CANADA

Province of Alberta

Report to the Minister of Justice and Attorney General Public Fatality Inquiry

Fatality Inquiries Act

WHEREAS a Public Inquiry was held at the in the on the on the before into the death of City
(City, Town or Village)

Law Courts Building Edmonton , in the Province of Alberta, , ,

year

of day of day of R.A. Philp

(Name of City, Town, Village)

30th and 31st

July

2012
year

, (and by adjournment ),

, a Provincial Court Judge, Samuel Takyi

(Name in Full)

73
(Age)

of 229-51149 Range Road 231, Sherwood Park, Alberta and the following findings were made:
(Residence)

Date and Time of Death: Place: Medical Cause of Death:

March 17, 2009 at 18:50 hours Grey Nuns Hospital, Edmonton, Alberta

(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)).

Peritonitis.

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)).

Accidental. Mr. Takyi underwent a colectomy for noninvasive adenocarcinoma of the sigmoid colon. The surgical anastomosis site separated when the patient was at home resulting in peritonitis.

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Circumstances Under Which Death Occurred: On March 10, 2009, Samuel Takyi underwent a laparoscopic removal of a portion of his large bowel. Upon being discharged from the hospital and returning home on March 13, 2009, he complained of increased discomfort at the surgical site. His family called for an ambulance which transported him to the Grey Nuns Hospital Emergency Room later that day. At the emergency room, Mr. Takyi was diagnosed with regular post-operative complications, received anti-nausea and pain medication and was discharged in the early morning of March 14, 2009. On March 17, 2009, Mr. Takyi experienced respiratory distress, was very weak, cold and was perspiring profusely. He experienced extreme pain in his abdominal area. Emergency services were called. En route to the hospital, Mr. Takyi became unresponsive and was intubated. Subsequent attempts to resuscitate him were unsuccessful. Mr. Takyi was 73 years old at the time of his death. Initial Discharge from the Hospital In the first two days following the surgery, Mr. Takyi was recovering well. He was passing stool and gas, indicating that there was a complete seal around the surgical site of the bowel. On the morning of March 13, 2009, Dr. Mackie saw Mr. Takyi at his bedside and provided discharge instructions. Mr. Takyi was specifically told to call Dr. Mackies office if he was having any problems and to attend an emergency room if the problems were serious. Later that day, Janet Quedado, a registered nurse, gave Mr. Takyi further discharge instructions. She informed Mr. Takyi to watch for signs and symptoms of infection, the presence of fever, chills or pain in the surgical area. He was told to inform a doctor if he experienced any of those symptoms. Carol Takyi, Mr. Takyis wife, was not present when Mr. Takyi received these instructions. Further, she did not receive any discharge instructions from the hospital staff at any time as it is not common practice to provide the family members with discharge information of patients. Upon discharge, Mr. Takyi did not request a prescription for pain medication, which Janet Quedado found to be unusual. Mrs. Takyi then arrived and took Mr. Takyi home. Return to the Emergency Room That evening, Mr. Takyi experienced increased pain in his abdomen so he called an ambulance. At 7:00 p.m., Aaron Jacejko, an experienced paramedic, arrived at the Takyis home. He noted Mr. Takyis demeanor to be calm. Mr. Takyi was not outwardly guarding his abdomen, but he informed Mr. Jacejko that he was experiencing significant pain. Upon examination, Mr. Takyi appeared to be in stable condition, but Mr. Jacejko was concerned the pain could have been due to post-operative complications. As a result he transported Mr. Takyi to the Grey Nuns Hospital Emergency Room. Mr. Takyi arrived at the emergency room at 7:31 p.m. on March 13, 2009. It was Friday night and the emergency room was very busy. Following a near six hour wait, Mr. Takyi was admitted to a bed and examined by a nurse. His vital signs were noted to be normal. Two hours following that exam, at 3:30 in the morning of March 14, 2009, Dr. Shelby Haque, an emergency room physician, examined Mr. Takyi. Dr. Haque did not notice anything out of the ordinary for someone who had recently underwent the surgery Mr. Takyi had. Mr. Takyi was passing gas and stool, his urine was normal, he did not have a fever, his abdomen was soft, his heart sounds were normal, and his lungs were
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functioning appropriately. Mr. Takyi did, however, indicate his abdominal pain was a 7 out of 10. Dr. Haque opined that such an experience was normal for someone just out of surgery and was likely due to the lack of pain medication. Dr. Haques opinion was that, at the time, there were no serious complications due to the surgery. As a result, no blood work or further tests were ordered. Mr. Takyi was prescribed pain mediation and was again discharged to his home in the early morning of March 14, 2009. Condition Worsening Mrs. Takyi indicated that Mr. Takyi experienced nausea and vomiting on the night of March 14, 2009 and off and on throughout the 15th. She was concerned and called Mr. Takyis family doctor at his home. She was unable to get in touch with the family doctor because he was not on call. She called a different doctor who informed her he was unable to take additional patients, but if she was concerned to take Mr. Takyi back to the emergency room. Mr. and Mrs. Takyi discussed going back to the emergency room, but were hesitant about another lengthy wait. On the morning of March 16, 2009, Mrs. Takyi called Dr. Mackies office. He was not immediately available, though he was able to call back later in the morning. Dr. Mackie inquired about bowel movement. Mrs. Takyi advised Dr. Mackie that Mr. Takyi had recently had a bowel movement. Due to the movement of bowel, Dr. Mackie was not concerned that Mr. Takyis condition was serious. He told Mrs. Takyi to go to the emergency room if the situation worsened and to call back the next day if they needed anything further. Mr. Takyis condition worsened overnight. The next morning, March 17, Mrs. Takyi called Dr. Mackies office once again. A nurse took a message and advised that she would ask Dr. Mackie to call them back. Later in the day, the nurse called back and informed the Takyis that Dr. Mackie was in surgery. She said she could interrupt the surgery if their concern was urgent. Not wanting to interrupt a surgery, the Takyis said they would wait until it was completed. They never received a phone call after that. Throughout the day, Mr. Takyis condition worsened and they continued to wait to hear back from Dr. Mackie. Mr. Takyi was extremely ill, very weak and his abdomen was hardening. Mrs. Takyi called for an ambulance which arrived at the Takyi home at 5:37 p.m. Ian Thomas, an EMT, conducted an assessment of Mr. Takyi who was extremely sweaty, presenting with obvious respiratory difficulties, and reported a 10 out of 10 for abdominal pain. Mr. Takyi was immediately put into the ambulance and rushed to Grey Nuns Hospital Emergency Room. En route to the hospital, Mr. Takyis condition deteriorated. He was intubated to assist breathing. Upon arrival at the hospital, Mr. Takyis heart lost all electrical activity. Attempts to resuscitate him with CPR were unsuccessful. According to the expert opinion of Dr. Mackie, had the leak from the bowel been discovered earlier and been treated with emergency surgery, it is likely that Mr. Takyi would have survived. The Autopsy Findings Dr. Graeme Dowling conducted an autopsy to establish the cause of death and the manner of death. The Medical Examiners Medical Certificate of Death lists the cause of death as Peritonitis (infection of the membrane that lines the inner abdominal wall) due to dehiscence of the surgical ileosigmoid anastomosis site (a surgical complication in which a wound breaks open along the surgical suture) with a contributing cause being adenocarcinoma of the colon.

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The Cause of Death On March 10, 2009, Dr. William Mackie, a colorectal surgeon with over 20 years of experience, removed a significant portion of Mr. Takyis large colon in order to remove three relatively large lesions, one of which was known to be cancerous and two of which were expected to cancerous. The surgery was conducted at the Grey Nuns Hospital and progressed uneventfully. Though it took slightly longer than Dr. Mackies average surgery time, he still described the procedure as routine. Dr. Mackie testified that the failure rate for the surgery Mr. Takyi underwent is about three to four percent. The cause of failure is almost always dehiscence (when healing does not occur properly between the two pieces of bowel which have been fused together, causing fluid to leak into the abdominal cavity). Dr. Mackie stated that once dehiscence occurs, a patient usually has from 12 to 24 hours to live if they do not receive emergency care. Dehiscence of the surgical site is what caused Mr. Takyis death. Recommendations for the Prevention of Similar Deaths: When appropriate, it is the role of the judge hearing a Fatality Inquiry to make recommendations to prevent similar deaths from occurring in the future. Upon initial discharge from the hospital, Mr. Takyi was given instructions to attend an emergency room if he was experiencing problems. This advice was heeded, and he attended the Grey Nuns Hospital Emergency Room less than 24 hours after his discharge. Unfortunately, it was very busy when he attended and he was forced to endure a lengthy wait before receiving the necessary service. When his condition significantly worsened throughout March 17, 2009, the operating doctor, Dr. Mackie, was unavailable to provide advice. The only recourse available to Mr. Takyi was a return to the emergency room. Having experienced such a long wait on the previous occasion, it is reasonable that Mr. Takyi was hesitant to return. It is understandable that he would attempt to endure the pain he was experiencing until he felt he had absolutely no option but to return to the emergency room. It is unfortunately Mr. Takyis endurance of this pain that resulted in his death. Had emergency treatment been received earlier he may well have survived. The lack of emergency room resources at the Grey Nuns Hospital resulted in a lengthy wait for Mr. Takyi. Because of this wait, he was dissuaded from returning when his condition became critical. Resources in emergency rooms are indeed scarce, but how a hospital decides to allocate those scarce resources is something that is outside of the scope of recommendations which can appropriately be made by this Inquiry. The only recommendation that I would make is that, subject to patient privacy concerns, discharge instructions should be given to the patient in the presence of a responsible, family member, if possible.

DATED at

October 4, 2012 Edmonton

,
Original signed

, Alberta. R.A. Philp A Judge of the Provincial Court of Alberta

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