Calgary Provincial Court

Judge S.A. Hamilton presiding

James Cairns allegedly died at the hands of roommate John Driscoll # 070475082 P1 in the early hours of April 22/07 at the BETHANY CARE CENTER, Calgary. There was no witness to this deadly assault.

It is troubling, that Mr. Driscoll who allegedly expressed strong paranoid fears, was placed in close proximity to another resident, James Cairns.

It is further troubling that staff failed to hear the violent altercation. This again reinforces our all too frequent finding, that locked dementia units are left unattended during the night.

Unless the police have conclusive evidence that in fact Mr. Driscoll was the assailant, no one can be certain who made the deadly assault on Mr. Cairns. We are again calling for cameras to monitor the care of vulnerable persons.

Finally, it is a well established principle of common law, that health care providers owe a duty of care to provide a reasonable level of safety to their clients. We allege that the Bethany Care Center failed to exercise their duty of care to Mr. James Cairns.

This law has been expressed in:

Stewart v. Extendicare Ltd.

(1986) 4 WWR 559

(1986) 38 CCLT67

(1986) 48 Sask R 86

Sask QB. Malone, J.

“Many nursing homes have become dangerous places largely because they are under staffed and under regulated”

-TIME magazine, Fatal Neglect” October 27, 21997 Vol. 150 No 17

It will likely be months before recommendations, if any at all, are made to Alberta’s justice minister stemming from a fatality inquiry in Lethbridge this week.

But the son of Sydney James Salter, who died in 2007 after wandering away from his residence, believes there should have been more communication among care providers.

Michael Salter told the inquiry into his father’s Dec. 31 death that after hearing two days of evidence Thursday and Friday in Lethbridge provincial court, he believes a policy should be developed that ensures once a client’s health changes, steps are taken to ensure the proper authorities are notified.

When he died, Sydney Salter, 88, was living in an independent living complex in Lethbridge, and was receiving some part-time home support through We Care Home Health Services. However, in the week before he died, he was becoming increasingly confused and exhibiting greater signs of dementia, yet that information was never relayed to other health-care providers.

“The system is there, but people have to access it,” said Lethbridge lawyer Ken Lewis, who represented Alberta Health Services at the inquiry.

Salter was also reportedly found wandering outside his apartment in the days before his death, and at least on one occasion in October had wandered outside late at night and had to be let in through locked doors.

During Thursday’s hearing, court heard witnesses testify that Home Care — a service provider employed by Alberta Health Services — had been notified of Salter’s failing health. But Neil Boyle, lawyer for Alberta Justice, said Friday the witnesses were mistaken and there likely hadn’t been any communication between We Care Home Health Services and Home Care in the week before Salter’s death.

Salter’s body was discovered about 8:30 a.m. Dec. 31, 2007, lying on the ground outside the complex. He may have been lying in the snow for several hours before his body was found by another resident. His death was reportedly caused by hypothermia.

Court heard Salter was barefoot and only wearing a light, long-sleeve shirt and pants. He also had abrasions on his fingers and toes, indicating he may have crawled some distance before dying. There was also a thin blanket of snow on the ground, but no tracks other than those of the resident who found the body, which suggests Salter may have been lying there at least since 2 a.m. when it had started snowing.

Joy Dykslag, who was Salter’s case worker for Home Care in 2007, testified Friday she, as well as other doctors and nurses, conducted assessments of Salter’s mental health in the weeks before his death — he may have also had Alzheimer’s disease — and recommended he be moved to a facility with greater security and full-time care providers.

“I did feel it was something we really needed to consider,” she said.

But they didn’t at that time consider the move urgent, and when a studio-style apartment became available Dec. 11 at another facility, Salter and his son decided to wait until a larger unit was available before moving.

Lewis noted in his concluding submission that Alberta Health Services was prepared to move Salter to another facility, which likely would have prevented him from wandering outdoors. He added, however, he’s not sure if Home Care could have done more even if providers knew his health was deteriorating in the days leading to his death.

The fatality inquiry does not look for blame but was held to determine circumstances surrounding Salter’s death and whether he was living in an appropriate facility given his mental and physical health.

Judge Ron Jacobson said at the inquiry’s conclusion, he will provide the minister of justice a report which may or may not include recommendations that could prevent similar tragic incidents. He also noted the minister could let the matter rest, or even order another inquiry.

Courtesy The Lethbridge Herald

January 12, 2009

VIA FACSIMILE 780 422 6621, Letter to Follow
The Honourable Ms. Alison Redford, QC
Minister of Justice and Attorney General
403 Legislature Building, 10800 – 97 Avenue
Edmonton, Alberta, T5K 2B6

Dear Ms. Minister:

Reference: Sudden Death of Lorraine Julia Adolph, December 11, 2008

Lorraine Julia Adolph was a certified patient of the Alberta Hospital Edmonton.

On December 4, 2008, at 11:00 AM, Ms. Adolph had been allowed unsupervised, outside the locked doors for a smoke. Ms. Adolph was found one week later, frozen to death, just steps from the hospital entrance, Building # 12.

We are asking you to call an Inquiry at your earliest under the Fatalities Inquiries Act, Chapter F6 in regard to this horrific happening.

Other analogous situations happened at the hands of Alberta Hospital staff.

1. The matter of the death of 82-year-old Nels Karsten Norregaard. Mr. Norregaard was noted to be absent prior to 11:30 AM, however there was failure by the Director of the Geriatric unit to notify senior management staff and fill out Form 8 until after the evening meal. His remains were found over a decade later near the Saskatchewan River. Geriatric unit, Building # 12, continues to be under the direction of the same physician Director.
2. The matter of the freezing death of Bob Earle who was a resident of a psychiatric Group Home. Group home owner, Rohana Weerasekera, an Alberta Hospital nursing staff, failed to call police until eight cold winter days passed after Bob Earle disappeared from the group home. Earle’s frozen body was found more than three months later, in some bushes about 25 blocks from the Mill Woods home. The Medical Examiner said he died of exposure.
3. Staff at Alberta Hospital Edmonton let 42-year-old Tim Dawson, who suffered manic depression, out on a day pass to be escorted to a group home. No one was at the group home and it is not known what happened then. Tim’s body was found a year later on a remote shore of the North Saskatchewan River near Two hills. Tim’s

Brother was quoted as saying that Tim had short term-memory loss due to seizures.and that he couldn’t remember his room number, or even put on his socks. At the Fatality Inquiry, the brother strongly questioned that they let Tim out on a pass.

We submit that it is imperative that this matter receive immediate government attention by your Department.

We would be grateful to be in receipt of your response in regard to this most urgent and distressing matter by the 31st of January, 2009. Thank you.

Yours truly,

Elder Advocates Of Alberta Society,

c.c.
Ms. Margaret Mrazek QC, Chair, Fatality Review Board,
Justice and Attorney General
Mr. Barry and Mrs. Michelle Adolph

Response

The Honourable Judge P.G. Sully
Judges Chambers
Provincial Court of Alberta
Edmonton, Alberta

Your Honour:

RE: Nels Karstan Norregaard Inquiry

Please allow us to comment in regard to the available documentation which demands attention:

1. April 22/87 Mr. Norregard was admitted to Alberta Hospital “against his will”, according to transcript of May 28/99, page 1, line 21 (Mr. Merryweather) However-
2. The nurses’ admission notes state that he was admitted, “voluntarily”, the next day the same nurse, V. Hutt RPN states that Mr. Norregard is still, “disoriented as to time and place”.
3. April 22/87, Consent For Diagnostic And Treatment Services – Voluntary Admission Form Dr Brahim had Mr. Norregard sign this form on admission. Page 2 states that the patient has been informed of his right to leave the hospital at any time.
   Paragraph 3 of page 2 has no entry which may indicate, Mr. Norregard may not have comprehended the document or that he was in a confusional state, as recorded in Dr. Brahim’s Discharge Summary.
   The signing of this form declared Mr. Norregard to be a voluntary patient. A voluntary patient cannot appeal for advocacy. In 1987, the Office of the Ombudsman had jurisdiction and since 1990, the Patient Mental Health Advocate has jurisdiction.
4. The DISCHARGE SUMMARY authored by Dr. Asad Brahim dated 26/07/87 stated that 1) the “mode of admission was voluntary, 2) Mr. Norregard was in a “confusional state” P.2, Para 3, L. 4
5. April 28/87,
   1. Mr. Norregard left the ward @ 9:30 AM and was brought back to the ward against his wishes. (Nurses notes) . What about the Voluntary Admission Form he signed on April 22/87 with Dr. Brahim stating that he could leave if he wanted (Page 2)?
   2. “He wanted to call his lawyer”. (Nurses notes)
6. May 1/87 Mr. Norregard was certified by Mental Health certificates – Form II
   1. Dr. Brahim certified as follows:
      • “confused and disoriented to time and place” “total lack of judgement and insight”.
      • “patient is incapable of taking care of himself” “delusional and would need supervision” “incapable of taking care of himself” (repeated)
   2. Dr. Slavos Hontella certified as follows:
      • “moderately confused in time and even in place” “he wants to go home and sell the car and the home”
      • “progressive mental deterioration – becoming dangerous to himself and others (driving car)”
   3. Dr. Hontella also marked off on the form, “is in a condition presenting a danger to himself or others”.
7. May 4/87 “Expressed desire to leave hospital.” (nurses notes)
8. May 6/87 Schedule I, Form I signed by Dr. Assad Brahim – as follows:
   • “patient is incapable of looking after himself or making any reasonable decisions”
   • “confused, disoriented to time and place”
9. May 12/87 Apparently, Mr. Norregard made Application to the Mental Health Review Panel, to have his Certificates reviewed and dismissed. We have not received a copy of this Application. It is not noted in the nurse’ notes.
10. May 15/87 “Demanding to go to Bank of Montreal” (nurses notes)
11. May 21/87 “Is disoriented at times”… “Will be discharged to a suitable setting in the community after further assessment…Presents no problem with elimination at this time. Total assessment complete and no new problems noted at present time.” (nurses notes)
12. May 28/87 “Dr. Brahim was made aware of Pt’s absence from the unit before lunch (1130hr).” “Prior to leaving, Nels discussed his certificates with staff…” “She records his jacket as being “beige” when in fact it was green” (nurses notes) It would have been helpful if the nurse had recorded what Mr. Norregard stated concerning the certificates.
13. May 28/87 4 page, Assessment of Decision Making signed by Dr. Assad Brahim, Terrence Chan, SW, Mona Marshall, RPN.
    Page 3, paragraph “G”. “He understood the reason for signing the appeal for his certification at AHE”.
    Page 4, paragraph “I” “He is capable of self care. He requires minimal supervision” (The former, contradicts all previous assessments of Mr. Norregard).
14. Mona Marshall RPN, who was a signee of the 4 page, Assessment of Decision Making, fails to make mention of this document in the nurses’ notes. It is curious that three staff members would sit around and fill out this form when the 81 year old elder is missing from the facility.
15. After supper, May 28/87, Form 8 is filled out by Dr. Brahim and senior staff are notified that Mr. Norregard is missing.
16. On May 28/87, the weather was warm however there had been some precipitation with light winds.
    The next day, May 29/87, was mainly cloudy with thunder showers, winds west 25.
    Saturday, May 30/87, mainly sunny with scattered evening thunderstorms, winds south 20. Similar unsettled weather on May 31/87.
17. The DISCHARGE SUMMARY of Dr. Assad Brahim dated 26/07/87 states:
    1. The “mode of admission” as voluntary.
    2. “….would eventually need some supervision” (diagnosis).
    3. Dr. Brahim regarded Mr. Norregard to be in a “confusional state”, P. 2, Para 3.
    4. Dr. Brahim does not record the signing of the Voluntary Admission Form, Consent For Diagnostic And Treatment Services
    5. Refers to Form 8 under the Mental Health Act
    6. Dr. Brahim stated on Page 2, paragraph 3:“By June 1, there was no word concerning the whereabouts of Mr. Norregard. The police had been looking for him and numerous media people had also been involved. Mr. Norregard’s certificates lapsed on June 1, 1987 and therefore his status was changed to voluntary after having gone out of the ward without permission”. (Not true. The police had not been looking for him prior to June 1/87.) “July 18, 1987…discharged from the hospital”
18. How disturbing! When we fail to be able to account for our vulnerable patients, we simply declare their status as voluntary and then discharge them.
19. We ask elderly persons to sign voluntary consent forms and them declare them to be “confusional” and “delusional”.
20. If in fact he was confused, they failed to protect him. When the police were notified of his absence, they were informed that there was no urgency.
21. The declared status of this elder was changed from, informal, to voluntary, to certified, and again to voluntary, all within a period of forty days. Then for no obvious reason, he was officially discharged.
22. In summary, we believe that someone should have to give an account of the unusual and confusing process to which Mr. Norregard was subjected, preferably the provocator, Dr. Assad Brahim.

To date we have not received:

1. a copy of the Application to the Mental Health Review Panel, requesting that his Certificates be reviewed and dismissed.
2. a copy of the form 8 which would have been the form submitted to the Police.
3. a copy of the Statement of Benefits Paid of the Alberta Health Statement as it relates to Mr. Norregard after he arrived in Alberta.

Respectfully submitted,

Elder Advocates of Alberta

HAND DELIVERED

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The week long Fatality Inquiry of November 28/05, was presided over by a Provincial Court Judge and seven lawyers. The lawyers represented Alberta Justice, the Nelson Family, the Jubilee Lodge Nursing Home and the Capital Health Authority. Though a Fatality Inquiry does not assign blame, the hearing provided a valuable, though disturbing, window into the attitudes, policies, and behaviors of staff in a long-term care setting.

According to the testimony of a Personnel Care Aide (P.C.A.), on the morning of January 2nd, 2004, she filled the Century tub in the Alzheimer unit with the hottest water available. That the water was hot was attested to by a service man who had been called some days after the incident, to test the temperature of the bath water. He found that the water was so hot, that he had to quickly withdraw his hand. He found it to be over 55 degrees Celsius.

A second P.C.A. brought Mrs. Nelson, who was scheduled for a bath, to the tub room. She placed her in a lift, and began lowering her into the water. Apparently, Mrs. Nelson immediately began to writhe and move her mouth upand down. Nevertheless, the P.C.A. stated that she continued to lower her into the water. During the hearing, she was asked if she had tested the water with her arm. She stated that she was busy. She also stated to the court “I never thought to test the water”. Although, when she was queried about her training and the extent of her training, she responded that she had been taught to test bath water with her arm and wrist prior to bathing an individual.

Because the patient had passed stool, probably because of the shock of the hot water, the PCA proceeded to drain the tub. She then began to refill the tub and while the tub was refilling, she proceed to wash Mrs. Nelson, front and back with a small white towel.

The PCA noticed redness on Mrs Nelson’s abdomen, skin peeling from her legs, and blood oozing from a toenail which was dripping into the water. At this point, she did not call a registered nurse (R.N), but called the other 14 year PCA employee who had filled the tub. They removed Mrs. Nelson from the tub and the lift and placed her in the wheelchair. An R.N. was called, who instructed the P.C.A’s to take Mrs. Nelson to her room and place her on her bed. Another R.N. present, called for wet towels to be placed on Mrs. NelsonOs legs, because sterile dressings were not available. Jennie Nelson died nine days after this incident.

Burns are immediate, intense, the pain is immediate and the resulting blisters, skin peeling and bleeding would have been immediate. She would have undoubtedly lapsed into periods of unconsciousness or semi-consciousness, due to the intense pain.

A physician was notified who ordered Tylenol but did not attend at the care facility. After an hour, she was however administered morphine, and after close to two hours, an ambulance was called to take her to the University hospital where she died nine days later. The Ambulance Report stated that Mrs Nelson was “flailing wildly” (even after having been administered morphine).

During the hearing, there was conflicting testimony in regard to the temperature gauges, as to whether they were functioning properly, or whether the P.C.A. had been instructed how to use them. As a matter of fact, throughout the hearing, there was much contradictory evidence, but because this was a fatality inquiry, and not a trial, witnesses could not be cross-examined as to the veracity of their testimony. On a number of occasions, lawyers who were acting for the Jubilee Nursing Home, challenged the familyOs lawyer, in regard to the manner of questioning.

Lawyers spent considerable time questioning staff in regard to the training of staff. Was the injury the result of untrained staff? In fact, every one of the participants of that horrific happening on the morning of January 2nd, 2004, had more more than adequate education and training.

• The physician, who was notified of the injury, had many years of professional education and training.
• The registered nurses, who disregarded the agony of the injured elder, and who failed to immediately call an ambulance to send her to an acute care centre, had years of professional training.
• The Personnel Care Aid had 18 weeks of training, which should be more then adequate for a conscientious worker who gives custodial care. It should have equipped her to give the very basic care, feeding, dressing, bathing, a kind of care that mothers, often individuals with little or no education, have been giving their progeny or elderly parents throughout the generations.

As evident at the John Dach Fatality Inquiry of January 2005, if there is a non-resuscitation order on the resident’s file, it is policy at the Jubilee Lodge Nursing Home (and most elder care facilities), to not send an elderly person to hospital for care no matter how horrific the injury or how intensely the person is suffering. The person is left to die.

Was there intention to give ethical nursing care and comfort to this severely injured and suffering woman?

1. The physician had been informed in of the critical condition of Mrs Nelson but because he was occupied seeing office clients he failed to come to the aid of the severely injured, writhing, flailing Mrs Nelson.
2. Professional nurses did nothing more than place unsterilized towels on open wounds.
3. The PCA called another PCA, the PCA who had filled the tub with the hottest water possible, rather than the professional, charge nurse.

This Fatality inquiry has left us with many unanswered questions. We will continue to ask these questions in the coming weeks and months, even as we did two years ago, when we brought this issue forward. To date no one has been held accountable, no one has lost a job, the facility has not been fined or disciplined and the criminal code has not been applied.

Finally, in this disturbing account of Jenny Nelson, it again becomes apparent that this victim has not received justice. This is indeed a complex issue that desperately cries out for needed reform. The manner in which this crime was investigated or failed to be investigated, tells you that the victim was a vulnerable, handicapped person. The police were not called. The government investigator, the Protection For Persons in Care investigator, recommended that the police not be involved.

When a person who is not elderly, vulnerable, or does not have disabilities, is physically or sexually assaulted, the assault is classified as a “crime”. The police are called, the crown prosecutor prosecutes, and the perpetrator is sent to prison or given other punishment. However, when a frail, dependent, elderly person or handicapped person, is physically or sexually assaulted, we classify the assault as “abuse”. Instead of a police investigation, the care provider organization itself,a social service organization, a licensing agency, or some other administrative body investigates the matter. The result may be an administrated remedy such as the firing of the alleged perpetrator. In the Jenny Nelson matter, there were no remedies whatsoever. No one was held accountable. One of the participants was given a signifigant promotion.

In Alberta and across the country there is no intent to afford vulnerable crime victims, justice. Alberta legislation, some of which has been enacted for over thirty years, the Health Facilities Review Committee act, the Ombudsman Act, the Fatality Inquiries Act and the non-punitive, non-inclusive Protection For Persons In Care Act, clearly demonstrates this.

This failure trivializes crime against vulnerable, elderly and all vulnerable persons and encourages perpetrators to target this population because they believe, and rightly so, that there is little or no chance that they will in any way be held accountable let alone arrested, tried, or convicted.

We must address this and demand change so that elderly crime victims receive equal justice.

Jenny Nelson was a victim of a callous, dispassionate and unjust care system. It is time that crime victims such as Jenny Nelson receive justice.

This blind 66 year old man was perceived to be choking on his breakfast toast, and became non-responsive. After applying the Heimlich maneuver and expressing some toast, the non-responsive Mr. Dach was removed from the busy, crowded dining room, taken up an elevator, taken down the hall to his room. His son, a drywaller, was phoned and asked what should be done. His son immediately came to the facility and found his beloved father dead.

The Medical Examiner, Dr. Graeme Dowling was aked by Alberta Justice to review the death some three months after the fact when family members complained to Alberta Justice that their father had choked to death in front of staff and no investigation had been done. Dr. Dowling stated to the vourt that Mr. Dach had died of Congestive Heart Failure though he examined only records and reports and not the body.

Four registered nurses testified that they treated Mr. Dach for choking and Dr. Joseph Tilley had informed the family that indeed Mr. Dach had died of choking.

Dr. Joseph Tilley testified he was wrong on two counts when he had entered an incorrect cause of death on the Death Certificate that stated that Mr. Dach died of “aspiration pneumonia”.

Adapted from “Senior didn’t choke to death, doctor testifies,” The Edmonton Sun January 20, 2005 p. 32

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A provincial investigation into the death of Jean Warden was again dismissed. Assessment by staff of the University Hospital, Edmonton, documented the following:

“malnutrition / dehydration, muscle wasting, decreased albumin levels, anemia, appeared totally emaciated, cachexia, swollen left great toe reddened with necrosis, pressure sores on coccyx and heels, pus oozing from a sore on her ear, pseudomonas infection in her urine.”

On admission to the U of A, she was observed to be in great discomfort. U of A staff stated that they were mandated to make a complaint to the Protection For Persons in Care Act – Section I- Part 6 –

“failing to provide the necessities of life such as food and medical attention.”

According to government officials and the Protection For Person in Care, this is acceptable care. We do not accept this.

Correspondence has been sent to the Honourable Ron Stevens, Minister of Justice and Attorney General, with a strong request for a Fatality Inquiry into the violent death of this elderly Albertan.

Response:

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A Fatality Inquiry has been ordered by the Fatality Review Board. No date has been scheduled.

Update

Detective Trudy Triplett, of the Edmonton Police Service’s elder abuse intervention team, confirmed Thursday that she is opening a criminal investigation into Jean warden’s death of September 23, 2005.

Edmonton police are investigating the death of a malnourished senior at a private nursing home 14 months after a provincial investigation dismissed allegations of neglect and elder abuse.

Rob Warden said that after recently reviewing documents and reports into his elderly mother’s tragic death, he decided he had no choice but to go to the cops. “I felt if we really want this investigated thoroughly and completely, then we should have the city police look at it, because that’s what they do,” Warden, 44, told Sun Media.

Jean Warden, 83, died Sept. 23, 2005, about two weeks after her family, horrified by her physical condition, pulled her out of a nursing home and took her to hospital. Documents that Warden has made public on the Internet at www.jeanwarden.com, say hospital staff found that his mother was malnourished, dehydrated and had several infections, including a gangrenous toe and pus-filled ear.

Warden alleges these fatal conditions arose during the time she spent at Devonshire Care Centre, a long-term care facility on the city’s south side. “Somebody’s got to be held accountable for this,” he said. In March 2006, a provincial investigation into the senior’s death dismissed the family’s allegation that she was neglected, noting there was “insufficient evidence of intentionally failing to provide adequate nutrition, adequate medical attention and other necessities of life.” Warden, who called the report a “sham” when its findings were released, had been reviewing documents in preparation for a five-day fatality inquiry scheduled for June 18, 2007.

Next month’s fatality inquiry has now been postponed pending the completion of the police investigation. Det. Trudy Triplett, of the Edmonton Police Service’s elder abuse intervention team, confirmed Thursday that she is opening a criminal investigation into Jean’s death. There’s no timeline for the probe.

Adapted from Edmonton Sun Media May 10, 2007

To date the police investigation has not been completed July 23, 2008