The Following is a story close to my heart. I would like to offer this as food for thought when discussing the near end of life. Is this an option that you would like eliminate? Would you not rather have a loved on go with dignity, on their terms, if they are mentally capable of choosing?

A Day in the Death of a Senior

This is a story about Helen, recently deceased. While we know that this letter will not bring Helen back , it is a hope that by some means, her story could be added to the growing list of names that belong to the seniors who have met their demise through a faulty system.

While not pointing fingers and pounding fists on tables or yelling out on street corners, this story would like to voice what Helen herself can no longer say.

Helen was living at an extended care facility in the south side of a city. She had been transferred there from a hospital after having medical issues that forced her from her residence.

Upon her placement at the long term care facility, Helen settled in to the routine and felt reasonably comfortable with the staff. At a family meeting shortly after her admission, she was asked if she would like to be listed as a “Do Not Resuscitate” (DNR) patient. Helen said “Absolutely not! I want everything done.” She loved life and still hoped her physical condition would improve enough to allow her to travel.

Helen was of sound mind and able to make all decisions regarding her care on her own. Helen’s daughter, was the medical director, should Helen not have been able to make such decisions with regards to her health. She was also in charge of any financial inquiries regarding Helen’s account as well. (This is relevant and will be disclosed why shortly.)

The conditions of Helen’s passing were abnormal, prompting the Medical Examiner to perform an autopsy. Her family also requested a copy of Helen’s medical chart from the care facility. The following is a presentation of circumstances based on review of this information and which we believe shows a serious lapse in care resulting in Helen’s death.

When Helen’s medical records were reviewed, it was found there were a number of issues on her file that were not relevant. One being anxiety, another depression and yet another being Parkinson’s disease. Helen was not being treated for either anxiety or depression and diagnosis of Parkinson’s had been discounted after testing. She was receiving medication used for those with Parkinson’s as she did have tremors, especially in the jaw, mainly when physically pushing herself.

On January 13th, 2014, Helen started showing signs that should have raised warning flags to staff and the RN. She started vomiting brown fluid, despite consuming only clear liquids.

Helen was given medication that is used normally for patients who suffer from upset stomach and pain. Once upon a time, protocol was to administer this “pink lady” cocktail only twice, and then seek higher medical advice. This was not done. Helen continued to receive this medication for another two cycles, without trying to discern the cause. The brown fluid continued to be expelled. Pain in her back and abdomen continued to increase. There was a marked decrease in her blood pressure.

It is recorded in her charts, that on January 14th, they tried to contact her daughter, via land phone. The voice message received was along the lines of, “There is a change for your Mom. It is not an emergency.” As the tone of the message did not seem alarming, the call was thought to be, as previously, a change in medication.

Helen’s condition continued to deteriorate. On January 15th, 2014 at approximately 14:45, Helen was able to call her other daughter, and tell her she was having terrible pain in her bowels and stomach and asked her to bring her GasX to help alleviate the pain and pressure.

At approximately 16:00, Helen went in to respiratory distress and an attendant called for assistance and suction to help clear her pathway. When the suction machine arrived Helen was in the final stages of death. Apparently they tried to suction, but to no avail. Then the records show they were able to suction brown fluid. She was showing no vitals by 16:15.

The records show that they tried to call the first daughter via her cell, to inform her that she needed to contact the facility. Funny thing is… the number they were using, was a contact number that was not on any file relevant to Helen, since five years previous. Thankfully, it was currently Vicki’s daughters’ number, and she was able to pass the message along with a phone number for Vicki to call. Vicki tried calling the number, but it was not working as given.

At approximately 16:55, the second daughter, unaware of the condition, walked into Helen’s room. She noted that Helen was frothing at the mouth and there was brown fluid trickling from the right side. She tried to get a response from Helen by shaking her shoulders. There was no response. She went out into the hallway and yelled for help. Three attendants were in the hallway, two went into another room and one walked towards the dining room/nurses’ station. In other words, all three ignored her frantic calls for help. She went back into the room and tried to get a response from Helen again. Still nothing. Then an attendant and the RN on duty came into the room and the daughter said not to worry, she was already dead.

The RN stated that, yes that she knew Helen was dead and that was why they left the phone message, thinking the second daughter was the first daughter contacted. When the daughter present said that she had not received any message, the RN realized it was not the first contact daughter, in attendance. Daughter two asked why she was not contacted when they had failed to connect with daughter one. The RN stated that they did not have daughter two’s phone number. She said that they had her phone number on file, as it came over with the Devon Hospital files.

Phone calls were made to locate the family by daughter two and son one (Helen’s son, living out of town). During a conversation between son one and daughter two a decision to request an autopsy was made. Daughter two went to the nurses’ station and informed the RN of this.

As daughter two approached the nurse’s station, an attendant walked up to the desk with a paper in hand, and she said that they did not have any other contact numbers on file for family. She then slipped the paper into Helen’s binder. Daughter two told the nurse that they would like to request an autopsy.

The RN said they needed to know the funeral parlour to make arrangements for pick up, should the Doctor not think an autopsy was required. She then called Helen’s doctor to let her know what had transpired. Was this the first time the doctor was contacted?

The Doctor was given daughter one’s real cell number to contact and discuss the reason behind the request for an autopsy. Daughter one received the call from the doctor once she arrived at the facility. It was decided to proceed with the autopsy and daughter one was informed that the medical examiners office would have Helen picked up shortly.

Helen was removed later that evening and taken to the morgue.

Once the autopsy was performed it was reported that she died from an ischemic colon. Upon investigation on the families’ behalf, it was found that this condition has a 7% mortality rate. If caught in time, it is treatable and recovery is viable. Surely the best place to be, if you have an obvious observable condition, would be an institution with medically trained staff

Questions are many. For example, once the nurse’s report were obtained, there was evidence that Helen was deteriorating. But this was over a period of days. There was ample time for an involved staff to prevent or at least mitigate the chance of death.

Were signs or symptoms not reported properly?

Was Helen unable to vocalize the intensity of the pain because of medication that she was on previously or because of the toxicity? There is no insight in the chart as to Helen’s mental status deteriorating as she became toxic. Did nobody notice that this totally aware woman was no longer?

Why did Helen not call one of the children as she usually would when she was in need of assistance? The only call came during the not so golden hour. It was already too late to treat the problem. She was in respiratory distress at that time.

Why did the RN not take the expulsion of brown fluid, charted days earlier as a flag to escalate the situation and seek help further up the line?

Why did the phone numbers on hand not correspond with the ones on file? Daughter one’s numbers are actually blacked out in the nurses’ report that we received. Yet, daughter one had been contacted many times, on her land phone and her cell, by the office regarding med changes and financial issues.

One of the notes on January 15th, show Helen complaining of what would be symptomatic of a heart attack. Why wasn’t an ambulance called?

Why didn’t the extreme deviation in her blood pressure, from normal, set off a warning sign? Why were her vitals not taken after that significant drop was recorded?

Changes to the system of care are required, but where does one begin? We all know that It would be easiest to blame the Health Care Attendants and RN, but is that right? Are the protocols not written in stone, or is it the observers’ perception that clouds the glass? Do staff members have the right to speak without fear of discipline if a step is missed?

As you can imagine, the family is devastated and frustrated. Their mother died in a manner that would have been both excruciating and terrifying for her.