FORMS (SECTION 6) conenens rus REPORT OF CORONER RONEN Deceased Information sven Name(s) - ‘amily Name - 7 al ee Annie Remit Kootoo = Male JX Female | M@*'S%S 1 Single x Manied | Wdowes | Dvoreed | Separated | Commomiaw aT ET CFCS RS eT TST ottawa, ON Ohta, ON Date of Death - mmddyy Date oF Bit - memiaaryyyy Age ‘Was Deceased Employed? = 11372015 Si21/1953 61 ves 7 urn [ives kno ai Details of Death We Desh srt sop Recu | Ottawa General Hospitl yes MNO a " wane Gocco” Acute Hepatic Failure secondary to Isoniazid Toxicity ) Yes DRNo ciate _ oven Aras Reuse? [Accidental [~ Suicide [Homicide )X Natural [~ Undetermined [— Unclassified Yes KNo Tox Fg inset — ote ein Circumstances of Death ‘A 61 year old female was reported deceased on January 03, 2015 at Ottawa General Hospital, ON. On June 02, 2015, the Office of the (Chief Coroner in Iqaluit, NU received a written request from the family members to conduct an investigation into the death of the late ‘Annie Kootoo, a resident of Iqaluit, Nunavut, expressing their concerns over the medical treatment. The Coroner accepted this case [pursuant to Section 8 subsection 1 (b) and (e) of the Nunavut Coroners Act. ‘Apparently, on November 14, 2014 at 1840 hours, Mrs. Kootoo was admitted to Qikiqtani General Hospital with complaints of levening fever for past three days and mild cough, sputum culture result was positive for Mycobacterium Tuberculosis in November 10, ors. ‘She was admitted to the respiratory isolation unit (negative pressure room) of the in-patient care for further treatment, when isolation room became available. Assessments by the Health Care Professionals revealed that no shortness of breath, no signs of hemoptysis, (chest was clear with good air entry to both lungs and abdominal examination was soft and non-tender. Mrs. Kootoo was asymptomatic; ‘she was recently developed night sweats and mild cough. Attending Physician started with anti-TB medications and she was advised to void taking Tylenol to prevent hepatotoxicity. Comments and Recommendations (if any) DATED IN. Iglu IN THE NUNAVUT TERRITORY THis 14 DAYOF February 20 17 CORONEROFFICE OF THE CHIEF COP9NER HAGSA*L D8d*LYcna-LaAb< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut aot ‘SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 On November 15, 2014, Mrs. Kootoo was started anti-TB quad therapy, during these days; she was instructed to avoid taking Tylenol for pain reliever and atorvastatin for anti-lipids. In addition, she was suffering with Osteoarthritis, hypertension, anxiety, diabetic mellitus, and obesity, she smokes marijuana regularly. On November 21, 2014, she was discharge from QG Hospital to a home isolation under the Public Health TB (Tuberculosis) team to follow up due to shortage of isolation beds in the hospital. ‘On 23 December, patient was complaining of feeling tired and loss of appetite to RN at home during her visit for DOT. There were no physical assessments were done and the complaints was not documented in the medical chart. Patients symptoms were followed by the RN in nonspecific manner with medication delivery of asking” how are you feeling today any problems” as a routine. On December 25, 2014, Registered Nurse attended the residence to administer her TB medications. (Direct observation of treatment) at that time patient was complaining of sore neck and loss of appetite, and the nurse advised to apply heat across the back of her neck. RN did not document the abnormal complaints in the clinical chart and did not inform the attending physician of the presenting symptoms of the patient for further assessments. On December 26, 2014, medical professional attended the residence and delivered DOT, RN observed that the patient and husband were in family dispute, however patient took her medication and walked away, no signs of jaundice, no safety concerns and no complaints were noted. On December 29" 2014, family members enquired about his mother’s presenting symptoms of being tired and loss of appetite and the RN explained about the upcoming appointment on 31 December and advised the need for blood work before the appointment. PAGE 2 of 4 Goverment of Nnavat Deparment of Jsee ono te hit Corner PO Box 1000 Station $90 galt, Nava 0A OHO (967/975-6318 & (867) 975-8367 Cell: (867) 222-0063 Toll Free 1 (888) 778-1022OFFICE OF THE CHIEF COPONER HAGSA*L DSd*LYcna-LaAb< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut 2a2T SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 ‘On the same day Mrs. Kootoo was admitted to Emergency room at Qikigtani General Hospital with the complaints of abdominal discomfort, decreased appetite, fatigues and yellowing of the eyes past two weeks. Blood investigations revealed elevated liver enzymes, INR of 2.3. She was diagnosed with acute liver failure; Attending Physician in Ottawa was consulted and advised to transfer for further management. Patient was sent to Ottawa General Hospital on a medevac. ‘On December 30, 2014, Mrs. Kootoo was admitted at Ottawa General Hospital with initial diagnosis of acute hepatitis, upon arrival at Ottawa General Hospital, INR test showed 3.4. Attending Physician ordered to discontinue TB medication and medical interventions were initiated. On December 31, 2014, Gastroenterologist consultation revealed that Mrs. Kootoo had no family history of liver disease, does not drink alcohol and denies IV drug use. She smoke marijuana daily, Assessments by the attending physician showed that she had acute liver failure most likely due to INH / Rifampicin, in the setting of Chronic Tylenol use, INR was increasing to 4.3 and with encephalopathy. Hematologi General Hospital was consulted for liver transplant; attending physician determined that due to her pulmonary tuberculosis, transplant procedure was contraindicated. in Toronto Clinical examination showed that the vital signs were normal. Due to Jaundice, discoloration of skin with scleral icterus was observed. Respiratory examination revealed faint crackles heard bilaterally on both lungs. Abdominal examination showed large abdomen, bowel sound present, soft, diffusely tender while palpation and grading with abdominal pain. Hepatomegaly with liver span approximately 24 cm was documented. Laboratory examination of the blood examination and liver function test showed elevated liver enzymes (ALT of 5679 U/L, AST 3838 U/L, ALP 359 U/L and GGT of 163}. Government of Nunavut PAGE 3 of 4 Deparment of lutice fie ofthe Chit Corner PO Bax 1000 Staton 590 ial Nunavut XDA OHO B367)97 7 867) 222-0063 onoOFFICE OF THE CHIEF COTONER HNGSA*L Dd*LYcna-LaD< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut Preae SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 Attending physician ordered to discontinue current hepatotoxic medication of the patient including Tylenol, ASA, metformin and Lipitor. On January 02, 2015, attending Physician explained the limited prognosis of Mrs. Kootoo to her family members, her liver function continues to deteriorate with GCS (Glasgow ‘coma scale) of 3/10. Supportive treatment and medications for comfort was consented by the family members. On January 02, 2015, microbiology examination result showed hepatitis B core antibody (anti-HBc) was reactive. CT scan of the head showed no abnormal findings. Chest X-ray examinations showed low lung volumes, middle lobe of the lung was collapsed (atelectasis) and right middle lobe scarring with lung collapsed were noted, in comparison to previous X-ray examination. In spite of medical intervention and management provided at Ottawa General Hospital, Mrs. Kootoo’s vital signs were progressively deteriorated; level of consciousness was decreasing, rapid shallow breathing, and progressing into encephalopathy and increasing abnormal blood enzyme levels. ‘On January 03, 2015 at 0740 hours, Mrs. Kootoo was lying in bed in unresponsive state with labored breathing, decreasing level of consciousness secondary to hepatic encephalopathy. Medical professionals provided palliative care for comfort measures. ‘At 1950 hours, Mrs. Kootoo was found not breathing, no apical pulse upon auscultation was noted. Attending Physician pronounced Mrs. Kootoo deceased on January 03, 2015 at 2105 hours with the presence of family members at bedside at Ottawa General Hospital. Autopsy was denied by the family members. Family history showed that Mrs. Kootoo’s father was hospitalized for lung surgery; her mother had been treated for pulmonary TB and had been operated. Two brothers were treated for pulmonary tuberculosis and older sister had history of taking anti-TB medications. PAGE 4 of Government of Nunavut Department of Justice POBox 1000 Station galt Nunavut X08 OHO 318 (867) 97 Toll ree 1 (845) Celt: (867) 222 R022OFFICE OF THE CHIEF COPONER HAGSA*L DSd*LYona LAb< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut oar ‘SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 Medical history showed that Mrs. Kootoo was diagnosed of active pulmonary tuberculosis in 1963, she received TB treatment in 1970 to 1973 and she contracted the TB bacteria from her parents. On May 1994, Mrs. Kootoo was seen by a psychiatrist after an overdose with various medications after the death of her common-law partner, history of acute reaction to stress and alcohol abuse in the past. An occasional fleeting suicidal thought due to low self-esteem, and does not feel she would act on them was documented. She appeared mildly depressed. She was treated with nortriptyline, counselling by family and prayers along with friends were helping her. On 2007 to 2012, she had history of active pulmonary tuberculosis. On November 07, 2012, Mrs. Kootoo started on surveillance program with chest x-ray and sputum every 6 months for 24 months, result showed chronically abnormal chest x-ray reports. She was seen by a cardiologist on November 30, 2012 for routine examination and grade 3 heart murmurs, assessments showed that she was hemodynamically stable and asymptomatic, normal ECG result and cause of her murmur was a flow murmur. On July 31, 2014 chest x-ray result showed RUL (Right upper lobe) nodule, CT scan showed no active diseases identified. On November 10, 2014 sputum culture results at Qikiqtani General Hospital showed positive for mycobacterium tuberculosis. She was treated with quad therapy including which composed of Isoniazid 300mg daily, rifampicin 600 mg daily, Vitamin b6 25 mg daily, pyrazinamide 1750 mg daily and ethambutol 1400 mg daily, liver enzyme showed AST of 20U/L, ALT of 22U/L, ALP of 85U/Land Hbaic showed 5.9. On November 22, 2014, Mrs. Kootoo was discharged from Qikiqtani General Hospital and to be treated by the Iqaluit Public Health TB team on home isolation due to shortage of isolation beds at the hospital before completion of quarantined period of 14 days of treatment at the hospital Government of Nunavut PAGE © of 9 Department of Justice oie ote Ciel Coroner galt, Naat X08 OFD (867) 975-6318 (R6T|9TS-G367 Cal: (867) 222-0063, Toll Fre: 1 (844) 7OFFICE OF THE CHIEF COmONER HINGSA*L DSd*LYcna-LaAb< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER 8 Nunavut aot ‘SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 She agreed for home isolation and case was transferred to public health for administration of medications and client monitoring for complications. During this time, she was seen by the TB team at home daily. She had no complaints, no signs of jaundice, no nausea and no abdominal pain was documented. In addition, Mrs. Kootoo was diagnosed with diabetes mellitus type 2 in November 1987, hypertension, obesity and dyslipidemia in 1984; she was on regular medication for the same. She was suffering with arthritis and asthma as per medical documents. As per family member's statements, Mrs. Kootoo was hospitalized and quarantined for 14 days of treatment. She was discharged early due to shortage of beds at the Qikigtani General Hospital. Attending physician stated that there were others people with active TB that was sicker than Mrs. Kootoo in a written complaint to the Coroner Service. Mrs. Kootoo was brought back to her residence for home isolation and developed abdominal pain, loss of appetite and yellowish discoloration on face and eyes were noted by the family. Mrs. Kootoo contacted QGH emergency department couple of times and was informed that she would have to wait for her appointment with physician assigned to follow up with TB patients was currently on vacation and no other doctor was assigned to take over patients and to wait until on December 30, 2014. There were no documented telephone conversations in her medical chart available. In reviewing the circumstances, investigation and medical documentation, | have determined that Annie Kootoo died on January 03, 2015 at Ottawa, ON as a result of ‘Acute Hepatic Failure secondary to Isoniazid Toxicity. | have further classified the manner of death as Natural. PAGE € of 9 Government of Nunavat Departat of fstioe (Offs of the Chief Corer PO Box 1000 Station Teal, Nunavut XA OHO BW (w6T/OTSAESIR_A (67)975-4967 Call, (867)222-0065OFFICE OF THE CHIEF COPONER HNGSA*L DSd*LYCna-LAPs HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut 2aor ‘SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 Recommendati: 1. The office of the Chief Coroner recommend that the Health Care providers should provide health teaching by using Inuktitut translators, about the potential complications of the TB medication, and the warning signs and symptoms to be monitored, so that the patient and family members can seek appropriate follow up care. 2. We recommend that simple written instructions should be provided in both languages of Inuktitut and English to the patient and the family members with TB medication use, complications and adverse sign and symptoms to be recognized for further management to avoid complications. 3. We recommend that the Department of Health should develop standard orders ication of the most responsible physician and identifying the physician, who will be giving cover for weekends and holidays to the Public Health Team for TB patient’s consultations. for n 4. We recommend that revisiting its current emergency telephone triage process at Emergency Department at QGH that accurate patient’s complaints, assessments and any high risk findings must be communicated to the referring physician and all telephone calls should be recorded in the patient's medical documents. 5. Office of the Chief Coroner recommends that all Health care professionals should fallow the Government of Nunavut, nursing standards, policies and guidelines in assessing the severity of the clients presenting symptoms, fully assessed and determine the appropriate plan of care, including immediate or differed clinic its for clients. PAGE of 9 Government of Nunavat Deparment of Justioe Office o the Chief Conse PO Box 1000 Station 590 galt Nunavat X0A OH WF (867)975-6818 _B (B6T9TS-6367 Call (857) Toll re: | (844) 778-102OFFICE OF THE CHIEF COPONER HAGSA*GL D8d*LYcnad-LAp< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut oaor ‘SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 6. We recommend that the hospital authorities should consider sharing this case widely for educational purposes with all health care professional for learning and preventing similar deaths in the future. 7. Office of the chief coroner recommends that documentation is a key element of every health care professions standard of practice. Regular chart audits need to be conducted to ensure charting practices meets the GN documentation standards and provide feedback to the health care workers involved with Meaningful suggestions to improve documentation skills for accuracy. 8. A quality of care review should be conducted (if not already done) by the Department of health regarding this case, and develop standard policy to treat patients with home isolation, assessments of presenting symptoms, verbal review of signs of drug toxicity at each DOT(direct observation treatment) and documenting the patients complaints at each home visit 9. We recommend that the Hospital authorities should consider developing a policy/procedure which sets out the process to be followed, when there is no appropriate bed to deal with the patient that requires admission by identification of the situation and steps taken to free up an appropriate bed. 10. We recommend that due to shortage of isolation beds, hospital authorities should consider moving patients from a negative pressure room to the one with less intense isolation room in the inpatient care, unless the patient’s condition has improved sufficiently to warrant home isolation. PACE 8 of 9 Deparment o sce rf of he Chit Conner 0 Box 1000 Saion $90 Ig Nort X04 00 Bass aasnerse Toll Fre 14) 7OFFICE OF THE CHIEF COPONER HASSA*L DSd*LScnad-LADp< HAVAKVIA ATANGUYAATA TUQUNGALIQIYIIT BUREAU DU CORONER CHIEF CORONER Nunavut 2aor SUPPLEMENTARY INFORMATION ADDITIONAL INFORMATION OF THE DECEASED Annie KOOTOO: DOD: 03 January 2015 Recommendation to the Nursing licensing board: 1. We recommend Nursing Licensing Board to review the standard nursing competency, integrated knowledge, skills, judgement and attributes required of a registered nurse to practice safe, compassionate, competent and ethical care in a designated role of nurses involved in this case management. — +5 Padma Suramala, Chief Coroner of Nunavut Government of Nunavut Deparment of lstice ee ofthe Chief Coroner PO Bax 1000 Station 590 ig Nanvat X08 O80 g Penge 9&4 tH Celt: (867) 222-0063 1022 Boones 2 e6nos-6 Toll Few: 1 (848)