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    In 2008, Ontario taxpayers spent $112 million to subsidize the medical malpractice fees paid by doctors. Doctors themselves paid $24        million, which means taxpayers picked up 83 percent of the cost of the malpractice fees. The subsidies paid to the CMPA are part of a “Memorandum of Understanding” between the Ontario Ministry of Health, the Ontario Medical Association, and the Canadian Medical Protective Association. Details of this Memorandum of Understanding between the parties were kept from public view until a court ordered it released following a Freedom of Information request in 2008.

The CMPA defence fund is unlicensed, unregulated and not subject to public scrutiny of their books.”

 

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Comments on: "Make doctors accountable" (28)

  1. E Coady said:

    I think you should name the doctors involved publicly and let the chips fall where they may. If you are right then this doctor should be required to explain her actions in a court of law.

    • I WOULD LOVE TO NAME THE DOCTORS INVOLVED BUT I HAVE A COMPAINT AGAINST THEM AS WELL AS THE CORONER WITH THE COLLEGE OF PHYSICIANS AND SURGEONS AND I AM LOOKING AT TAKING LEGAL ACTION, SO I DON’T WANT TO SPOIL MY CHANCES WITH THESE. IT WILL ALL COME OUT EVENTUALLY. STAY TUNED.

  2. All the power to you with this issue. My son is the same age as Joshua and my heart and prayers are with you, your family and friends. I am also Bipolar and can relate to some of your son’s issues. I can’t believe what you have been through though. I was admitted to a Kitchener hospital (OD in 2005 or abouts) and they were exemplar there from the emergency to the psych ward but I do remember when Mental illness was a dirty word (a little better now) and the hospitals were absolutely terrible. I had an emergency nurse at the now ‘good’ hospital threaten to restrain me after a suicide attempt (back in 1986) because I was disturbing the ‘real sick people’ –I was hysterical because as they carried me out on a stretcher from our apt., my ex-husband threatened to kill my cat and to send our 5-mth baby away from home and then refused to come see me so I was very upset and thought I had a reason to be! The older gentle in the bed next to me was much more sympathetic and spoke back to the nurse for me (God bless people like him!). As for the nurse…I’d still like to kick her ass. And I support YOU in whatever you do to set Justice for your son. Good luck and God Bless. Some nurses and Doctors need a wake-up call to reality, sensitivity and accountability. xo.

    • thank you. I need all the support I can get as this is going to be an uphill battle all the way. I am very strong and not afraid of them.. They do not know who they picked on.

  3. thank you. I need all the support I can get as this is going to be an uphill battle all the way. I am very strong and not afraid of them.. They do not know who they picked on.

    • First and foremost, my deepest and sincerest condolences and warm wishes go out to you and your family in this very difficult time. As a mother myself, I can only imagine the pain of losing a child, this in itself is any mothers worst fears realized. Your story has touch my heart and know that you are in my prayers.
      Keep strong and keep fighting…in the end it will be your son looking down on you saying “Mom, we won”. I have signed the petition and will continue to follow you on your journey. God Bless you and your beautiful child.

  4. We had a problem with a female doctor at Cambridge Hospital.We rushed our 6yr old son by ambulance, he was dehydrated and lethargic from vomiting and diarrhea. Our 5 month old was sick too. This Dr discharged our baby without seeing him. We complained and this so called doctor refused to see our oldest son who was very very ill and on IV. We did get care but it was from the nurses. I spent every second with my son to make sure he was ok. A doctor did not see him untill four days later. It is a long long story but to cut it short….the behaviour of some of these Dr’s is sad and juvenile. I don’t know if this is the same doctor but contact me and I can tell you the name. We have not contacted the College of Physicians and Surgeons but maybe we should!

    • you should get the records from the hosptial. They have to give them to you. the phone number is 519-621-2330 x1382. then contact the physicians and surgeons with your complaint. If you don’t complain they will never know. It is important and it will make the doctor more carefull. I don’t want to share the names yet as I don’t want to jerpardize my options

  5. you should get the records from the hosptial. They have to give them to you. the phone number is 519-621-2330 x1382. then contact the physicians and surgeons with your complaint. If you don’t complain they will never know. It is important and it will make the doctor more carefull. I don’t want to share the names yet as I don’t want to jerpardize my options.

  6. My condolences to you and your family. I will never take myself or my children to CMH. I will travel to Brantford before I go there, which doesn’t help you much now. I believe that everyone who has a concern with any doctor or nurse should report it. They should be held accountable just like everyone else.
    My thoughts and prayers are with you.

  7. So sorry to hear about your son passing away. You should go to CTV News and share your story with them.

  8. Don’t vote for Rob Leone! That man can’t even call you directly. He has to have his assistant do his bidding. I am Josh’s aunt and I asked him for some help with the public inquest. He hid behind the fact that he can’t call the coroner’s office directly. What happened to going public and making public statements of support demanding these things. If Cambridge Hospital does not change it’s protocols, they will kill more people and not just in mental health. People being incapacitated and lying in a bed for more than 3 days happens for many rasons. They need a standard protocol to make sure people don’t die as a result of this type of issue. He obviously didn’t find the safetya of Cambridge residents to be a very important issue when it comes to their health. This is a big issue and everyone should be not using the Cambridge Hospital until they put in proper protocols. I thought Rob Leone was an elected official who was hear to help the people of Cambridge. I guess it is only where his personal mandate is concerned! It is absolutely disgusting!!!!!

  9. Corinne Comeau said:

    First i want to express how sorry I am for your loss. I have recently had an experience with the emergency and the so called mental health staff at Cambridge Memorial. I have three children that almost lost their mother because the so called caring staff laughed at me when i went to the emergency department begging for help. I was off my medication because i could not afford to renew my prescription. I wasn’t thinking straight and knowing from past mental issues i knew i had to get somewhere safe. I told them that i needed to talk to someone before i hurt myself. They sent me to the waiting room where it seemed like i was waiting forever. I left the hospital without telling anyone and went to my quiet place to try and calm down. Later that night I found out the hospital had sent the police to look for me and when they finally found me they threatened to arrest me if I did not go with them. I was taken back to the hospital. While i was there they sent a worker in to talk with me I was so worked up by this time that i just started rambling about everything. when i finally stopped talking he left the room and went to the nurses station and started laughing at me. Him and the nurses were staring right at me and laughing. I don’t know about you but mental health is not a laughing matter. About an hour later they sent me home.
    The next day i drove my vehicle into a hydro pole and was taken back to the hospital only this time in the back of an ambulance. I spent the night in emergency before going up to there glorious mental health ward. They do not know how to handle the really bad cases. It is like they are scared of them. If you can function somewhat normally they are fine with you but if you show any sign of anger or frustration they cop attitude with you. while i was there not once did they give me any medication which is what i drastically needed. After being let out for a two hour pass i returned with my wrist sliced by a piece of glass i had found behind the hospital. The next day they sent me home with no follow up apointment and no support of any kind. They just shoved me back into society to deal with my three kids by myself and not only put my life at risk but the lives of others as well.
    They Just Don’t Care.

    • I do believe you since I have witnessed this myself. Did you ever get your records from the hospital. They keep them for seven years. You can call the hospital and ask for patient records. It would be interesting to see what is written. Let me know if you need any help. They need to be exposed for the bad care they give so many.

  10. I was wondering how things went with the CPSO, did it get referred to Discipline or Fittness to Practise? Did you file a separate complaint with the College of nurses? How did you find the process?

  11. I had to go through the same experience. I lost my husband to that system. If I would publish my story, you would think, I would be a widow from Iran or Afghanistan ! Canadians have to learn to stand together, so these situations cannot continue !

  12. Just some information with regard to the OCPS. They will never really investigate a complaint. My daughter died 12 hours after being released from hospital. This College has rendered three decisions of which I have appeal to the Health Professions Appeal and Review Board twice and won. Now I have to appeal the College’s third decision.
    What the College likes to do is always reference a decision with “but this did not affect the unfortunate outcome” or something very similar.
    The Chief Coroner’s Office also failed to thoroughly investigate my daughter’s death and placed their first priority in protecting the surgeon and not the citizens of Ontario.

    See http://anangelinourlives-awk.blogspot.ca/ for whole story from the beginning.

    See below with respect to the College’s third decision:

    The College of Physicians and Surgeons render yet a third decision. Just as inept as the previous two. So once again I have appealed to the Health Professions Appeal and Review Board. This nonsense has been going on since 2007, now 7 years after Terra’s Death.

    The following statements regarding self-regulation are taken from the OCPS’s own website:

    “Physicians have been granted the privilege of self regulation. Society allows physicians to regulate themselves in return for the covenant that this regulation will occur in the public interest.”

    “Meeting these responsibilities requires efficient and appropriate governance and a reliable system of accountability. Fulfillment of this duty is essential to self-regulation.”

    “One important responsibility of the College of Physicians and Surgeons of Ontario is to respond to concerns and to investigate complaints from members of the public about doctors licensed to practice medicine in Ontario. In all that we do, the College must act first and foremost in the best interest of the public.”

    THEY CONTINUE TO FAIL!

    From their 3rd Decision!

    Now really who is the following really for except to “SWEET TALK” HPARB?

    ROLE OF THE COMMITTEE

    The College’s complaints process provides a route for members of the public to raise concerns about a doctor’s practice or conduct. The Regulated Health Professions Act requires the Committee to consider every complaint submitted to the College. The Committee, with the assistance of staff, conducts an investigation, then meets to review the written record of investigation and reach a decision.

    The Committee cannot award financial compensation of any kind. Its process is not focussed on determining liability, or on punishing doctors. The Committee evaluates the investigative information available. It then determines what action, if any, is warranted, taking into account the seriousness and context of the concerns raised, the physician’s insight into his or her practice, his or her capacity for remediation, and the physician’s relevant College history, if any.

    The Committee’s role, broadly, is to protect the public by determining whether remedial action is necessary and, if so, what action would best enhance the quality of medical care of the particular physician, and the general quality of medical care in Ontario, by reinforcing the standards of practice.

    The range of dispositions available to the Committee includes taking no further action, providing advice, cautioning a physician in writing or in person, or requiring a physician to complete a specified continuing education or remediation program.

    In a small number of very serious cases, the Committee may refer a specified allegation of professional misconduct or incompetence to the College’s Discipline Committee. The Committee will do this only where it believes that no alternative course of action could adequately protect the public interest, and that the available information has a reasonable chance of supporting a successful prosecution.

    The Committee appreciates Mr. Kilby’s action in bringing his concerns to the College’s attention. Public engagement aids the College in protecting the public interest and improving the quality of physicians’ care throughout the province. The Committee also acknowledges Dr. Klein for demonstrating professional accountability by providing a response.

    Now, really, Is the above not just a bunch of Bull Shit! They have proven over and over again that their first priority is to protect the surgeon, not Ontario patients or citizens.

    Committee’s Conclusion/Reasons

    The Committee has determined that the appropriate disposition is to advise Dr. Klein to individualize the use of pre-operative prophylactic antibiotics for patients where it is warranted based on the evolving standard of practice. This is an educational disposition, designed to assist the physician in improving future practice.

    In its July 2011 decision, the Committee issued a counsel to Dr. Klein on the timely documentation of discharge summaries, which the Board accepted as reasonable in its June 2012 decision. The Committee, therefore, includes this counsel to Dr. Klein as part of the current decision. A counsel [predecessor of the Advice disposition] is an educative disposition designed to guide a physician’s future practice.

    SUMMARY OF DISPOSITION

    For the reasons set out above, the Committee advises Dr. Klein to continue to consider the use of prophylactic antibiotics at the time of conversion from laparoscopic procedure to open laparotomy based on the evolving standard of practice.

    What a bunch of CRAP!

    I have sent the following today to HPARB.

    Attention: Ms Lori Coleman, Registrar
    The Health Professions Appeal and Review Board

    I request that the College’s third decision be reviewed by the Health Professions Appeal and Review Board.
    I have attached a copy of their third decision. You will note by reading it that they are presenting a new argument. That being, that Dr. Klein was not aware of the possibility of a colon resection until he conducted the open abdominal surgery. I have documented proof that he indeed did!

    They are now trying to backtrack on their comment with respect to “Neglected” and “Oversight”.

    You will also notice that the College spend a considerable amount “kissing up to HPARB” by explaining their role in investigating a complaint from the public. This was definitely not for my benefit!!!

    You will also notice that they seem to alway referred to the unfortunate outcome, (Terra’s death) when they make a statement with regard to her surgeon’s actions. The outcome is not a part of the complaint. They do so to make their statements appear to be correct. We are talking about the Standard of Care in 2006, NOT 2007, 2008, 2009, 2010, 2011, 2012, or 2013. Yes, a considerable amount of time as pass since the original complaint .

    ****************************************

    From the College’s Third Decision.

    Although conversion to open surgery is always a possibility, his intention was that the surgery would be performed laparoscopically to remove a mesenteric cyst. However, during the surgery he determined it was necessary to immediately remove what he suspected was more concerning than a simple mesenteric cyst. He could not rule out sarcoma at that time, and it was not until after he converted to a laparotomy that it was clear that this cyst could not be removed without a bowel resection.

    AWKILBY’s Response: The above is pure BS. He knew before he converted to a laparotomy!!

    Note the following: This proves that Dr. Klein was going to attempt laparoscopically a colon resection for a mesenteric mass. This was before he converted to a laparotomy!!!

    Note the Procedure Desc.
    Laparoscopic Colon Resection Attempted For Mesenteric Mass”

    The second Procedure Desc. indicates the laparotomy.

    AWKILBY’s Response: The College once again fails to thoroughly look at the Hospital Records. OOPS or is it intentional—- My claim it is intentional— three times they have studied the charts and still it is I who must point out the concerns substantiated by the records. Dear HPARB panel, please don’t let them make cover up this neglect to the Standards of Care for a fourth time!

    And from Dr. Taylors’(the College’s I.O)letter to Angela Bates

    May 8th, 2011,

    “During the surgery on July 11 2006, Dr. Klein realized that the mass was not separable from the colon or retroperitoneum and obtained consultation with a colleague and went ahead with an open right colectomy. This is well documented in the operative note on page 48.”

    OPERATIVE PROCEDURE 1-/ Diagnostic laparascopy

    2-/ Open right hemicolectomy and excision of mesenteric cyst.

    PROCEDURE;

    At the time of laparoscopy, a large cyst could be seen in the mesentery of the right colon. It was densely adherent to the bowel as well as densely adherent to the lateral abdominal wall. It felt very solid and not at all in keeping with a simple mesenteric cyst. We therefore made the decision to convert to an open procedure

    AWKILBY’s Response: So both proves Dr. Klein knew prior to conducting open abdominal surgery that a colon resection had to be performed. Why did he go ahead without ensuring my daughter received the mandatory antibiotic prophylaxis!

    AWK Note:— But when he discovered the mass could not be removed with the laparoscopic procedure, open abdominal surgery should not have gone ahead without the patient being properly prepared. This was not an emergency surgery but day surgery!

    WHY DOES THE COLLEGE NOT SEE THE ABOVE BUT THE COMPLAINANT CAN. — THEY HAVE CLEVERLY DISMISSED ALL OF MY OTHER CONCERNS BY QUALIFYING THEIR STATEMENTS SUCH AS:

    NOTICE HOW THEY SKIRT THE REAL ISSUES!

    The IO provider set out the following information in an addendum to the IO report:

    • The issue of antibiotic administration at the time of conversion to an open procedure is really not relevant to the outcome for this patient.

    AWKILBY’s Response: The outcome is not part of the complaint! *************************************************************
    • Most general and colorectal surgeons administer antibiotics preoperatively prior to laparoscopic or open colorectal surgery, as they have been shown to reduce the incidence of wound infection. Antibiotics, however, have not been shown to decrease the incidence of anastomotic leak.

    AWKILBY’s Response: Temporarily forget the anastomotic leak. The above statement indicates the Standard of Care that was not followed by Dr. Klein.

    • Many surgeons believe prophylactic postoperative antibiotics are unnecessary. They have very little impact on the incidence of wound infection.

    AWKILBY’s Response: Antibiotics after?????—–but she didn’t have the preoperative antibiotics which means the need for post antibiotics is cleverly minimized by the College!!!

    • The administration of antibiotics after the conversion to the open surgery would likely have been of little benefit in terms of preventing a postoperative wound infection and would only have had the potential of causing side effects, which included C. difficile colitis.

    AWKILBY’s Response: The conversion to open surgery should never have been done without antibiotic prophylaxis. This surgery should have been postponed so that the patient could be properly prepared!

    Dr. Klein provided the following information in response to the addendum and subsequent information from the IO provider:

    • He agrees with the IO provider that:

    o The issue of antibiotic administration had no bearing on the outcome of this case,

    o The only benefit of pre-operative prophylactic antibiotics is to prevent a
    postoperative wound infection,

    o Preoperative antibiotics have no preventative or beneficial effect for an anastomotic leak.

    AWKILBY’s Response: But she did have a post-operative infection! And what about the many negative bacillia seen?

    · The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by Dr. Klein in this case. The Committee would suggest that Dr. Klein consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case.

    AWKILBY’s Response: The outcome is not part of the complaint!

    • In addition to the IO provider’s views, the Committee notes that at this time there is no consensus in the medical community based on available research to support that antibiotics should be administered at the time of conversion from a laparoscopic procedure to an open laparotomy. As such, the Committee agrees with the IO that the administration of antibiotics at the time of the conversion would not be required to meet the standard of practice.

    AWKILBY’s Response: The above is pure BS. Gee what changed from your thorough examination done for the second complaint and your findings then? “Neglect” & “Oversight”

    Think about it,—a surgeon is going to make a 8 to 10 inch incision in your abdomen, spread it apart, move around some internal organs to get to the tumor, cut open a colon etc—–All done without antibiotic prophylaxis—-I DON’T THINK THIS IS A STANDARD OF CARE AND IT CLEARLY IDICATES NEGLIGENCE!!

    Further to this clarification, the Committee notes that, as supported by the IO, the lack of antibiotics in this case did not influence the unfortunate outcome, given there was no evidence of sepsis at the time of the discharge from the hospital.

    AWKILBY’s Response: The outcome is not part of the complaint! And there were numerous issues prior to her release that Dr. Klein ignored and the College supported this negligence.

    *********************************

    SUMMARY OF DISPOSITION
    For the reasons set out above, the Committee advises Dr. Klein to continue to consider the use of prophylactic antibiotics at the time of conversion from laparoscopic procedure to open laparotomy based on the evolving standard of practice.

    AWKILBY’s Response:
    This decision is BS — “consider the use of…”. Prospective Patients should be able to look up the Surgeon’s Record and be able to access decisions made concerning complaints against this Surgeon! If HPARB accepts this, the College could hide further or past complaints against this Doctor and Ontario citizens would never know.

    What also concerns me is a statement Dr. Klein made when a nurse asked him if antibiotics should be prescribed for the infected incision after all the staples had been removed. His response was “The Body Will Heal Itself.” I think this explains a lot about his belief in using antibiotic prophylaxis and post operative antibiotics. It would be extremely interesting to study the records of all patients undergoing surgery by Dr. Klein to see whether he has failed to use antibiotic prophylaxis and post operative antibiotics when the standards clearly indicate so, and what the results are with respect to infections and perhaps deaths!!!

    Ontario Facebook Users, please e-mail your MPP’s!

    • The hospital at their own expense created a Memorial Garden outside the front entrance.
      One would expect that both the Chief Coroner’s Office and the OCPS would be seen as proof of my concerns being real.

      Some Day Soon We’ll Be Together, Again
      April 22, 2012 at Terra’s Memorial Garden 1:00 pm LOVE DAD

      May visitors wonder why this is here?
      Hearing your story they may shed a tear.
      Your young life ended with much more to do.
      A beautiful soul left us too soon,
      Leaving behind in our hearts, a very deep wound.

      A symbol of negligence, a reminder to all,
      A warning for patients lest they befall.
      A Memorial Garden dedicated to you.
      For your family and friends, —-this— a symbol of love,
      Thinking of you, looking down from above.

      Still hiding the truth are those in the know,
      Lacking transparency and not willing to show.
      For surgeons and doctors you know what to do.
      Your patients require much more than your charm.
      Remember “primum non nocere–first, do no harm”!

      A sister, a daughter, a niece and a friend.
      All her love and friendship both did ascend
      To those she met and to those she knew.
      Was a compassionate , romantic and intelligent girl.
      Enthusiastically giving all experiences a whirl!

      The time will come when together we’ll be,
      Reunited again with our little “Louie”.
      Never more will we ever say “adieu”.
      Our caresses and kisses we will certainly regain
      Some day soon, —-we’ll be together again!

      ****************************************************
      The Chief Coroners Office of Ontario failed all citizens of Ontario when they did not grant

      me a public inquest, did not grant my request for Terra’s death to be looked into by the

      Patient Safety Death Panel and also refused my request for an Eastern Ontario Coroners

      Review. What are they trying to hide. Four years after the fact, they shut down the surgical

      department of the hospital due to a serious of deaths and brought in an expert to look at

      this department. Just think, lives may have been saved if they took Terra’s death seriously

      and my all of my requests.

  13. I presently have a complaint against the Chief Coroner’s Office of Ontario which is being reviewed by the DIOC— Death Investigative Oversight Council

    Death Investigation Oversight Council

    Dear Council Members

    My complaint is against the Chief Coroner’s Office and in particular, Dr. Lauwers and Dr. McCallum. I still maintain that Dr. McCallum error was supporting his subordinate’s flawed investigation into my daughter’s death. I am sure that Dr. Lauwers appreciated his support as a co-worker but Dr. McCallum failed the citizens of Ontario by doing so.

    I maintain that while conducting the investigation into my daughter’s death they purposely ignored, overlooked, and concealed factors related to my daughter’s death. Answering the mandated investigation questions is not their only important role to the citizens of Ontario.

    They failed to:
    1. Conduct a death investigation in a manner that is effective and accountable.

    2. Conduct a high quality death investigation to ensure that no death will be overlooked, concealed or ignored. (By basing all of their decision on a medical expert consultant whose report omitted numerous crucial factors)

    3. To help improve public safety and prevent deaths in similar circumstances (apparently there were 6 more deaths by the bariatric department of this hospital during 2009 and up to Feb. 2020 under similar circumstances—it is almost impossible for me to obtain the details but the Chief Coroner’s Office and the hospital would have them—–these deaths may have been prevented if my daughter’s death was thoroughly investigated) by denying my request for my daughter’s death to go before the Patient Safety Death Committee and denying my daughter’s death be looked into by the Eastern Ontario Coroner through a review. (I know that legislation prohibited me from questioning the denial of a public inquest which I feel definitely limits a citizen’s right to appeal a wrong decision)

    4. Making sure their concerns and needs of grieving families are met as this office has refused repeatedly to answer specific questions and concerns I have had and relayed to them. They have also refused to communicate with me via telephone, faxes, e-mails.

    They failed by:
    3. Overlooking, concealing and ignoring crucial factors related to my daughter’s
    care or lack of care which in turn did factor into her death

    Is it not incumbent for the Office whose finances are paid by the public purse to pursue and ensure patient safety is protected especially when the hospital refuses to answer the question from the grieving family? As well, I’m sure the attorneys and committee members are aware of the dismal record of investigations by the Ontario College of Physicians and Surgeons. The Chief Coroner’s Office has the authority through holding pubic inquests, utilizing the Patient Safety Death Committee and having Regional Coroner investigations to obtain these answers.
    *******************************************
    Dr A McCallum, Chief Coroner of Ontario’s comment, letter dated March 13, 2009

    “Given that the care was appropriate, (A Kilby note- not administering mandatory, preoperative antibiotic prophylaxis is not providing the standard of care!) it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance.”

    Letter dated March 13, 2009 from Dr A McCallum

    “As you are aware, I have some background knowledge regarding your daughter’s untimely and tragic death because I met with you and your wife after your daughter’s death in my capacity as Regional Supervising Coroner for Eastern Ontario, prior to my appointment as Chief Coroner.” “There has been a great deal of scrutiny or your daughter’s case. As part of that scrutiny, an expert review was obtained from an independent surgical consultant. Based on my review of the independent expert, review’s opinion, I conclude that there are no omissions or commissions during your daughter’s treatment that contributed to or caused your daughter’s death.”

    “Given that the care was appropriate, (A Kilby note- not administering mandatory, preoperative antibiotic prophylaxis is not providing the standard of care!) it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance.” Letter dated April 1, 2009 from Dr A. McCallum “While I realize that you have many remaining questions, I am not in position to respond. You may wish to speak with your daughter’s caregivers regarding these questions.” “However, I can state that our investigation did not reveal an issue in care that led to your daughter’s tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.”

    Letter dated November 17, 2008 from Dr A. Lauwers

    “You have requested that I review the quality of care that this patient received and I have done so.” “The operative procedure was carried out according to the appropriate standard of care and good decision making is evident.”“There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no need for supplements of things like Vitamin K and Calcium.”

    “While the patient suffered the most devastating complications of an operation, and specifically one of the common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. ” In spite of the outcome, I find no area of concern with respect to the standard of care she received.” (A Kilby note- not administering mandatory, preoperative antibiotic prophylaxis is not providing the standard of care!)

    How can you ignore the fact that anti-biotic prophylaxis was not done???

    Letter dated June 25, 2009 from Dr A. McCallum

    “As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter’s death. The Patient Safety Review Committee’s mandate is to look at systems issues contributing to a death. As there are no systems issues contributing to your daughter’s death identified by our investigation, it would not be appropriate to refer her case to that committee.”

    ***********************************************************
    NOW THE TRUTH.

    I have sent out more than 3,000 e-mails to surgeons in the USA and abroad. Not wanting to overburden them I simply asked the following questions as I feel that it does pertain to appropriate standard of care that the above feels Terra received. The surgeons names have been left off because I don’t trust the Chief Coroner’s Office.

    Should a patient undergoing colon resection via open abdominal surgery be given anti-biotic prophylaxis prior to commencing the operation?

    SOME RESPONSES I HAVE RECEIVED. NOTE: not one from within Canada
    I have over 100 replies from surgeons outside of Canada.

    1. Antibiotic dose within one hour of surgery that can be continued for up to 24hrs after surgery is standard of care. MD

    2. Bowel preparation and administration of antibiotics for prophylaxis prior to surgery have been a standard of care in surgery for at least 25 years. In my opinion you have every reason to deserve frank answers about what happened to your daughter.  MD

    3. There is no doubt she should have been given pre-operative and post operative antibiotics. MD

    4. I know that it is the accepted procedure to use prophylactic antibiotic coverage for colon surgery in the hospital where I work here in Denver, CO. I believe that is true throughout the US. It is disheartening to hear of the lack of transparency on the part of the medical / governmental establishment in the Canadian health care system.  MD

    5. I do think it is fair to say that a preoperative antibiotic dose for a colon resection is the standard of care in this country.  MD

    6. The standard of practice for prevention of wound infection in colon surgery is to use prophylactic antibiotics.  MD

    7. Yes antibiotic prophylaxis prior to colon surgery is standard. MD

    8. In the United States, it is standard of care to administer appropriate antibiotics within one hour of surgical incision for any case deemed at risk for infection. MD

    9. The Surgical Care Improvement Project (SCIP) has established clear guidelines on antibiotic prophylaxis prior to all surgery (timing, type). Here in the US our hospital is literally graded on compliance with the SCIP protocols. As a department chair I am responsible for compliance on my team and have to have appropriate procedures in place to assure compliance. MD

    10. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. MD

    11. It is standard of care in the United States that all patients undergoing bowel surgery should receive pre-operative prophylactic antibiotics at least 20 min before the incision is made.

    12. It is standard that all pts receive perioperataive antibiotics with a goal of administering them within 30 minutes prior to skin incision. It is a well validated quality outcome parameter. MD

    13. I really am sorry that the system has failed you so badly. I have no idea what happened with your daughter (proper care or not), but the system has certainly failed in that they have not allowed you to have closure.  MD

    14. Absolutely yes, it is malpractice not to!  MD

    15. . It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected. 

    16. I can only say by the description here that there must have been some kind of contamination either during or after surgery most likely coming from the bowel itself based on the gram negatives you describe. 

    17. Anti-biotic prophylaxis should be given at time of surgery according to practice guideline in US and in China as well while performing transabdominal colon resection based on evidence-based colorectal surgery.  MD

    18. Receiving ATBs preoperatively before an abdominal surgery is a standard of care.  MD

    19. I would conclude that she was poorly, even negligently served by the surgeon entrusted with her care.  MD

    20. The short answer to your question is yes, giving an antibiotic prior to an elective colon resection is the standard of care in the US. In the US the sequence of events that you describe would usually generate a lawsuit.  MD

    21. I know that it is the accepted procedure to use prophylactic antibiotic coverage for colon surgery in the hospital where I work here in Denver, CO. I believe that is true throughout the US. It is disheartening to hear of the lack of transparency on the part of the medical / governmental establishment in the Canadian health care system. MD

    22. In the United States, it is standard of care to administer appropriate antibiotics within one hour of surgical incision for any case deemed at risk for infection. We get in trouble for any case not administered and documented as such. MD

    23.. The short answer to your question is that, yes, antibiotics should be given prior to colon surgery (and most other surgeries for that matter). The discharge of somebody with abdominal distention who had undergone a wound packing for infection also seems well below acceptable standards here in the US. Usually if abdominal distention arises post op the etiology of that distention needs to be sought prior to discharge. MD

    24. It sounds like your daughter did not receive the appropriate standard of care. Patients undergoing colon resection (if not an emergency), should receive colonic cleansing pre-op. Additionally, all patients undergoing surgery should receive pre-operative antibiotics. It does not seem that her nutritional supplementation was adequate. Finally, it seems that she was discharged while still infected. MD

    25. I can only say by the description here that there must have been some kind of contamination either during or after surgery most likely coming from the bowel itself based on the gram negatives you describe. MD

    26. The short answer is obviously YES, your daughter should have been prepared for elective colon surgery with both a mechanical (purgation) and an antibiotic bowel preparation. These have been the standard for at least the last 30 years. Suffice it to say, on the basis of the few facts of your daughter’s case presented in your short email to me, I would conclude that she was poorly, even negligently served by the surgeon entrusted with her care. MD

    Why won’t those who supposedly investigated my daughter’s death answer my questions???

    Why was I denied a public inquest, denied having the Patient Safety Death Committee look into my daughter’s death, denied have an Eastern Ontario Coroner’s Review of my daughter’s death?

    PERHAPS, IF YOU WISH TO HELP, PLEASE CONTACT YOUR OWN MPP, IF HE/SHE IS A LIBERAL YOU WILL FIND NO SUPPORT AT ALL. YOU MAY WISH TO CONTACT the DIOC directly at DIOC@ontario.ca Kilby vs Chief Coroner’s Office

    Ontario citizens deserve more from this publicly paid institution.

    • Never give up Arnold
      The truth will come out

    • Why did woman die after routine surgery?
      Terra Dawn Kilby died at age 28 — and no one is to blame?

      By Alan Shanoff ,Toronto Sun

      First posted: Saturday, October 12, 2013 06:32 PM EDT

      Arnold Kilby wants answers. He wants to know why his daughter, Terra Dawn, died at the age of 28 after routine surgery to remove a noncancerous tumour from her abdomen.

      The operation took place in July, 2006 at Humber River Regional Hospital. Shortly after commencing the operation in a minimally invasive laparoscopic manner, the surgeon converted the surgery to an open operation.

      The surgery was said to have been “uneventful,” in other words successful.

      Terra was discharged on July 20. She was dead within hours of arriving at home and Kilby has been searching for answers ever since.

      Among his questions: Why was Terra discharged when, according to a decision by the Health Professions Appeal and Review Board, there were “consistent observations in the nursing charts of a foul odour and an oozing incision with large purulent discharge — commencing July 15 and continuing to the date of his daughter’s discharge”?

      Why was she released when her abdomen was distended, at a time when she hadn’t had a normal bowel movement?

      Why had the surgery taken place without the prior administration of antibiotics?

      Kilby didn’t sue. He didn’t want money; he wanted an apology, an acknowledgment of error and a commitment to fix things.

      So in 2007, he filed a complaint with the College of Physicians and Surgeons of Ontario complaints committee.

      But the CPSO dismissed the complaint. In doing so, it couldn’t come up with any reason why Terra died.

      Not satisfied, Kilby requested a review of the decision by the Health Professions Appeal and Review Board.

      The HPARB concluded the CPSO decision was unreasonable and sent the case back to the CPSO, directing it to address Kilby’s questions.

      The second CPSO decision wasn’t much better.

      There were answers of a sort, but the CPSO still wasn’t certain of what occurred. The direct cause of death could not be ascertained.

      Yet the CPSO was clear no one was to blame and there were no grounds for a disciplinary hearing against the surgeon.

      But the CPSO did caution the surgeon over his five-month delay in completing Dawn’s discharge summary and stated “the routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by (the surgeon) in this case. The Committee would suggest that (the surgeon) consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case.” The surgeon was told he “may wish to consider” the use of preoperative antibiotics in future cases.

      Of course Kilby sought review of the second CPSO decision. If the routine use of antibiotics prior to bowel surgery is “important” then why was the surgeon merely told to “consider” its use? How can we be sure the surgeon’s “oversight” did not contribute to Terra’s death?

      The HPARB agreed and sent the case back to the CPSO.

      The third CPSO decision didn’t advance the situation much further. There was still no answer as to the reason for Terra’s death. Kilby sought review by the HPARB for a third time.

      But this time the HPARB decided to uphold the CPSO decision. It’s almost as if the HPARB threw up its arms and said, “we’re sorry, we tried to help you but we are up against a brick wall.” So, six years after the initial complaint, with three CPSO investigations and three HPARB reviews, no one seems to know why Terra died.

      Barring any formal inquest, and Kilby has been denied his request to hold one, he still has no answers.

      He only has the fact of his daughter’s death, which apparently occurred for no reason. No one is to blame. No one was at fault. No one has apologized.
      But the hospital did create a memorial garden with a plaque in Terra’s name.
      ***************************************************
      Please respond to Mr Shanoff and ask for more articles delving into the cover-up of Terra Dawn’s death.

      alan.shanoff@sunmedia.ca

      Arnold Kilby

      Terra Dawn Kilby
      “An Angel In Our Lives”
      April 22/78 to July 21/06
      http://anangelinourlives-awk.blogspot.ca/
      No Accountability or Transparency in Ontario

      RESPONSES FROM SUN READERS ON LINE.

      Suchstuff
      Such a sad story made worse by the lack of closure for the family. There’s something really wrong with physician oversight that puts the interests of paying members before the interests of the public whom they have promised to protect. How can the hospital or physician learn from their mistakes if they won’t even acknowledge them? Oversight in name only from the College and again from our government’s HPARB – if they haven’t got any teeth – what’s the point of being there? This man has waited 7 years for an answer – shame on our health care system (and the fake oversight that goes with it) for ignoring and avoiding his questions.

      ***************************************
      bafflegab
      Anybody who has ever complained to the CPSO quickly discovers it is a waste of time. I know from experience. The CPSO let the public down with respect to the Dr.Charles Smith debacle – the Wia Ping butchery – and countless other public scandals. In every case we discover long after that the College had provided covered for the doctors rather than protected the public. And now this. The CPSO is not to be trusted. The CPSO promises to protect the public but in fact poses a danger to the public. The CPSO needs to be shut down and its cover-up artists (employees) need to move on to some other line of work. Something more honest. Put simply, everything you need to know about the CPSO (its investigators, its administrators and its executive) is clear from reading Mr. Shanoff’s accounting of it pathetic behaviour in this sad case.
      ******************************************
      John Kyndesen
      Like most so called “professional” review boards they sure circle the wagons in time of troubles. Eventually people get worn out or run out of money battering against the wall of silence that greets them and then it’s business as usual.
      ******************************************************
      Dachshunds
      My condolences Mr.Kilby, how truly tragic and unnecessary your daughters death must be, I hope you get the answers and apologies you so rightfully deserve. May your “Angel” rest in peace and may this never happen again to another family as the results from her unfortunate passing. I will hug my daughter a little closer today and hope something positive comes from all these inquiries and examinations of this “uneventful and successful” surgical procedure. My heart goes out to you and yours and I hope you can somehow find closure in this mess. You are a better man than I, Mr.Kilby and your daughter was very lucky to have a father such as yourself, its too bad she didn’t have a better surgeon. Bless you Mr.Kilby, and bless you Terra, lest your passing be in vain…David Clarke.
      ***************************************************
      Deepwell
      The college of physicians and surgeons is having a consultation on their transparency when it comes to complaints about their members. It’s an issue that affects all patients who have a right to know whether the doctor who treats them has a bad track record. Right now there is no transparency as Mr. Kilby has found out – the CPSO is all about protecting their members and nothing about protecting the public from bad doctoring like this. Consumers should let the college and our government know that we won’t tolerate abuse of the public in this way and that their lack of action to protect the vulnerable should result in charges against those who are contributing to wrongful deaths. If the CPSO isn’t part of the solution then they are part of the problem. Look up ‘draft transparency principals’ on the CPSO website – and let the cpso know that their oversight is worse than none at all – it is facilitating bad doctoring. Thank you Mr. Kilby (and Mr. Shanoff) for exposing this often fatal flaw of the lack of physician oversight in Ontario and my sincere sympathy for the loss of a loved one.
      *******************************************
      Ruledbythemoon
      They are scared of a lawsuit so nobody is going to put down anything concrete in writing that could be used later. Makes you wonder why we even have a review board?
      I had similar surgery at NYGH a couple years ago and they would not discharge me till I had pooped. Not easy when you are on a liquid diet but that was their rule.

      ******************************************
      InScarborough55*
      My sincerest condolences Mr. Kilby to you and your family. It is just so sad that someone is allowed to die because the supposed expert is incompetent. And then to have the board, supposedly put in place to oversee these experts and root out the bad ones, just defends them is beyond irrational.

      ********************************************
      G_Goon
      Don’t stop Mr. Kilby my wife works in the health care system all sorts of mistakes made that never see the light of day .So sorry for your loss stay strong stay focused.
      *************************************
      Z71guy
      I too was in a relationship with a critical care nurse who routinely told me of unreported medical errors committed by both doctors and nursing staff. I would wager that more lives are lost unnecessarily to medical treatment errors than impaired drivers. But where is the uprising of MADD – mothers against dumb doctors?? You’ll never see it because of coverups, lack of reporting and oh yeah, they bury their mistakes……unfortunately literally in cases such as Ms. Kilby’s.
      No SIU type agency to hold doctors to a higher standard, how long overdue is this? A doctor shortage? Pfffft….please. This is an internally controlled monopoly controlled by the college of physicians to keep supply low and their demand and earnings high. This province has many highly qualified medical applicants kept from becoming practicing doctors for made up conditions to control the supply of services. The numbers relegated to veterinary school or dentistry , qualified foreign doctors refused to be recognized just to control supply – absolutely criminal. The recent expansion of nurse practitioners needs to continue.. For logic sake there are medical apps available for iphones that can make many medical tests simpler and almost instantaneous. Doctors are not gods but unfortunately many feel they are. Keep the pressure on Mr. Kilby
      ***************************************************
      kickyourproblemstothecurb
      sir I saw the web page and am shocked that there was no inquest given the circumstances. I presume you have a COMPLETE copy of her chart.
      go through it with a very fine tooth comb. check for phone calls made to ANY doctor re the condition of the wound and any abnormal lab results or vital signs. after all, if they are documenting the bad condition of the wound before discharge, then they must of called a doctor to come and see it. and then the doctor called is responsible to act appropriately.frankly, wonder how she got discharged with a surgical wound in that condition. did the doctor who did the operation write the discharge orders?
      ps check the labs if any done the week of her discharge in particular the INR. and look at the medications she was on just before discharge. if she had a high INR then the doctor would have been called and a medication change order written.
      ps application called pocket lab values available for iphones, ipods through the apple web site. very easy to use and very informative.
      very sorry for the loss of your loved one. and i hope you get the answers you want. hope I’ve been of some help. we went looking for answers ourselves after losing a loved one years ago.
      OMG and he never ordered any anitbiotics? i am so sorry and frankly don’t understand how this happened.
      god bless you because you have the courage and strength to try to make sure this doesn’t happen to anyone else.

  14. Mike Patey said:

    Hey josh, your cousin mike here just wanted to say hi man, was thinking about you tonight and how much I missed you.. Going to Cambridge to see my dad just isn’t the same without you there… My girlfriends 19 year old sister is in the icu right now because she got in a car accident and hit her head, She’s been in a coma for
    almost 4 weeks now.. Being there I’ve
    noticed a lot of medical mistakes and it really bothers me and then makes me think about you and what you went through. I think it’s great that your mom took action into this to try and get things changed, and I support her all the way, good luck Mary and we support you!

    Your cousin mike

  15. ONTARIO, CANADA GRANTS SURGEONS/DOCTORS
    “MEDICAL IMMUNITY”

    The above title for this article is the absolute truth! After my seven plus year adventure searching for true transparency and accountability within Ontario’s health care system, I have come to accept this. The very institutions that supposedly protect patient safety are, in fact, covering up “adverse events” including deaths and harboring negligent surgeons and doctors. I am confident any Ontario citizen dealing with these institutions would agree.

    To provide some brief background, my daughter Terra Dawn went to the hospital for a scheduled day surgery to remove a tumor from within her abdomen. Now the procedure was to be done in a minimally evasive manner. (Laparascopic Surgery). The surgeon discovered the tumor was attached to the colon. He decided to change the procedure to open abdominal surgery to remove the tumor and perform a colon resection. Unfortunately, for my daughter, he did so without administering the mandatory “antibiotic prophylaxis”. In fact, no antibiotics were administered at any time prior, during, or post operation even when the abdominal infection became very infected leading to all the staples being removed and test results indicating “many gram negative bacilli”. My daughter bled to death less than 12 hours after being released from this hospital as the colon resection broke down due to “necrosis of the tissue”.

    The hospital took five months to provide me with the hospital records. I met with five administrators whereby they entered the room carrying only two blank scratch pads. They did not answer one single concern I addressed to them, except to defend their in-hospital mortality rate which was the second highest in all of Canada. After a three-year ongoing conversation, the COO of the hospital finally admitted there was no record of the antibiotic prophylaxis being administered. Of course, they would not provide any documentation I could use against the surgeon. They would not provide me with a copy of the internal hospital investigation. But, I do appreciate the hospital creating a memorial garden outside the main entrance with a plaque in Terra’s name. Thus, this is the first example of “medical immunity” given to the surgeon by a government funded (taxpayers’ dollar) institution.

    The local investigating coroner informed me the Chief Coroner’s Office of Ontario had deemed the death unusual and was going go look into the matter further. I had looked forward to this until they rendered their decision. The motto for this office is “We Speak For the Dead To Protect The Living”. I would discover, after many years, this to be a fallacy. When it comes to investigating a death associated with medical care or lack there of, this Office will ignore the evidence even when pointed out to them.

    This office denied my request for a public inquest, (they have never granted one involving a hospital), denied my request for my daughter’s death to go before the Patient Safety Death Panel, denied my request for an Eastern Ontario Regional Coroner’s Investigation, denied Mr. Robert Runciman my MPP, presently a Canadian Senator, to reconsider the public inquest, denied my request to assemble a Chief Coroner’s panel to look into Deputy Chief’s decisions, denied a request from the Ontario Ombudsman’s Office to meet with me and address my concerns and finally denied an Ontario Provincial Police Detective’s request to meet with me and address my concerns. No, instead they used their persuasive authority to contact the Toronto Metropolitan Police to investigate my e-mails. When the O.P.P. detective came to my home, he stated that the Chief Coroner’s Office had cut and pasted and taken my e-mails out of context. This was just an attempt to silence me! Did this stop my e-mailing and faxing? No! Behold, twice more I had to meet with this O.P.P. detective at the station for video taped interviews! Nothing even close to the laying of charges; it was merely a continued attempt to silence me. Gee, has this Office ever heard of “block sender” so they wouldn’t receive my e-mails? No, they wanted to continue to know what I might be up to. I found out later with the co-operation of the Chief Coroner’s Office this hospital department was shut down temporally in 2010 due to several (5 or 6) deaths similar to my daughter’s –bleeding to death. This is the second example of a government funded (taxpayers’ dollars) institution granting “medical immunity” to this surgeon.

    The third institution is not funded by the Ontario government but is supposed to be overseen by the Ministry of Health. C.T.V.’s “W-5” and the Toronto Star have in the past exposed the failings of the Ontario College of Physicians and Surgeons. They have been granted self-regulation and Ontario citizens are to go to them if they have a complaint against a doctor/surgeon. I did and they appeared very sincere and helpful, but only to make my complaint weaker. They suggested I rewrite my complaint so it would be more concise and actually did it for me and asked me to consent to the rewrite. What a mistake that was, easier for them to dismiss, but fortunately when I appeal it, I include my original. This College rendered its first decision after seven months. I appealed it and the decision was sent back. It then took more than 400 days to receive the second decision that I immediately appealed. The third decision was done in record time and of course I appealed this. At this time it should be noted that no Canadian doctor/surgeon would offer up an opinion with regard to the care of another Canadian doctor/surgeon. So, to prepare for all of my appeals, I sent more than 3,000 e-mails to surgeons throughout the world. I received more than 100 responses providing me with valuable expert opinions. This was a complete waste of my time as all institutions ignored these opinions. It should be noted that the College and their own expert stated in the second decision with regard to the mandatory antibiotic prophylaxis that the surgeon “neglected” this and that this was an “oversight”. Being a teacher, I am quite aware the noun form of neglected is “negligence” which is exactly what I was maintaining. If one goes to the College website, the surgeon’s record would be spotless, not even the lesser punitive warnings will show up. The College only acts if there is a police investigation involved, just look at their decisions over the years. (sexual impropriety, selling or using illegal drugs, defrauding the government and oh yes, I did discover that a doctor was severely reprimanded for prescribing drugs to his neighbour’s dog. Of course the complainant for this was the College of Veterinarians)
    Now, we have the third institution entrusted to protect patient safety opting to protect a surgeon’s reputation and grant this surgeon “medical immunity”

    One may expect, as I continue my quest for transparency and accountability, I could depend upon two institutions funded by the Ontario government (taxpayer’s dollars) and created to give citizens another avenue to pursue should he or she feel the College of Physicians and Surgeons had erred and/or the Chief Coroner’s Office had erred.
    These accountable institutions are, in fact, created to give the illusion that an Ontario citizen will not really recognize the mirage until they have closely examined it.

    The Health Professions Appeal and Review Board is what I turned to next. Their mandate is to look into College decisions when a complainant submits a request within 30 days of receiving the College’s decision. I have made three requests and submissions to this board and had moderate success with the first two appeals and was totally bewildered by the third appeal decision. This Board can only examine to see if the College’s decisions are “adequate” and “reasonable”. I somehow expected the College’s decisions would be held to a higher degree! This Board totally ignored my expert’s opinions, the irrefutable facts contained within the hospital records, and documentation from medical books, journals, articles etc. and the panel without question accepted the College Of Physicians and Surgeons’ unsupported opinions. Oh yes, it should be noted that a College representative is not required to appear before this H.P.A.R.B. panel and they do not! Their attendance is via a telephone conference call even though the College’s Offices are within walking distance to the H.P.A.R.B. office building. I traveled over 300 kilometers to be present. This panel and the Board lack plain common sense. If H.P.A.R.B. felt they couldn’t do an “adequate” and “reasonable” job, it should be asking the Ontario Government through legislation to give them more authority. After all, all they can judge the College is on adequacy and reasonability! The fourth institution within Ontario to grant a surgeon/doctor “medical immunity”!

    The fifth institution is the Death Investigative Oversight Council created to handle complaint against the Chief Coroner’s Office. Its own mandate states when an Ontario citizen submits a complaint against the Chief Coroner it is to be handled immediately.
    Well, two years after my initial submission, they started to investigate.
    It should be noted they failed immediately with respect to transparency and accountability as they meet behind closed doors and the complainant and the public is prevented from attending. Now there is an excellent start to a citizen’s complaint! When I received their decision approximately two and a half years after my submission, I was shocked to see they can not comment on the medical aspects of my daughter’s care!
    So, why were they created as an avenue for one to pursue? Of course, any complaint against the Chief Coroner would have to be about a death investigation, and of course, it would have medical aspects related to the case. Again, we have another government funded (taxpayers’ dollars) institution within Ontario that has granted “medical immunity” to a surgeon by not challenging the effectiveness of a death investigation by the Chief Coroner’s Office of Ontario.

    At this point, a reader may ponder, “Why did Mr. Kilby not pursue a malpractice suit?” Three law firms stated that the expense would be great, as would the amount of time that would go by. Should I win, the judgment would be between $45,000 and $135,000. This is not the United States of America. This was never about money, but the truth, transparency and accountability. As well, the Canadian Medical Protection Association (the medical insurer for all Canadian doctors) has of this date a Three Billion Dollar Reserve Fund to be used to provide legal council and to settle malpractice suit that would be the last thing they would do, and only after years of exhausting delays to a trial. Every trick in the book would be used with the intent of draining you financially, emotionally and physically. One must wonder why our own Ontario Government pays 85% of the surgeons/doctors membership fees (insurance) to the C.M.P.A.?

    The final institution to grant “medical immunity” to Ontario surgeons and doctors is our Liberal Provincial Government, and unfortunately all MPP’s within Ontario whose salaries are paid for by Ontario taxpayers. I have sent e-mails, and faxes continuously throughout the years pleading for the Premier, his Ministers and his Caucus to look into my substantial and very serious concerns and have been totally ignored. Unfortunately, the Conservative and New Democratic Party have failed not only me but also all the citizens of Ontario. So they have become the final party to grant “medical immunity” to all surgeons/doctors within Ontario.

    It is so wrong to think this, but I am convinced. In a hospital setting a surgeon/doctor could actually commit a murder and get away with it. They are getting away with negligence contributing to adverse events and deaths taking place in hospitals with no fear of being reprimanded or held accountable. The record of Terra’s surgeon remains spotless although there are more deaths associated with him, and there is no way for citizens to be aware of his past. This is the reality within Ontario.

    I would propose the Ontario Government abolish the H.P.A.R.B.’s and the D.I.O.C.’s authority to investigate complaints submitted by Ontario citizens and use this financial savings to allow the Ontario Ombudsman to expand their role. (Ontario is the only province/territory whereby he does not have the authority to investigate Health Institutions or those related to it)

    This article is dedicated to my daughter, Terra Dawn Kilby, An Angel In Our Lives and to all citizens of Ontario who have been abused by the non-transparency and un accountability in this province and those that will encounter the same in the future.

    My love, prayers and best wishes go out to you all.

    A.W. Kilby 888 Country Rd 2 Lansdowne, Ontario K0E 1L0 1-613-659-2906

    TEARS BEFORE WE SLEEP

    As we lie within our beds,
    Streaming tears are always shed.
    This occurs each evening and night,
    Waiting for dawn’s first light.

    Thoughts of you are all around,
    With many restless nights abound.
    Awaking each morning I still dread,
    Wishing and hoping, I was dead.

    Your sister and you were very tight;
    Continuing on is quite a fight.
    Loneliness, emptiness brings us down,
    No peace as yet— have we found?

    Teardrops fall upon the pillowcase,
    With memories of you, a beautiful face.
    A mother’s love forever there,
    A heart weighted down with such despair.

    Terra, we see you most every day,
    In our minds and hearts to forever stay.
    Four family hearts in full embrace,
    Will eventually meet in a higher place.

    People pass by us — so unaware–,
    It’s like we are playing solitaire.
    Our tearful lives in such disarray,
    But loving you won’t fade away.
    Love Always,
    DAD

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