.C. Three years ago, there were three clinical nurse specialists.
During education seminars around the province, nurses who care for the elderly are asked to look at the website, www.esthersvoice.com.
“It’s just an amazing success and it never would have happened if it wasn’t for the approach that Catherine Winckler took to this tragedy,” Hunt said.
Pat Light, the health services administrator for Chilliwack health services, went so far as to suggest that Chilliwack Hospital is now a safer place for elderly people. “Esther’s voice has been heard loud and clear,” Light said. firstname.lastname@example.org