Fatality inquiry report

Report to the Minister of Justice
and Attorney General
Public Fatality Inquiry
WHEREAS a Public Inquiry was held at the Date and Time of Death:
Royal Alexandra Hospital, Edmonton, Alberta Medical Cause of Death:
(“cause of death” means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)). Manner of Death:
(“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable – The Fatality Inquiries Act, Section 1(h)). Report – Page 2 of 2
Circumstances under which Death occurred:
Recommendations for the prevention of similar deaths:
A Judge of the Provincial Court of Alberta Introduction
On July 29, 2007, Corona Dorinea McChesney (“McChesney”) died at the Royal Alexandra Hospital as a result of head injuries sustained in an accident which occurred outside of the Glenrose Hospital on July 26, 2007, when the wheelchair that she was using overturned. The public fatality inquiry into this incident took place on September 17, 2009. Medical Treatment Prior to Accident
In June of 2007, McChesney was a 69 year old woman who had been admitted to the University of Alberta Hospital in Edmonton, Alberta, for a T6-T7 transthoracic endoscopic discectomy. Post operatively, McChesney had reduced neurological function with no voluntary movement of her legs. Her condition was described in her medical charts as a “T6-T5 On June 28, 2007, McChesney was transferred from the University of Alberta Hospital to the Glenose Hospital to undergo a program of rehabilitation. On arrival at the Glenrose Hospital, in addition to paraplegia, McChesney was also noted to have significant bruising in the abdomen and to most of the left arm. She had also been experiencing nose bleeds and vaginal bleeding. McChesney had a history of coronary artery disease which resulted in a myocardial infraction in 2004 and the insertion of a stent in 2007. She also had hypertension (high blood pressure) and hypercholesterolemia (high blood cholesterol). While at the Glenrose Hospital, McChesney received medications including a combination of aspirin and Plavix in connection with her coronary artery disease. In addition, she had been prescribed and was receiving Fragmin and an anticoagulant, Heparin, for deep vein thrombosis prevention. McChesney was also prescribed and was taking Baclofen for spasms. An initial physiotherapy assessment was undertaken at Glenrose Hospital on June 29, 2007. The results of that assessment contemplated that a manual wheelchair would be ordered for McChesney “ASAP” and that she would participate in a wheelchair skills class. A rehabilitation program began immediately on the basis of a treatment plan which included range of motion exercises, strengthening exercises, mat work, transfer training, balance training, patient education and wheelchair skills training. The physical therapy program designed for McChesney included a direct physical therapy session for one hour per day for the time that she was at the Glenrose Hospital. On July 11, 2007, a multi-disciplinary program conference was held. Participants in the conference included the attending physician, Dr. John Guthrie, as well as representatives from nursing, occupational therapy and physiotherapy. At the time of the conference it was reported that, from a medical perspective, McChesney was doing “amazingly well”. From a physical therapy perspective McChesney was reported as being very coordinated although she had “poor sitting balance”. The goals for McChesney included mobility, strengthening and wheelchair skills. Overall, the physiotherapist reported that McChesney was “doing better than In the very early morning hours of July 26, 2007, approximately 16 hours prior to the time of the accident which lead to her death, McChesney began to develop spasms in her legs which were much stronger than any spasms she had previously experienced. In addition, McChesney complained of nausea. The resident on call, Dr. Matthew Prowse, attended on McChesney at approximately 2:45 a.m. In evidence Dr. Prowse indicated that spasms could be of some concern for a patient with a spinal cord injury such as McChesney because it could be an indicator of potential infection or a potential cardiac issue. Dr. Prowse conducted a “full head to toe assessment”, including an electrocardiogram to rule out any potential cardiac issues. In addition, he gave instructions for a urine sample to be taken to rule out potential infection. During the course of his assessment, the spasms spontaneously resolved and Dr. Prowse concluded that no further investigation was required. Wheelchair Selection, Training and Set Up
Karen Benterud (“Benterud”) is an experienced physiotherapist who graduated with a B.Sc in physiotherapy from the University of Alberta in 1992. After working for a number of years in acute care settings in hospitals in Alberta and abroad, she came to the Glenrose Hospital in 2000 to work as a physiotherapist in the spinal cord injury unit. Benterud was directly involved in the initial assessment of McChesney on June 29, 2007 and participated in the July 11, 2007 multi-disciplinary conference. Benterud was McChesney’s primary care physical therapist and in that capacity directly assisted McChesney in her rehabilitation program on five occasions between June 29, 2007 and July 23, 2007, when Benterud left on her vacation. Benterud had no involvement of any kind with McChesney from July 23, 2007 to July 26, 2007, the date of the accident which Early in the rehabilitation program, Benterud discussed the wheelchair options which were available to McChesney. The factors which need to be taken into account when selecting a wheelchair include comfort, safety and mobility. The options for a wheelchair included both a rigid chair or a heavier folding chair. Based on her assessment, Benterud concluded that either The wheelchair originally used by McChesney was a folding wheelchair owned by the Glenrose Hospital. However, after an initial trial with a folding wheelchair, McChesney requested a trial of a lighter rigid chair which Benterud concluded would be a good choice for McChesney’s propulsion and mobility. As a result, a Quickie GT model was ordered on a trial basis for Benterud conducted an initial assessment of McChesney’s wheelchair skills. This assessment was conducted while McChesney was using the heavier folding wheelchair, and included observations of McChesney undertaking rudimentary movements such as turns, entry into and exit from the elevator and into and out of the bathroom. When Benterud was satisfied that McChesney was independent in those basic maneuvers she referred McChesney to the wheelchair skills class which was taught by a physiotherapist assistant. A large component of the skills classes related to safety issues, including risks associated with the use of the wheelchair on uneven surfaces, issues associated with reaching or leaning from the wheelchair and circumstances which could result in the wheelchair tipping over. As part of the wheelchair skills class, McChesney was taken outside of the Glenrose Hospital to a patio area which consisted, in part, of a flat concrete surface but which also consisted of a patio constructed of interlocking bricks. The patio area also had a number of obstacles, including large concrete planters and picnic tables. The skills class which McChesney participated in also required her to use the wheel chair on uneven surfaces and on slopes. The classes were designed to simulate real life situations which students could and would face upon discharge from the Glenrose program. Based upon her assessment, Benterud had no concerns with McChesney’s use of the wheelchair. She described McChesney as a “cautious user” and as a person who was not a Joshua Bashow (“Bashow”) is a physiotherapist on staff at the Glenrose Hospital. He graduated from the University of Alberta with a B.Sc in physiotherapy in 2001 and has been employed with the Glenrose Hospital since the spring of 2002. Bashow had limited involvement with McChesney prior to July 26, 2007 although on approximately two or three occasions, while Benterud was away on holidays, he assisted McChesney in developing a series of sitting balance techniques and also with transfers from a In addition, and while Benterud was away on holidays, Bashow was involved in making arrangements for McChesney to begin a trial with the Quickie GT model wheelchair which had been supplied and serviced by Echo Medical Equipment Ltd. (“Echo”). The Quickie GT model was delivered to Glenrose prior to July 26, 2007, but it remained in storage until an Echo representative could attend at the hospital to make the necessary adjustments to the Michael Constanzo (“Constanzo”) has been an employee of Echo since approximately 1980. In July 2007, he was a part owner of the company and was also the sales manager. He described Echo as being in the business of supplying and servicing medical rehabilitation equipment, On the morning of July 26, 2007, Constanzo attended at the Glenrose Hospital and met with Bashow, who requested that Constanzo make the necessary adjustments so that the Quickie GT would be as stable as possible for McChesney. The Quickie GT is a rigid wheelchair which, according to Constanzo, is one of the lighter wheelchairs on the market. It comes with a number of safety features including, in particular, a seatbelt and also “anti-tipping bars” at the rear of the wheelchair to reduce the risk that the chair will tip over backwards. In addition, the Quickie GT was designed with the rear wheels cambered at an angle of six degrees to add to the stability of the chair. The Quickie GT was first available to Echo in early 2004 and thus, at the time of the accident, Echo had approximately two and one half years experience with the model. The Quickie GT was, according to Benterud, frequently in use at the Glenrose Hospital. Prior to July 26, 2007, neither Constanzo nor Benterud were aware of any problems experienced by the Quickie GT To accommodate Bashow’s request for maximum stability, Constanzo made three adjustments the rear wheels were moved back on the frame to increase the wheel length and the rear of the seat was slightly elevated to reduce the risk of backward tip-overs; the back of the chair was slightly opened by approximately ten degrees from the Constanzo described these as standard adjustments to make the chair more stable. During the 27 years which Constanzo was in the industry he had participated in a number of hands-on training sessions provided by manufacturers. He had not, however, taken any training which On the afternoon of July 26, 2007, Bashow met with McChesney and provided her with the Quickie GT model wheelchair. Bashow observed McChesney in the operation of the wheelchair and specifically noted that she had the seatbelt engaged and the anti-tipping bars were in position. Bashow had no concerns with respect to McChesney’s use of the Quickie GT and, as a result, he left McChesney with the physical therapy assistant who continued with the wheelchair skills class. The physical therapy assistant reported to Bashow after the skills class on July 26, 2007 and advised that McChesney had done “very well” with the wheelchair both indoors and outdoors. The only difficulty experienced by McChesney in the wheelchair skills class that day was in moving up ramps where she needed assistance. The Accident
On Thursday, July 26, 2007, shortly before 6:00 p.m., an unknown visitor at the Glenrose Hospital attended at the front desk and advised a security officer that a patient had fallen from a wheelchair in the picnic area located east of the main entrance to the hospital. The security officer directed a second security officer, Derek Campbell (“Campbell”), to investigate. On arrival at the picnic area, Campbell found McChesney in a wheelchair which was laying on the ground on its right side. McChesney’s seatbelt was on and her head was pressed against the base of a concrete planter. McChesney was being attended to by Dr. Curtis Hlushak. Campbell spoke to McChesney on his arrival. McChesney reported to Campbell that: she had been in her wheelchair moving backwards between two planters to get out of the sun when she became stuck. She attempted to free the wheelchair and this resulted in it flipping backwards on top of her; the wheelchair was new and she was not used to it; and she had almost fallen earlier that day however someone behind her had caught the chair and prevented it from falling. There were no witnesses to the incident and therefore the only evidence available regarding the accident consisted of the physical observations of McChesney in the wheelchair immediately following the event and the verbal report provided by McChesney. Campbell found McChesney seat belted into her wheelchair which was lying on its side. I conclude that it would be virtually impossible for a wheelchair to flip over backwards and yet be found lying on its side as reported by Campbell. Furthermore, the wheelchair was equipped with anti-tipping bars which would reduce the risk of backwards tipping. On the basis of the evidence that is available, I conclude that McChesney fell over sideways in her wheelchair and struck her head on the concrete planter. I conclude that she did not fall over backwards in her wheelchair as was reported to Campbell. I thus conclude that the comments which were made by McChesney to Campbell immediately following the accident were inaccurate, likely because in the accident McChesney struck her head on the planter and was somewhat confused. Medical Response to the Accident
The nursing response team at the Glenrose Hospital was alerted to the accident by pager at approximately 6:30 p.m. Bonnie Thomas, R.N. (“Thomas”), was a part of the team which responded to the accident. On her arrival at 6:36 p.m., she and her partner, Patricia Mitchell, saw that McChesney was on the ground out of the wheelchair and that she was being attended to by a physician and by a security guard. Dr. Hlushak, Campbell and Thomas assisted McChesney into her wheelchair. Thomas then undertook a cursory medical assessment by obtaining her pulse, respiration, blood pressure and oxygen saturation levels. Thomas also noticed a small scratch on McChesney’s right wrist and a small bump on the back of her head which was tender to the touch. McChesney’s pupils After being examined, McChesney was returned to Unit 3B where she was monitored by medical and nursing staff. On arrival at the unit, nursing staff noticed that McChesney was oriented as to person, place and time. She reported no loss of consciousness in the incident but was observed to have a bump on the right side of the back of her head as well as bruising to the inside of her right elbow. She also had a cut to the top of her right wrist. Nursing staff assisted McChesney with a shower, cleaned her wounds and settled her into bed. At approximately 7:15 p.m., a Licensed Practical Nurse (“LPN”) again checked on McChesney and found that she was complaining of headaches and nausea, and had discharged approximately 50 ml of vomit. The LPN notified the Registered Nurse, Norma Golemblski (“Golemblski”), who in turn placed a call to Dr. Matthew Prowse, the resident on call that evening. Dr. Prowse was briefed regarding McChesney’s fall earlier that evening and, in addition, was briefed on her progress in hospital following the incident. Dr. Prowse had some familiarity with McChesney since he had assessed her in the early morning hours of that day. Dr. Prowse was aware that McChesney was taking anti-coagulant medication, Heparin, and was aware that the anti-coagulant medication increased the risks associated with a patient with a head injury. He explained in evidence that he took this into account when considering the information provided by Golembski in connection with McChesney’s condition at 7:15 p.m. on July 26, 2007. Dr. Prowse directed that McChesney be monitored for the next one half hour and that her neuro-vital signs be taken every two hours. In addition, Dr. Prowse advised that he should be contacted again if there were any changes in McChesney’s symptoms or if she developed any new symptoms such as, in particular, blurred vision. At 8:00 p.m. on July 26, 2007, the LPN attended on McChesney and provided her with her anti- At 10:00 p.m. on July 26, 2007, the LPN again checked on McChesney and found that she was resting quietly. At that time, McChesney was responsive to person, place and time, her pupils were equal and reactive to light and she had strong motor function with both hands. McChesney did however report continuing headaches, but indicated that they were no better or no worse than the headaches she had been experiencing earlier that evening. McChesney continued to be nauseous. At that time the LPN noted a discharge of approximately 150 ml of vomit, which was a volume in excess of that which had been discharged at 7:15 p.m. Following her assessment of McChesney at 10:00 p.m., the LPN reported to the RN, Goleumbski, but no attempt was made to report to Dr. Prowse with respect to McChesney’s At 10:40 p.m., the LPN once again checked on McChesney. At that time the LPN was not able to wake McChesney, but did find that McChesney could squeeze with her left hand but not her right. The LPN called for the assistance of Golumbski who in turn placed a telephone call to Dr. Prowse. When learning of McChesney’s symptoms, Dr. Prowse ordered that: a physician who was in the hospital at that time, Dr. Kwan, be paged; and an ambulance be called to transport McChesney to the Royal Alexandra Hospital. After concluding the call with Golembski, Dr. Prowse left his home and began to travel to the Glenrose Hospital so that he could participate in the assessment of McChesney. Immediately after becoming aware that McChesney could not be awakened, nursing staff took steps to suction vomit from her mouth and to monitor her vital signs. They noted that the right pupil was dilated and not responsive to light. McChesney continued to be stable but unresponsive until the code blue team arrived at 10:50 p.m. The nurses from the code blue team continued to monitor her vital signs and assessed her cardiac condition with an Dr. Kwan responded with the code blue team. He took a brief history and concluded that McChesney was likely experiencing an intracranial hemorrhage secondary to the fall from the wheelchair. He confirmed the earlier instructions from Dr. Prowse that McChesney should be transported to the Royal Alexandra Hospital. Emergency Medical Services (“EMS”) personnel arrived with an ambulance almost immediately. EMS were met by security staff at the main entrance to the Glenrose Hospital and were escorted directly to McChesney’s room. EMS received custody of McChesney and left the Glenrose Hospital at 11:10 p.m. for transport to the Royal Alexandra Hospital. The Royal Alexandra Hospital is located directly across the street from the Glenrose Hospital. As a result, McChesney arrived at the Royal Alexandra emergency department very shortly after 11:10 p.m. A CT scan in the emergency department showed a large right subdural hemorrhage. Neurosurgery was consulted and McChesney was taken to the operating room on an emergent basis for a craniotomy and evacuation of a subdural hematoma. Following surgery McChesney was taken to the Intensive Care Unit. The neurosurgeon, Dr. Steinke, assessed her prognosis as “hopeless”. This prognosis was discussed with McChesney’s family. McChesney died in the Royal Alexandra Hospital on July 29, 2007 at 7:52 a.m. Recommendations
The evidence tendered at this public fatality inquiry clearly discloses a series of events which led to the death of McChesney. However, the evidence does not disclose any deficiencies which could be remedied by the implementation of any reasonable recommendations designed to prevent similar deaths in the future. It could potentially be argued (but was not argued before me) that wheelchairs can and should be designed in such a fashion that they cannot tip. However, the Quickie GT wheelchair used by McChesney was designed with anti tipping bars which minimize backward tipping. The wheels are cambered by six degrees to make the chair more stable and in this way the design reduces the risk of tipping to the side. Furthermore, the chair was adjusted by Echo for improved stability only hours before this unfortunate incident. Most importantly however, the witnesses at this fatality inquiry, who had significant experience with the placement of patients in wheelchairs, confirmed that the type of sideways tipping which occurred here is almost unheard of. As a result I conclude that it is unnecessary and would be improvident to make any recommendations with respect to the design or set up of wheelchairs. It could also perhaps be argued (but was not argued before me) that hospital staff who select wheelchairs and train patients in relation to the use of wheelchairs might implement more rigorous procedures designed to ensure a higher level of safety. However, I am satisfied on the evidence available to me, that no recommendations are necessary. The Glenrose Hospital has in place protocols for the selection of wheelchairs and the training of patients. There is simply no evidence available which would permit reasonable recommendations to prevent similar accidents in the future. Accidents of this type are unpredictable and represent risks which all Finally, it could perhaps be argued (but it was not argued before me) that some recommendations be made with respect to the medical and nursing care which patients receive following incidents of this nature. Again, I do not believe that there is any legitimate basis for making any recommendations in this regard. In hindsight, perhaps the exercise of medical judgment might have been different at various critical points following the accident. However, I believe that it is unnecessary and would be unwise to make recommendations which might affect medical treatment and medical decisions in the future. This is particularly so when there is no medical evidence which suggests recommendations would improve care or prevent future Given all of the above, I conclude that no recommendations are necessary or advisable in connection with this public fatality inquiry. Dated at the City of Edmonton, in the Province of Alberta

Source: https://justice.alberta.ca/programs_services/fatality/Documents/fatality_report_McChesney_2009_11_23.pdf