http://www.ontla.on.ca/web/house-proceedings/house_detail.do?Date=2008-12-02&Parl=39&Sess=1&locale=en#P655_170736

LEGISLATIVE ASSEMBLY OF ONTARIO

ASSEMBLÉE LÉGISLATIVE DE L'ONTARIO

Tuesday 2 December 2008 Mardi 2 décembre 2008

ORDERS OF THE DAY

CORONERS AMENDMENT ACT, 2008 /
LOI DE 2008 MODIFIANT
LA LOI SUR LES CORONERS

"There can be nothing more tragic than the death of a child. Many families have already been through so much more than many of us could imagine. So, too, are miscarriages of justice tragedies for our justice system and for the individuals affected." That takes me to a letter I'd like to read into the record today from the Farlow family, and the Farlow family is with us today. Tim and Barbara Farlow are in the members' gallery, along with their children Rob, Jack and Jenn. I'd like to welcome them here today. They have been very, very strong advocates on a case involving their little sister and daughter. I think if this legislation can prevent what happened to the Farlows from happening to other people, then it will be a success. The letter reads:

"Dear Mr. Dunlop:

"We would like to share our family's experience with the Ontario coroner's office at this critical time when the Coroners Act is being amended.

"The motto for the coroner's office is, 'We speak for the dead to protect the living.' Thank you, Mr. Dunlop, for providing a voice for our baby daughter, Annie. The coroner's office has failed to do so.

"Three years ago, our 80-day-old daughter"-and that's 80 days-"died at an Ontario hospital under a very disturbing set of circumstances. We raised the issues with the hospital and received letters of apology from hospital executives and from its chief of critical care. However, we could not resolve the problems with effective recommendations.

"We became aware that the hospital was in violation of the Coroners Act and once we alerted the president of this, the coroner was notified immediately.

"This is when our dealings with the coroner's office began. We first met with Dr. Jim Cairns in June 2006 and we placed blind trust in his expertise and integrity and that of the coroner's office.

"Dr. Cairns told us that the pediatric death review committee would investigate Annie's death. He said, 'Don't worry, I carry a big stick. I foresee that I will chair a meeting between you and the hospital once the review is finished in two or three months.'

"We had two goals: (1) to understand why or how Annie died, and (2) to obtain recommendations from the coroner to ensure that another child would not suffer and die in the same way.

"Our daughter was born with a serious and complex condition. We expected to make 'best-interests' decisions for her, and with the advice of her doctors.

"Something went very wrong with Annie's medical care. She died in a tragic set of circumstances within 24 hours of arrival at the hospital. Annie developed respiratory distress and the doctors told us it was pneumonia. A few hours after arrival, our daughter had a respiratory crash.

"When this happens, everyone is supposed to come running from all directions. For over one hour we stood there alone with the therapist, who was bagging Annie to help her breathe, until finally, the doctor called the critical care unit.

"Annie died 16 hours later. They told us she needed a type of surgery that she would not survive. Of course, we trusted and respected the doctors.

"When Annie stopped breathing we did not want her to be put on life support because we were told there was no hope.

"Days after our daughter's death, we realized that many things didn't make sense. We obtained a copy of the medical records. Our instincts were confirmed when a nurse with 10 years experience in a critical care unit reviewed the records. She said, 'I'm sorry, what happened wasn't right.'

0950

"Here is what we learned:

"-A 'do not resuscitate' order had been placed in the records before we gave consent;

"-No diagnostic tests had been done. There were many things that could have been wrong with Annie and many were treatable.

"-The final medication report was missing.

"We were in shock. We were so sad that our daughter died in this way.

"After nine months the coroner's review was complete. There was no meeting chaired with the hospital as Dr. Cairns had told us. The report stated that the care provided in the final 24 hours was not appropriate but before that the committee thought that Annie's care was reasonable and appropriate. The diagnosis for pneumonia was not definitive. No specific cause of death could be determined, but the report stated that the death was natural. It also stated that it was not certain that our daughter needed the stressful surgery. The committee made only two recommendations. The first was that they should do a forensic audit of the narcotic cabinet from the day that Annie had died. The audit was done and the report stated that all the narcotics were accounted for and that no active steps were taken to bring about Annie's death. The second was that the hospital should make sure other hospitals knew about their patient-centred care policies.

"We were very upset. These recommendations would not change anything.

"We met with Dr. Cairns. He refused to answer our questions about what happened on Annie's last day. We asked, 'How much narcotics were signed out for Annie?' Dr. Cairns said he did not need to tell us that. He became angry with our many questions and refused to answer them. He told us, 'The committee determined that your daughter's final care was not appropriate. You can go to the college or the civil or criminal court. That is not my call.'

"That was not what we wanted. There was something wrong with the system, not just one doctor. We believe that there was a problem with the medical care provided to children like Annie. All we wanted was to understand what happened and ensure changes were made. The coroner's office is the only body that has the expertise to review medical deaths and make recommendations.

"Besides, children like Annie have no protection in the legal system and a senior crown prosecutor told us that no matter what, they would not investigate.

"We decided to appeal for a coroner's inquest.

"We met with leaders from most of the major disability groups and with Senator Sharon Carstairs, who had authored many studies on end-of-life care. The groups understood our concerns and supported us. They all wrote letters to the coroner in support of our appeal for an inquest. The letters represented tens of thousands of vulnerable lives.

"The executive director of Community Living Ontario wrote a letter to the chief coroner. It stated: 'Nothing (the parents) have learned and communicated to us convinces either them or us that an inquest is unnecessary in this tragic case. In fact, the persistent attempts to close the book on this matter convince us all the more that it ought to be fully opened to public scrutiny.'

"Meantime we obtained copies of the narcotic sign-out sheets through freedom-of-information legislation. Dr. Cairns had refused to tell us how much narcotics had been signed out for Annie.

"We learned that in the final hours, two lethal doses of narcotics were removed from the narcotic cabinet with no doctor's order. We were very concerned.

"We decided to have a medical expert review our daughter's records.

"The reviewer informed us that our daughter endured continual and progressive asphyxiation from the fifth day of her life. He wrote, 'I am in complete disagreement with the coroner's reference that the early management of treatments and care of Annie's respiratory insufficiency were reasonable or appropriate.'

"With respect to the missing narcotics and the missing medication records, the reviewer wrote that the coroner's committee took 'a dismissive and cavalier view of the violations.' He wrote, 'Unless there are adequate and sufficient explanations, aren't we left with uncomforting but plausible and suspicious speculations?'

"Our medical reviewer also documented 14 material errors in the 19-page coroner's report.

"In June of this year, we received a letter telling us tersely that our appeal for a coroner's inquest was denied. There was no justification and no answers to our questions.

"We wrote a letter to the new chief coroner, Dr. McCallum, asking him how it was determined that the narcotics were accounted for.

"Dr. McCallum wrote that there was no provision in the Coroners Act for him to review the case subsequent to the denial of an appeal for an inquest.

"He added, 'The matter is therefore concluded from our perspective.'

"After three years, we find it difficult to believe that we do not know how or why our daughter died or why it cannot be determined.

"Annie's death raises three major concerns related to the system.

"(1) There is a need to review the prenatal genetics program and the effect of the treatment of infants with genetic conditions.

"(2) Transparency is required regarding the admission criteria to the intensive care unit and the manner in which narcotics are used.

"(3) There is a need to review why there is no protection in Ontario for vulnerable lives like Annie's.

"On September 24 of this year we wrote a letter to Minister Bartolucci. We questioned the conduct and accountability of the coroner's office. We wrote that we were looking for proof and assurance that our daughter's death was natural and inevitable. We are still waiting for a response.

"All that we asked of the medical system was to give Annie a chance if it seemed to be in her best interests. Otherwise, we wished for her to have a peaceful and dignified death. When a child suffers without need and dies in this manner, something is very wrong.

"Hubert Humphrey wrote: 'The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, needy and the handicapped.'

"Mr. Dunlop, we feel the coroner'� s office failed us. We are of the supportable position that the coroner is deliberately withholding the truth. With the scathing conclusions of the Goudge inquiry, all Ontarians are left with justifiably shaken confidence in the accuracy of the coroner's office reports.

"We feel the coroner's office has proven to be incapable of policing itself and ask that you propose adequate checks and balances are installed to ensure the coroner's office can meet its mandate."

That's signed by Barbara and Tim Farlow. They are members of Patients for Patient Safety Canada. I want to thank them for being here today and for their persistence in this case. It's people like the Farlows who bring about the reason for change and the reason why we're here today. What I would like to say as we move forward with this is that this shouldn't happen to any family. In the end, the results of the inquiry and the passing of Bill 115 have to make sure that that transparency is in place so all of these types of questions are answered.