February 21st through March 5th, 2000

(From progressive handwritten notes by daughter Catherine taken throughout her mother’s hospital stay and typed out for the Coroner March 7, 2000)

Weeks prior to surgery February 21st
I spoke with Mum on a number of occasions re: the upcoming full hip replacement surgery and what she could expect. She told me that her G.P. Dr. Noble and ‘the team’ had looked at her history and it was decided to do a spinal as opposed to a general anesthetic. She said that this was part in response to her life-threatening experience in 1994 for what was to be a double decompression at two levels of her spine, whereby the second procedure was aborted because of hypotension and hypoxemia. She told us that Dr. Noble had assured her that “EVERYONE at the hospital knows about your case and not to worry, they were not going to take any chances and would do the spinal.” Her pre-surgical anesthesia consult with a Dr. Lavin confirmed this recommendation in writing. At no time was she or the family told that there was any possibility that the decision to use the spinal would be substituted at the last minute due to the judgment of whoever the anesthesiologist appeared to be at the time.

Sunday afternoon, February 20th
Mum left a message on my machine at home saying that she was comfortably ‘checked’ into her room but that she was very confused and concerned in that the anesthesiologist had already been in to see her and informed her that she was to undergo a general. Her voice was anxious and I was concerned as surgery was early the next morning and as it was a Sunday night I was unable to check things out with Dr. Noble or surgeon, Dr. Wickham.

Monday, February 21st, 11 am
Dad called and said that Dr. Wickham had called to say the surgery had gone well and she was in recovery. Dad went to the hospital around 2:30 pm and was told she was still in recovery. He saw her. She was ‘out of it’ he said … and he left.

Tuesday, February 22nd, 5:45 am
Dad called and said the hospital called him at 4 am (Internist, Dr. Richmond) to say that things were very serious and he and the family should ‘get down here.’ No details except that she’d been transferred to ICU.

8:15ish   Brother Ron and I arrive in ICU and are told that she’d had a very bad turn around 2:00 am and she was still very critical. That they had had to use the paddle; that she was hooked to dopamine and some other lifesaving drugs; that her blood pressure had gone way below 100; that she was on 100% oxygen; and that blood tests indicated that there could have been a heart attack (a ‘silent’ heart attack Dr. Richmond called it.)

Dr. Noble came in and I asked him how mum was and he said she was stabilizing as best as could be expected. I asked him at this time why mum was given a general and he looked surprised and said, “I don’t know. You’ll have to ask Dr. Wickham.” I reminded him that Mum and he had discussed the preference for the spinal and he nodded affirmatively. I also reminded him that specially given Mum’s previous experience, we’d understood that this was the way to go and that this had been discussed weeks prior to the operation. He nodded affirmatively again and said, “Yes, that’s true.” He then volunteered that “sometimes things change at the time of surgery.” I pointed out that this change had come at 6 pm that night before and that the decision had come as a shock to Mum. He said to be sure to discuss this with Dr. Wickham.

Shortly thereafter (I think 9ish) Dr. Wickham came in and I asked why the general? He said, “I’m not sure. It’s the anesthetist’s call – he runs the show – and I don’t know why the decision was made.” I continued to probe and he (Dr. Wickham) tried to placate me by offering that she received the “cadillac of anesthetics.” I pointed out, was that really the point given her history and the fact that the spinal had been indicated all along for a number of reasons which had been outlined to her? He then went into an educational style mini-lecture on how it was a more difficult operation under spinal because of the length of operation and the positioning. I pointed out that none of these aspects had NOT been known prior to Sunday night… and why again would the decision have been made independent of everyone’s input and wouldn’t he ask given he’d come in to the operating room expecting a spinal??? He mumbled and left.

I asked Dr. Richmond the same question and he said, understandably, that Mum had not been in his care pre-op so he did not know.

During the morning we stayed beside Mum and at different times, her nurse Debbi would say things like, “Tests indicate it was her heart; this can happen when there is a general.” And then something to the effect that the respiration can be suppressed and can bring on hypoxia or something. Later when we commented on the swelling and extreme puffiness of our mother, she directly attributed that as well to the general. When I asked her if she knew why Mum had had a general and not a spinal, she went to the chart and said that it was strange but there was no notation on the chart. I asked if the name of the anesthetist was there and she said no.

By evening visit, the nurse Marissa said that Mum was 200% improved then when she’d come down the night before when her breathing had been poor and her heartbeat irregular.

Wednesday, February 23, 9:30 pm
I arrived at hospital and talked with Dr. Richmond who felt Mum was doing reasonably well and that it had been a heart attack and he was going to put her on Amiodarone. That it had significant side effects and that she would be kept in ICU to monitor her closely.

1:00 pm  I called Dr. Noble’s office and asked that he give me a call at his convenience. He called between 2 and 3 and brother Ron listened on the other line. I shared with Dr. Noble that Dr. Richmond was a very difficult person to talk to – he volunteered that he had a certain lack of bedside manner but was a good specialist. Dr. Noble told us that enzymes showed that she had had a heart attack and was showing cardiac instability. That she would be in ICU for at least 5 days being monitored, that they would give her blood thinners to prevent clots; and that as soon as she was stable from the cardiac point of view, the rehab people would be called in to work with her. I ended the conversation by asking again about the general anesthetic; he said that he’d been unable to find out more and that when he himself had asked Dr. Wickham today, in Dr. Noble’s words, “Wickham mumbled something at him and talked about the cadillac of anesthetics.”

I asked if Dr. Noble had any information on the file of why/who? He had his file in front of him and flipped through and said that he would read me out loud the pre-op consult report from a Dr. Lavin. It spoke of Mum being optimized for surgery. That given the history and discussions, a spinal was recommended.

“But Dr. Lavin isn’t necessarily the same person who gave her the anesthetic on surgery day,” Dr. Noble said. “And I haven’t found out yet who that is.”

I told Dr. Noble that our family wanted to know and would be following up. He suggested he would get the name and number and I could speak to them myself. I finally asked (paraphrasing the nurse) whether, “the general might have not suppressed the respiration and could it have brought on the hypoxia, especially given the fact that Mum had told us that at the pre-surgery clinic they had asked if she’d ever been told about a little murmur before?” Dr. Noble immediately said, “Oh no, that’s not possible.”

Thursday, February 24 through Friday, March 3rd
Visits showed her slowly and progressively recovering, getting taken off oxygen in increments, off the dopamine etc. Our understanding is that she was transferred out of ICU on February 29th to the 3rd floor and then on March 1st to the general ward on the 5th floor. She was walking small steps and sitting in her wheelchair. Various visitors describe either visits where she would 100% engage in the conversations, looking forward to getting out or visits where she was just a bit addled at times, thinking her Manitoba sister was walking down the hallway. One visitor spoke to us of Mum’s concern that she was not really ‘all there.’ She said, “I don’t know how to describe it Doreen. It’s the oddest feeling as if I’m here but not here” (this was on Tuesday the 29th I think.)

Saturday, March 4th
About noon, I came into Ward 5, Room 535 and couldn’t see her from the door. There was no medical staff around. I went into the room, rounded the far corner curtain and was met by a woman strapped into a wheelchair, near naked, eye area bruised, nose bleeding, scabs on side of face and in an extremely agitated state. She was making no sense and was trying desperately to pick at the leather strap to get it off her stomach. She kept complaining that ‘it hurt, it hurt.’ I immediately tried to pull her together before my father came into the room (he was tracking down her wedding ring which had been misplaced for her stay.)

A nurse’s aide came into the room, saw me and immediately started going on about how difficult my mother had been all night. How she was completely agitated and taking sheets and clothes off herself and the woman in the bed next to her. How they’d had their hands full and it had really been extremely difficult having to deal with ‘this woman.’ I stopped her from blathering on and said, “Look, I’m five minutes into seeing a woman I don’t even recognize as my mother. This is NOT Esther Winckler. Can’t you see that I’m incredibly upset and couldn’t you be just a little more compassionate.” I then asked her to get me a doctor to talk to. She said that wasn’t possible but that I could talk to the RN.

In awhile the RN came down and I talked to him in the hall. Told him that this was 100% different than the person we’d known. That she was distressed, sore (he volunteered it was probably the leather around her stomach). He also said that he was glad that I had told him about her; they had no idea this wasn’t her personality. I asked about the bruise and he said she’d fallen. That I should talk to the GP who had examined her in the morning.

I went to the front desk and had them get hold of this GP, who turned out to be Dr. Quinn (filling in for her GP, Dr. Noble, for the weekend.) He said that she’d had a fall and that they’d found her next to the bed and that he had come in to examine her; that she’d checked out OK, but he offered that he had never met her before and so didn’t have anything to compare her behaviour to. I talked with great concern about her very upsetting and almost crazy wild behaviour and her struggling to get out of her chair because she was sore. He said that it was a combination of “the surgery, multiple medications, and anesthetic.”

I got off the phone and asked the nurse to tell me what medications my mum was now on. She said” Sotalol, Rampirol, fluticasone and ventolin puffers, Tylenol 3 (which have always been absolutely awful for my mum for bowel blockage)… and laxatives. At this time I expressed surprise that the heart medication had changed. We had been told that she was on Amiodarone by Dr. Richmond and that he’d keep us apprised of how she was reacting to it. No one had told us that she’d been switched to a new heart drug… or why.

As well, there was no mention that she had been given Atavan the night before. Something I was later to learn from Dr. Quinn that this had been administered by the nursing staff without his knowledge or approval and that this can often lead to more agitation.

I asked the nurse at the station whose care she was under and they said Dr. Noble and Dr. Wickham. I asked when Dr. Wickham had been in to monitor this complete change in my mother; she could not tell me. I asked when the last visit or consult with Dr. Richmond had been (especially given his assurance that he would closely follow the med reactions through her stay) and she said that it was February 28th. I asked about the last bloodwork and O2 levels and there was no reply.

I went back to my Mum and Dad and asked the nurses aide if there was anything I could feed her in the liquid drink range. She had not eaten her food and Dad was worried as she was looking thinner by the day and her skin was incredibly dry; lips crusty. I wet her mouth and tongue, put cream all over her legs and face… and then the aide brought a Boost drink, asking me, “Do you really need this? You know I understand she spilled the shake you brought her … and these are very expensive you know?” I told her that we were happy to pay for the Boost; in fact I’d bring in dozens; that I’d been the one to clean up the spilled shake … and the spilled food of the lady in the bed next to Mum who was sitting there for 1/2 hour upset because there was food all over her lap. I asked her to just be patient with my mother; this was totally out of character… and couldn’t she find it in her heart to be a little more understanding.

I took my Dad back to his home at Cultus Lake as he was devastated. This was a complete turn of events for him. She was tearing off her clothes, making no sense… and there was no one helping her. He was in danger of falling apart and so I returned to the hospital early afternoon without him.

When I came around the corner this time, she had all her clothes off and no medical personnel was in sight at all. She was moaning, living mentally in her childhood home in Hamiota, Manitoba, clutching at her stomach and saying, “Larry, Larry, my tummy hurts so much.” She cried to get out of her chair through that part of the afternoon. Would not keep her clothes on. Moaned in pain. And tried manically to pick at the leather strap to free it.

At one point late afternoon she said, “I need to go to the bathroom. NOW NOW!” She went on herself and the chair. When I asked one of the nurses when she could be taken to the bathroom she admonished me not to touch her because of the hip. I said I had no intention, but couldn’t someone look to her needs. She said that they wouldn’t until the doctor got to her to quiet her down; then they’d clean her up once. “If we do it now,” she said, “She’ll just take everything off all over again.” When I asked when that doctor visit would be, she said she didn’t know.

By this point I was getting desperate (around 6ish). I called my medical friend in Vancouver and asked what I should do? I called a friend in geriatric medicine in Vancouver and asked what to do. Both said that I needed to demand a doctor look at her immediately.

I went to the front desk and asked the nurse politely what my options were. Is there a doctor in the hospital right now I could see? She said the resident was currently unavailable. If I can get my Vancouver doctor’s friend (a Chilliwack specialist) to come in as a favour to look at her, would that help, I asked? She volunteered that he would be third on the totem pole and that he couldn’t prescribe. She said that the first choice would be the GP in charge. “But he doesn’t even know my mother,” I said. She said that this was still the best bet… but that they didn’t usually phone them UNLESS the family insisted. “Consider this an insist,” I said.

I went back to my mother; cradled her and rocked her. Her stomach was now three times normal for her size. She kept complaining of being very sore there. Still there was no nursing staff or assistance.

Dr. Quinn arrived sometime thereafter and I stepped out. When he filled me in on her condition he said he was concerned. Her blood pressure was low 80. She had a tender abdomen. He was going to hold the sotoril to try to bring up the blood pressure and withhold the loxopene. He told me then that there had been Atavan that he had not known about and that this might have caused some of the behaviour of the night before. He ordered blood tests stat, an x-ray, and had the nursing staff clean her up and put her to bed.

I went back home and at 11:00 that night got a call from Dr. Quinn who said that they had an “abdominal catastrophe” on their hands. That she had a high white blood count with a shift, that blood pressure was dangerously low. That it might be an infection or inflammation intra-abdominally. That he had contacted the surgeon on call, and they had discussed it over the phone and it was felt she wouldn’t survive abdominal surgery and more anesthetic. That they would do simple things overnight. Intravenous and a bolus of IV fluid as well as intravenous antibiotics. “Let’s hope it’s not a perforation.” He said. Then told me that in the a.m. she’d get a CT scan.

I called back to the nursing station and found that all of this was being done by phone; neither were with my mother. I asked/insisted that the x-rays be read that night and would someone please call me with the findings. Dr. Quinn immediately called back and said, “I understand you can’t get any sleep until you hear about the x-rays; well, there just happened to be a radiologist in reading another patient’s chart and they read your mum’s and there is no perforation. It’s marginally good news. Go to sleep – that’s what I’ll be doing.”

I asked one last question, prompted by my Vancouver contact. Is there any chance of an ilius? He said no.

At 3:30 in the morning, someone new to us (a woman doctor—the resident???) informed me that Mum had passed away. That she had been given lots of morphine. As if that was to make me feel better knowing that there was a ‘no morphine’ caution on her wristband given her hallucinations under the drug!

I waited until 6:30 in the morning to tell my father that his wife had passed away. Later that morning Dr. Quinn called to pass along his condolences. He said that her abdomen had indicated sepsus or something. That there probably was a heart attack.

To date, her surgeon Dr. Wickham has never called my father; never followed through with his patient. (This information was as of March 7th; a week later he did call my father and then following a note I wrote to him to express my concerns, he said he’d like to share my concerns with the head of nursing as that seemed to be where the trouble lay.)

Monday, March 6th
Dr. Noble called first thing to express shock and I mentioned that I had already called his office to set up a 1:15 pm debriefing meeting with he and my brother and I. At this time he expressed complete shock that he had come in Monday morning to the news. That when he saw her Friday, she was on the road to recovery with only a few lapses in memory, which he said was common post-operatively. I told him of our complete horror at the weekend’s treatment and he said he understood our need to call for an autopsy if it would make us feel better.

I did not know what was involved with an autopsy. I knew that we were not looking for blame; but to have a reason for the ongoing lack of concern, care, and the mixed messages we were getting. I called the Chief Coroner, and he put me in touch with the Chilliwack division and explained the procedure and the difference between the autopsy and a coroner’s autopsy. I reiterated that we wanted only to make sure her voice was heard.

In a nutshell, these are the things that our family does not understand:
(Note: This list was written by the family in the days following her death March 5, 2000 when we had no details yet from anyone)

1. Despite a file with historical evidence of problems with general anesthetic, despite the pre-consult report with Dr. Lavin, despite the care team’s meetings with my mother, and despite her wishes and fears for a general anesthetic, why did a Dr. A.A. Suleman on the Sunday night unilaterally make a decision without sharing it with family or GP or the surgeon for the hip replacement surgery? Did this affect outcome?
2. Why were medications changed without our family’s knowledge? When was the last consult with the heart specialist and was he continuously monitoring the combinations of medications, blood pressure etc. When was her last bloodwork done prior to the night of her death? And where was Dr. Wickham in all of this? Should the abdomen have been his responsibility? Why did no one know she was septic? Who was in charge of her… and how could they leave her over the weekend with absolutely no one who knew her case?
3. With no history of heart disease, what did happen in the operating room… and was the anesthesiologist present at all times?
4. Why was Atavan given the night of her most agitated state? Why were no doctors consulted during this supposedly highly delusional night? Was she simply dismissed as a senile old lady with too many health problems to address? Were any tests run to see why her personality had changed 100% from the time her GP, Dr. Noble saw her on Friday through to Saturday a.m.?
5. Why was she found lying at the side of her bed, bruised, bleeding on Saturday a.m.? How long had she been there? What was done to examine what must have been a sore abdomen even at that time?
6. Were Drs. Wickham, Richmond, or Noble (those who knew her case) ever consulted over this critical period given they were the ones who knew her? Was she left to Dr. Quinn who had never met her before… and then were staff so hesitant to call him in on a Saturday afternoon or evening that they left her sitting in the chair for hours?
7. Given the obvious staffing shortage, why is family not advised so that we could bring in someone to watch her through the evening and day? Why was she situated behind the curtain on the left side so that no one would be able to see her from the door of the ward room?
8. Why was it left to the family to insist (via having to phone contacts in Vancouver to describe symptoms to them over the phone) that a doctor be brought in to see her STAT. It was fully obvious that unless I had stood at the front station and insisted on the phone call, my mother would have been left sitting in the chair until someone had got to her at evening’s end.
9. Why was more morphine administered given the no morphine on her wristband.
10. Who called us to tell us of the death? Given four doctors we knew: Noble, Richmond, Wickham and at the end, Quinn… did we really need a new one at 3:30 in the morning whom we couldn’t even ask questions. She was short, to the point, and hung up immediately.
11. Most importantly, is what we have experienced as a family, doomed to be repeated for others? Can people not realize that 77, cancer survivor, and post op does not mean relegating a proud and articulate woman to the back corner behind a curtain to die in extreme discomfort?

Medical notes from medical examiner’s findings

The following notes were taken at the reading of the Medical Examiner’s findings a year later in March 2001. The family was allowed to take notes, but not photocopy any of the findings. These are our notes:

Apparent Chain of Events

Autopsy showed “Ischemia and infarcation of the transverse colon and extensive organizing hemorrhage cerebral infarcts, due to prolonged oxygen de-saturation and hypotension, status postoperative left hip replacement.” Also fractured ribs and no evidence of an MI.

Chain of Events: Seen by Dr. Suleman on Feb. 20th, the night before surgery, @ 2200. Classified her as level three, high risk, due to severe system involvement. High risk, yet no EKG was done pre-op. Potassium was 2.9; result ignored. Urinalysis showed ++ white cells and red cells; no culture sent off. Foley still inserted next day.

Questions around the use of general anesthesia. Previous surgery of 1994 shows previous aborted surgery under general anesthetic. Based on this history, a February 2, 2000 pre-op consult was ordered with anesthetist Dr. Lavin, who wrote a letter (on file) which stated clearly that general anesthesia was ill advised for this elective hip replacement surgery. Everyone was apparently in agreement, except Dr. Suleman who acknowledges he was aware of this letter, but went ahead with a general anyway. Mrs. Winckler called her daughter after Dr. Suleman’s Sunday night visit and expressed extreme concern about the general, but there was no GP or surgeon around that night to talk to. Note that she had expressed on numerous occasions to family, friends, and her GP that if a general was used, she was not comfortable going ahead with the surgery given her 1994 experience.

According to Dr. David Wickham’s statement, risks of surgery were explained. Given that he told the daughter following the surgery that he was “as surprised as anyone to see her under a general when I got to the operating room,” when was he aware that all risks were explained? It was the family’s understanding that he was in total agreement with the spinal. Was it he that ordered the pre-op consult? Had he scheduled an operation based on a spinal or a general? Was there any written document or signed document supporting Mrs. Winckler’s comfort with the decision? Did Dr. Suleman explain risks of general anesthesia, especially given her past history?

Re. Operation February 21, 2000. Operation started around 9 am, completed 1015. Was operation completed very quickly, especially for a total hip replacement? Again, what was Dr. Wickham’s OR schedule like for that day?

During the operation Mrs. Winckler was given 2000cc (2 litres) of fluid; output 150cc. The patient weighed not too much more than 100 pounds. At 1020, BP found low and she was given 500cc of Ringers. Portable CXR done showed interstitial edema. Nothing was done. Mrs. Winckler only had one lung, already compromised now due to fluid overload. Received now 2500cc (21/2 litres) of fluid in less than 2 hours.

EKG finally done. Repeat electrolytes showed low potassium; pre-op low potassium was ignored. O2 saturation low, pulmonary edema not treated; instead given ventolin.

In the recovery room Mrs. Winckler received another 1275cc of fluid; rate of infusion not noted. In total she has now received 3775 cc (almost 4 litres) of fluid in a couple of hours. She was now in atrial fibrillation.

Internist Dr. Richmond now involved in her care. Her SaO2 was 84% on 97% O2. Dr. Richmond said this was satisfactory. (Is this considered satisfactory according to common medical practice?) He diagnosed a myocardial infarction based on an increase in the CKMB (Could this not have arisen due to hip surgery itself?)

Her blood pressure now drops to 73/40 and she is given another 500cc of Normal Saline.

Summary to date:

Mrs. Winckler underwent a hip replacement under general anesthesia, yet this appeared to be contraindicated. No EKG was done, and pre-op potassium was low, but not corrected. She is found to be in failure post op, yet no treatment for pulmonary edema was given. Instead she continued to receive more fluids. She has one lung and is hypoxic, and as a probable result she is in atrial fibrillation. The underlying pulmonary edema was not treated and her hypoxia continued.

It was now noted that her renal perfusion has decreased. Her breathing is already compromised, but now @ 0120 she was given more Demerol. Her pH was 7.3, PCO2 54 and PO2 45. This shows severe hypoxia (lack of oxygen). Was anyone called? She was on now a dobutamine drip. At 0230 her heart rate was 35-50. Was she electrically cardioverted at this time? Why? At 0324 she was intubated. Why so long? Hypoxic for a long time. Still, underlying pulmonary edema not treated.

At 0330 CXR showed pulmonary edema and lasix finally given. At this point this is the first mention of lasix given and to date no mention of an anticoagulant given. She just had a hip replacement, in atrial fibrillation and apparently cardioverted, but no anticoagulant yet.

EKG has now new finding of left anterior hemiblock. She is also on an epinephrine drip. Why? Dr. Richmond believes she has a myocardial infarction. No mention of infusion rate during this time, but mentioned that they finally decreased the rate to 25 cc/hr.

WBC increased with shift to left. At 1500 given Ancef and Tinzaparin (first mention of anticoagulant) At 2100 she was restrained. What was her PaO2? Could she not have most likely been restless due to hypoxia?

February 22 CXR showed consolidation of lung, clearing. Did she have an infiltrate, or was this resolution of her pulmonary edema? Hgb now 87 ( ?dilutional or due to blood loss), Na 131 with normal CKMB.

February 23 @ 0130 BP 190-200 systolic. Was she still on epi drip? What was being given in her epidural and at what rate? She now was given narcan (Why was narcan given?), but later given demerol again. At this this time it was first noted that her abdomen was distended.

February 25 Facial droop note. She has had a CVA; Was she still in AF (atrial fibrillation)? She was complaining of nausea, she was distended and has not had a BM since the surgery.

February 26. It was noted that she had decreased air entry to lung bases (has had a R lung resection), and bronchial breath sounds. Her potassium now was 2.7. The treatment for her now was an antipsychotic, loxapine and restraint jacket. She still has not had a BM.

February 27. She was confused so Loxapine given again. What were her blood gases like? Was she still hypoxic? Was she still in AF? Has anyone listened for bowel sounds?

February 28 Still no BM. Very little charting for someone who apparently suffered a MI and was in ICU on multiple drugs. (Question: Where was Dr. David Wickham, her surgeon through this hospital stay? There are no notations by him on her chart following surgery. Who is taking care of Mrs. Winckler?)

March 1. Pulse 54. Still no BM.

March 2. No BM.

March 3. Suffered fall, was anyone notified at time? (According to interview later, no one initially told). No one examined her. Family was not given any information at this time about falls, lack of BM, low potassium.

March 4. Found lying beside bed. Seen by her GP’s partner, Dr. Quinn, who tells daughter he had never met her and so was at somewhat of a disadvantage as he had no ‘baseline’ for her current behavior. No investigations. Now WBC 34.9 with shift to left. Nothing done. At this time the patient’s daughter is keeping progressive notes of the day in her Journal. These notes comprised part of the Medical Examiner’s investigation. Notes speak to total absence of attention by doctors or nurses, extreme agitation of patient, swollen abdomen and dehydration as well as inability of family to find anyone to attend to the patient. Why were no calls made to her GP or her surgeon?

March 5. At 0100 complaining of ++ pain, she was given a warm blanket. Finally x-rays of abdomen ordered; however was there anyone to read them? Why were they ordered if the surgeon already said he was not coming in that night and would see her in the morning?

At 0300 she was pronounced dead.

Autopsy

Ischemia/infarcation of the transverse colon. Subdural hematoma Fractured ribs. No evidence of an MI.

Summary

Mrs. Winckler was a bright and articulate 77 year old woman with a previous history of lung cancer (diagnosed and treated in 1986) but still had a very good quality of life. She suffered from a great deal of pain because of her hip and went into hospital for elective hip replacement surgery. Note: The week prior to admission she was still in her garden, visiting neighbours, watching TV with family, cooking meals and aside from the high level of pain she was experiencing, was enjoying life and the possibility of traveling once again, once the pain had been minimized in her hip and knee.

Statements show discrepancy: while she was deemed high risk by Dr. Suleman, it appeared not to be high enough risk to get an EKG or supplement her potassium. Note: It was previously discussed that she should not have a general, but that the operation would be performed under epidural and there is a letter on file from Dr. Lavin regarding this recommendation. Despite this, Dr. Suleman made the decision to go ahead with the general even though this apparently was not the wish of her other doctors, the patient, or her family.

During the operation of about 1 hour and 15 minutes she received a great deal of fluid considering her body weight and the amount of blood loss and her already compromised medical health. In the recovery room she received more fluids and was now in pulmonary edema. The underlying fluid overload was not treated, and most likely because of the interstitial fluid in her one lung and the subsequent hypoxia, Mrs. Winckler went into atrial fibrillation.

Because it appears that the underlying pulmonary edema was not treated, she remained in atrial fibrillation. Dr. Richmond diagnosed a myocardial infarction and now was treating as such, giving her more fluids and putting her on an epinephrine drip. She continued to receive medications which would be an insult to her already compromised health.

Her confusion was treated with antipsychotics and restraints instead of treating the underlying hypoxia.

Her distended abdomen and the total lack of a BM since admission and her complaints of pain were all ignored until it was too late to do anything about it.

The pathologist had to be re-questioned regarding the cause of death as there was no evidence of a myocardial infarction. The cerebral infarctions and bowel infarctions were said to be due to the hypotension she suffered and this, according to the pathologist, could also explain the subdural hematoma.

Mrs. Winckler was in atrial fibrillation for a long period on time and severely compromised due to pulmonary edema and was not initially coagulated. Would it not appear more reasonable that her infarctions were due to emboli secondary to her atrial fibrillation and her fracture ribs and subdural more likely related to at least two documented falls?

Following the reading of the Medical Examiner’s Notes one year after the death of Esther Winckler, these are the questions our family still wants answered:

• Why was a general anesthetic given?
• Why was there not a pre-op EKG done?
• Why was her initial potassium ignored?
• Were all risks of procedure explained to Mrs. Winckler? By whom and was anyone on her medical team notified (ie. GP, surgeon, and family)?
• Did Dr. Wickham have a busy surgical slate that day? Is one hour and 15 minutes sufficient time to do a total hip replacement from opening to closing? Did Dr. Wickham influence the decision to do the procedure under general? Would this have made the procedure quicker versus epidural alone?
• Why did Mrs. Winckler receive so much fluid?
• When the chest x-ray showed interstitial fluid, why wasn’t anything done?
• Was her blood gases really satisfactory as stated by Dr. Richmond? Was the diagnosis of myocardial infarction a correct presumption based on her findings?
• Why wasn’t she intubated much earlier?
• Was her atrial fibrillation corrected properly?
• Where was Dr. Wickham during her stay? Should he not have been checking on his surgical patient daily? Should he not have listened for bowel sounds at some point?
• Why wasn’t she anticoagulated earlier?
• Why wasn’t her pulmonary edema treated earlier?
• Why were there not more detailed nursing notes, considering the seriousness of her condition?
• Why was her restlessness treated with restraints and antipsychotics instead of looking for an underlying cause?
• Why was her distended abdomen ignored for so long and finally her daughter told that it was because of the leather strap on the wheelchair they were using to confine her
• Why was her lack of a BM since admission ignored?
• Why was no one called in after her first fall? Note that the autopsy found broken ribs and subdural hematoma.
• Why was she in a position to fall at least twice?
• Why did the daughter have so much trouble throughout the day March 4th finding a Doctor to attend to Mrs. Winckler; told the Resident was occupied (all day).. then had to finally insist on calling in a Doctor on the late afternoon of March 4th given Mrs. Winckler was in such obvious pain? Why hadn’t the nurses already called a Doctor?
• After they took x-rays of Mrs. Winckler’s abdomen, was there anyone to read them? Why had the surgeon called by phone that night said he would not be in until the morning when it was obvious that she was distended and in a great deal of pain (Note: this comment made before the results of the x-rays made available).