September 24, 2008
Ministry of Community Safety and Correctional Services
25 Grosvenor St, 18th Floor
Toronto Ontario
M7A 1Y6
Attn: Honourable Rick Bartolucci
Dear Minister Bartolucci:
Re: A Demand for Accountability of the Coroner’s Office Regarding theInvestigation into the Death of Child with Disabilities
The purpose of this letter is to express our profound concern regarding the conduct and
accountability of the Coroner’s Office of Ontario related to the investigation into the
death of our daughter, Annie on August 12, 2005. Based on overwhelming evidence, and
a refusal to provide explanation to the contrary, we must conclude that our daughter’s
death was directly attributed to the unauthorized administration of lethal quantities of
narcotics.
We have every reason to question the integrity of the Coroner’s Office of Ontario.
Documents recently obtained through Privacy legislation indicate that two
withdrawals of lethal amounts of narcotics were signed out for Annie and
medication records are suspiciously absent. The Coroner’s Office reported to have
performed a “forensic audit” of the narcotic cabinet but refuses, without reason, to
provide the details by which he made the assertion in his Report that “no active
steps were taken to bring about Annie’s death.”
We are seeking proof and assurance that our daughter’s death was natural and
inevitable. It is tragic and inexcusable that nobody has explained why or how
Annie died and why a specific cause of death cannot be determined. This is
especially concerning because over her entire life, Annie’s care was directed by
staff physicians at our respected and renown children’s Hospital
We recognize that Annie was born with a congenital condition associated with potentially
serious medical challenges. We expected to make treatment decision in consultation with
Annie’s physicians but this did not occur. It is clearly evident to us that that a unilateral
and imposed “quality of life” determination had been made. The Coroner’s dismissal of
the issues surrounding Annie’s care represents a serious threat not only to vulnerable
patients in Ontario’s hospitals who fear similar treatment but to all Ontarian’s who rely
on the unquestionable integrity of the Coroner’s Office to provide “high quality death
investigations” and to ensure that no death is concealed.
As Minister of Community Safety and Correctional Services, your responsibilities
include accountability for the Coroner’s Office. You are therefore compelled to
investigate this matter thoroughly and immediately.
We request that you contact us to discuss and respond to this matter. In the absence of a
response by October 3, 2008, we will consider that this matter is of no interest or
consequence to you or to your government.
Sincerely,
Barbara Farlow BEngSci MBA
SUMMARY OF ISSUES OF CONCERN REGARDING THE INVESTIGATION BY THE ONTARIO CORONER’S OFFICE INTO THE DEATH OF ANNE MARY FARLOW ON AUG 12, 2005
Annie’s death, at the age of 80 days within 24 hours arrival at the Hospital involved a “Do Not Resuscitate” order without informed consent and multiple violations in policies related to medication administration including an inexplicably missing final medication report.
Regrettably, the Hospital did not deem the fundamental right of consent and practice of safe medication administration practices with as much concern as we. They rightfully apologized and admitted they “could have done better” but their recommendations were meek and failed to specifically address the nature or implications
of the serious violations to sanctioned hospital policies.
We believe that the provision of appropriate medical treatment and care for infants born with what many believe to be “preventable” conditions via genetic screening, testing and termination is an acutely important matter. The choices of some must not be imposed on others.
Following a meeting with the High Commissioner’s Office in Geneva Switzerland, we
have been requested to keep that office informed of events.
The Coroners’ investigation and Report was fundamentally flawed for the following reasons;
1. There was no specific cause of death provided in the Report and yet, the Chief
Coroner recently verbally advised us that Annie died of “respiratory failure” due
to many causes. However, none of these causes were diagnosed, criticalsymptoms demanding a diagnosis existed for most of her short life and allcauses would have been treatable.
2. The Report stated that the Hospital does not have a protocol of
withholding life-saving treatment from infants with conditions related to
disabilities. According to the Report, this important conclusion was not based on
an investigation into the deaths of other infants but rather a chat with the Chaplain
and the Bioethics Department.
3. The Report stated that based on a forensic audit of the narcotic cabinet, the
conclusion could be made that all narcotics had been “accounted for providing
further evidence that no active steps were taken to bring about Annie’s death.”
(“Further” evidence or reference which might indicate the cause of the death or
that it was inevitable or unavoidable cannot be found in the Report.)
The facts are that:
· Massive quantities of narcotics (Morphine and Fentanyl) were signed out
for Annie in her final hours of life.
· There was no physician’s order for these medications.
· None of the narcotics are indicated as being wasted or returned.
· The final medication administration report is missing from Annie’s chart.
· The final nurse responsible for admitted breaches in multiple violations in
standard policies involving narcotic administration has left Canada and is
now registered in the US
· The Hospital has refused to allow a forensic audit of its
electronic system to prove or disprove the existence of the final
Medication Administration Report. They claim to download electronic
records such as this report onto a paper copy when a patient is discharged.
The Hospital, (an acknowledged leader in medical electronic health
records) further claims that it then “purges” the electronic files, and
rescans the entire paper chart back into the system. Therefore, deletions or
changes made to reports would not be auditable. Such a practice,
according to the experts we consulted, “…would seem to me to be quite
unbelievable” and, “With regard to institutions downloading data onto
hardcopy and purging the electronic record, the trend is exactly the
opposite. I have never heard of such a practice.”
4. The expert medical review, undertaken by the experienced physician, Dr. Paul
Byrne, who is board-certified in neonatology and paediatrics, substantiated our
concerns. Dr. Byrne’s review detailed 14 noteworthy errors or omissions which
challenge the validity and conclusions of the Report. Dr. Byrne’s review stated:
It is reprehensible and contrary to basic tenets of good practice of medicine that this infant was left to endure continual and progressive asphyxiation.
Annie’s rapid breathing, elevated carbon dioxide levels, acidosis, elevated bicarbonate levels were observed, accepted and disregarded. Annie did not receive testing and evaluations like other infants without a genetic label. When Annie could no longer continue to breathe fast enough and her kidney function was insufficient to compensate,sedation and narcotics were used.
My review of the issues surrounding medication procurement, administration and documentation in the final 3.5 hours based on the Narcotic Control Records as well asthe medical records lead me to conclude that the (Coroner’s) Committee took adismissive and cavalier view of the violations that occurred.Where is the final Medication Administration Record? Where are the missing narcotics?Assuming that these and other questions about the missing narcotics have been clarified beyond question, why can’t this significant information be shared with the general public? Unless there are adequate and sufficient explanations, aren’t we left with uncomforting, but plausible and suspicious speculations?
The medical treatment provided to Annie by the medical system did not reflect standards of practice, professional codes of ethics and family-centered care as described by Hospital Policies. Failures of this nature are not expected of pediatricians and pediatric specialists in any hospital, much less a hospital dedicated to the special needs and requirements to treat sick infants and children.
5. Recently, the Coroner’s Office declined our appeal for an inquest. This appeal had
been made with letters of support representing tens of thousands of vulnerable
citizens. The Chief Coroner provided no justification for this decision, and no
answers to our questions regarding our daughter’s death.
6. No autopsy was performed. When only Annie’s father was present, with Annie in
his arms and surrounded by young children, the physician insisted that he quickly
sign-off to decline an autopsy.
The Following are Some of the More Important Letters Related to our Journey.
1. First Letter to the hosptal regarding concerns. Dec. 4, 2005
2. Letter to Chief of Critical Care after Hospital Meeting of March 6, 2006
3. Letter to Hospital at the start of the Internal Review
4. Letter to Hospital advising of Violation of Coroner's Act
5. Response by Hospital Regarding Violation of Coroner's Act
6. Letter to Coroner at Initation of Review.
7. Letter to Coroner to appeal Death Review Committee Report
8. Letter to Coroner to Appeal for an Inquest.
9. Final Letter to Coroner to Appeal for an Inquest.