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Dr. Sauvageau / Goltman inquiry

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Lisa Goltman Fatality inquiry Day # 7 April 13, 2016

Dr. Anny Sauvageau addressed Inquiry April 13, 2016.
Dr. Sauvageau was the former Chief Medical Examiner and is a Forensic
Pathologist.
Dr. Sauvageau has comleted external investigation on 20,000 deaths.
She provided a most articulate and informed testimony to the Inquiry.

In the matter of the death of Lisa Goltman, Dr. Sauvageau informed the
Inquiry, that she was attempting to obtain medical information to conduct
the Inquiry.
She reported that she received 11 pages, no cover sheet, then 24 pages.
When she had completed the report, the family wrote to her October 25/13,
questioning her decision.

Dr. Sauvageau told the inquiry that the Office of the Medical Examiner
has full right to all the medical information, including Net-Care.
However, they ARE NOT ABLE TO ACCESS THE INFORMATION ON NET-CARE.
She was questioned by Mr. Guthrie, Counsel for the Hospital, why she
did not ask for all the information.
Dr. Sauvageau responded TO QUESTIONING BY COUNSEL, that she COULD NOT
MAKE A REQUEST FOR INFORMATION THAT SHE DID NOT KNOW EXISTED.
Initially she reported the death as a “NATURAL DEATH. Later she
described the death as SUSPICIOUS.

Initially she determined the FOLLOWING INJURIES to be the result of
resuscitation measures – by CPR
The decedent 5’3”” – 174 lbs. – (obese, which developed after she was
hospitalized- prior to hospitalization weighed 115 lbs.).
1) INJURY RIGHT ARM – INTERIOR
2) BRUISE- SIDE OF NECK – 3CM. X 1CM.
3) BLOOD AROUND LIVER, LEFT LOBE (BLUNT TRAUMA)
4) BLOOD AROUND RIGHT LUNG

Dr. Sauvageau found the heart normal

Dr. Sauvageau told the inquiry, she was given little information –
not been made aware of
1) possible thyroid issues
2) seizure activity
3) RESTRAINT by STRONG SHEET – POSSIBLE ASPHYXIATION

Undetermined cause of death – POSITIONAL RESTRAINT ASHYXIATION

RESTRAINT by STRONG SHEET (canvas sheet)
1) Cannot use abdomen to breathe
2) Put face down – restrict breathing
3) contraindicated for person known to have seizures

Level of restraint?
1) Tightness – cannot breathe
2) Obese – dangerous position- If a subject is obese, the
excess fat tissue is forced upwards into the abdominal cavity, pressing
on and immobilizing the diaphragm
3) Excessive body weight makes it harder to move the chest wall
and expand the lungs, especially while prone
4) Propanolol – affects exhalation
5) Prolonged struggle or physical exertion – Armendra Prasad,
Peace Officer, told the Inquiry that Lisa’s pants were dropped
“because of STRUGGLE”

PHENOMENAL INCONSISTENCIES”

Dr. Sauvageau commented in regard to the “PHENOMENAL INCONSISTENCIES”
in regard to the clinical staff charting – recording in patient file.

1) – SECLUSION – could not determine
– if restrained or not
– could not determine if “wrapped” or not
“Didn’t know what to believe”
Suspicious case for now.
Could not breathe

2) Dr. Sauvageau told the Inquiry that there was clear indication
that Lisa had been “WRAPPED” & “WRAPPED” & “WRAPPED” (restrained and
secluded again & again),

Medical notes – why no notes?

POSITION – How wrapped?
Dr. Sauvageau strongly alleged that MEDICAL FILE SHOWED DISCREPANCIES.

1) Not written in continuity
2) Was observed 15 minutes, 30 minutes or 1 hour, WHICH WAS IT?
3) Can’t even know when Lisa last checked.
4) Wendy Wiiliams wrote 2:15, 2:30, 2:45 AM in the medical file.
Dr. Sauvegeau commented –“IF MAKING ROUNDS, LOOKING THROUGH THE WINDOW,
THAT’S NOT ENOUGH”.
Recorded – in MEDICAL FILE – (which is a legal document)
May 4, 2013, “SLEEPING 3:00 AM to 5:00 AM”
IN FACT LISA WAS DEAD during those hours.
INTERNATIONAL STANDARDS FOR CHARTING – if entries are made late in the
file, should be stated

Dr. Sauvageau stated to the Inquiry –
“LISTED ARE ALL DIFFERENT VERSIONS, I DO NOT KNOW WHICH IS THE TRUTH“
Position found face down, blue

Everyone testified – Lisa was COLD & STIFF @ 3:00AM except one staff,
Lillian SlashinskyRN, said Lisa was WARM to touch @ 3:00 AM, May 4/13

Wendy Williams, psych aide, charted “SLEEPING @2:30 AM” in the patient
file May 4/13.

RIGOR MORTIS –
Affects jaw & fingers 2-4 hours
Arms & legs 4 to 6 hours
Dr. Sauvageau stated that if she had been dead that long, (according to
rigor mortis – 3- 4 hours) impossible that injuries due to CPR

AUTOPSY REPORT
Bruise on neck
Blunt trauma – bleeding in liver

Circumstances obscure & suspicious

Dr. Ubaid Abdullah, HOSPITAL DUTY PHYSICIAN, ASSISTED IN CPR TO THE DECEDENT.
Paramedics could not give IV, arm – rigid due to rigor mortis

Possibly died shortly after seclusion?

MYOCARDITIS suggested as cause of death –
Dr. Sauvageau stated MORE TESTING should have been done to prove or disprove
the diagnosis or presence of Myocarditis- not utilized all criteria to diagnose
Dr. Sauvegeau disagreed with Dr. Brookes-Lim – whom SHE ALLEGED, had failed
to use the Venetian Study.

Dr. Sauvageau was subjected to intense questioning by Mr. Guthrie, Counsel
for Alberta Hospital concerning her findings of injuries of the decedent.
She responded that she needed to know how Lisa had sustained the severe injuries
as again noted –

1) INJURY RIGHT ARM – INTERIOR
2) BRUISE- SIDE OF NECK – 3CM. X 1CM.
3) BLOOD AROUND LIVER, LEFT LOBE (BLUNT TRAUMA)
4) BLOOD AROUND RIGHT LUNG

Dr. Sauvageau indicated that at the time of the autopsy, she had been provided
limited information as to the circumstances surrounding Lisa’s death.
She indicated that she had been led to believe that the injuries to Lisa
occurred during the CPR which took place after 0300 Hours on May 4, 2013.

However when Dr. Sauvageau learned that Lisa must have deceased 3-4 hours prior
to the resuscitation attempt, she informed counsel, IT WAS IMPORTANT TO KNOW
HOW LISA HAD SUSTAINED THE INJURIES. 09/05/16

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