September 11, 1999

Mr. Carl Roy, Chief Corporate Officer, Senior Executive
Grey Nuns Hospital
VIA FAX 930 5998
Dr. Harry Zirk,
Northern Alberta Regional Geriatric Centre
Edmonton, Alberta

Dear Sir:

RE: JAMES BAIN – UNIT # 51 – GREY NUNS HOSPITAL

The above named James Bain informed us that on Thursday, September 9th, 1999, a male person attended at his room who presented himself as a representative of Dr. Harry Zirk. Mr. Bain was not certain of the name of the person, nor did the person leave a card identifying himself as to his professional status.

According to Mr. Bain, the gentleman then proceeded to query him. He asked questions which Mr. Bain believed were meant to assess his mental capacity. He was asked what day it was, how to spell little and worlds backwards and other questions. Mr. Bain said that he thought that the gentleman was probably from Alberta Hospital.

According to Mr. Bain the gentleman failed to ask permission prior to the questioning, nor did he give him a reason for the querying. If in fact this gentleman was carrying out a competency assessment and surrogate decision making process, then the failure to obtain a valid form of consent is indeed an ethical failure and subject to challenge.

We are concerned regarding the intent of the questioning. Some months ago, when Mr. Bain lived alone in an apartment and was facing eviction, he received no support or assistance. We were told that Central Placement had no room for him and he could move “wherever he likes”. Nevertheless one day, the Case Worker brought a gentleman to query Mr. Bain and failed to inform him as to his identity. Next day we telephoned the social worker as to the identity of the visitor and it turned out to be Dr.Assad Brahim of the Alberta Hospital. She then phoned Mr. Bain to clarify the situation.

Mr. Bain is legally blind, and somewhat hard of hearing, therefore it would have been appropriate to have a friend and advocate present. Coincidentally, that same afternoon, Arlene Engel phoned the former caregiver, who has continued to be a compassionate friend to Mr. Bain. Ms. Engel requested information such as how much money Mr. Bain has, whether he has made funeral arrangements, or whether he has a will and other very personal questions of which she had no knowledge.

If you are aware of who was present in Mr. Bain’s room querying him on September 9, 1999, please inform us.

We shall be waiting to hear from you. Thank you.

Yours truly,

Elder Advocates of Alberta

Attachments

Duty of Persons to Provide Necessaries, Criminal Code Part VIII, Section 215

November 17, 2006

The Honourable Mr. Ron Stevens, QC
Minister of Justice and Attorney General
Room #208, Legislature Building
10800 – 97 Avenue
Edmonton, AB T5K 2B6

Dear Mr. Minister:

JAMES Keith BAIN deceased at Capital Care, St. Josephs Auxiliary Hospital, 10707 – 29 Avenue NW, Edmonton, AB, November 22, 2000.

We strongly allege that Mr. Bain died of starvation and dehydration because he was denied nutrition and hydration.

On November 17, 2000, We made Application to the court for the Guardianship of Mr. Bain. He was under Trusteeship of the Public Trustee DAO3 10673.

Mr. Bain, 91 years of age, was blind, debilitated, physically and chemically restrained. On the afternoon of the court hearing, when we served him with the Application for Guardianship, he appeared comatose and non-responsive.

The following individuals strongly opposed the Application of Elder Advocates of Alberta. By their utterances, they lead the court to believe that the blind, debilitated, physically and chemically restrained Mr. Bain, who appeared comatose on afternoon of the court hearing, was not in need of guardianship:

• Ms. Pat Henderson, Counsel for the Public Guardian’s Office
• Mr. Les Hills, lawyer, Office of the Public Trustee
• Mr. Richard Hreczuch, Trust Officer, Office of the Public Trustee, by affidavit
• Ms. Doris Bonora Counsel for St. Josephs Auxiliary Hospital
• Ms. Colleen Freese, Public Guardian Representative filed an affidavit. Her affidavit cites the Public Guardian as Applicant. Ms. Freese was present in court. TAB (1)

During the Court Hearing of November 17, 2000, Ms. Doris Bonora Counsel for St. Josephs Auxiliary Hospital informed the court that she had “reviewed the nurses’ notes”.

Ms. Bonora stated that there were “orders on his chart [...] not to receive things by mouth”. (Transcript p. 29 Lines 1-3)

Her disclosure explains Mr. Bain’s empty colostomy which not only appeared to be empty but appeared absolutely clean at all times of the day, without any flatus.

Her disclosure accounts for Mr. Bain’s illness and subsequent death.

Ms. Bonora stated:

“there were times when he was not to receive things by mouth. On those days when you match the nurse’s notes to Ms. Adria’s Affidavit, he was fed by her on those days”. 

If there were Orders not to feed him:

1. Who wrote the alleged orders?
2. Why were his meal trays not cancelled Whenever I or (Mira N). fed him, we fed him what was on his tray and after that, anything additional we had brought from home. He always appeared hungry. Is this withholding of food and hydration, something which is carried out on the confines of the ward and not disclosed to auxiliary staff, dietary and kitchen staff?
3. Why was there no sign on the bed or anywhere in the room that he was not to be fed or receive nothing by mouth?
4. In any facilities in which I have worked as a registered nurse, when there was an Order for nothing by mouth, a NOTHING BY MOUTH sign was posted on the bed or above the bed. Others who fed him or visited him can corroborate that there wasn’t any sign, at any time.
5. On the evening of October 23/00, the Personal Care Aide brought Mr. Bain in from the hallway for me to feed him.
6. On November15/00, I was present for the breakfast meal, there was a breakfast tray.
7. No Intake & Output sheet was posted.
8. November 14/00 AM, Mr. Bain said he was hungry! He begged Mira N. to feed him. “Feed me, I’m hungry.”
9. November 15/00 Mr. Bain told me, “I don’t get too much food lately.”
10. Why was no IV or clysis being administered?
11. Was he being deliberately dehydrated?

In a long term care facility, administering clysis is within the scope of the facility to administer.

Ms. Bonora has failed to explain to us why there was a ‘no feed’ order on the file.
Ms. Bonora made an undertaking to the court to provide an affidavit which she refused to honor.

The result of a ‘nothing by mouth’ order would rapidly result in dehydration and ultimately death, especially in an elderly person.

dehydration: Lack of fluid results in electrolyte imbalance, shock; kidney or bladder infection; elevated temperature due to water lack which regulates temp mechanism. The decreased plasma volume due to lack of fluid due to dehydration results in decreased blood flow to kidneys and ultimately results in kidney failure; cellular dehydration in brain results in apprehension, restlessness and confusion, followed by coma, cardiac insufficiency and death.

We submit that Mr. Bain:

• Was deliberately not adequately fed or hydrated (after October 22, 2000)
• Was hungry – begged to be fed
• Evidenced severe neglect
• Evidenced dramatic weight loss
• Expressed fear of his situation, said he was in trouble
• Expressed concern about unfinished business
• wished to give someone something
• Was being seriously chemically restrained.
• Sufffered from an advanced #4 bed sore which could necessitate amputation or result in systemic sepsis which could cause death.
• Suffered from a virulent infection
• Suffered from bone contractures, severe foot drop
• Was administered poor hygiene, frequently did not appear washed, shaved or cared for, teeth not in place,
• Failed to be taken out of bed or out of facility
• Was neglected by the physician who failed to keep himself informed of Mr. Bain’s health issues and bedsore

Ultimately Mr. Bain was disallowed any outside contact totally isolated,

• not allowed to receive phone calls from family in Scotland and England
• a guard was posted at his door November 16, 2000.
• not allowed visitors and advocates
• not allowed a visit by a Priest

Mr. Bain died at noon on November 22/00.

His remains were sent to the Medical Examiners Office.

We have extensive, detailed documentation concerning this matter.

We respectfully ask your investigation into this matter. We would be grateful to be in receipt of your response by December 7, 2006.

Elder Advocates Of Alberta Society

HAND DELIVERED

CC:

Honourable Iris Evans, Minister of Health and Wellness
Honourable Yvonne Fritz, Minister of Seniors & Community Supports
Dr. Kevan Taft
Mr. Brian Mason, BA

Attached Documents

Attached Images

 

October 22/00 6:30PM: There were pink toothet mouth swabs on his bedside table which one only finds at the bedside of post surgical patients and terminally ill patients who are unable to eat or take fluids and therefore require mouth care. That same evening, I fed him three dixie cups of ice cream and a muffin, which he eagerly received. I later wondered why these oral swabs were there when in fact he appeared to be eating well.

October 24/00 3:15PM: Mr. Bain was on a semi-recliner. Around his mouth was dirt, there were remains of a yellowish liquid which had dripped down his cheeks onto his neck and a dirty towel. His face and eyes were unwashed. He was unshaven and unkempt, his gown filthy. The soiled towel around his neck covered the night gown which was soiled from spilled liquid that had dried. He appeared heavily drugged, totally neglected, and gravely ill. We found later that he had a severe infection from the bed sore. Shortly prior to 5:00 PM, we called the Protection for Persons in Care, but it was already closed. We reported to the Protection for Persons in Care the next morning at 8:20PM. We had to repeat the complaint to three different people at the facility, all Registered Nurses.

October 24/00 3:15PM: I examined his colostomy bag and found it to be totally flat and empty, there was no flatulence in the bag, it appeared to be clean. There was a taut gauze bandage which came from his back and extended across the top of the round opening of the colostonomy bag. I assumed that he must have had a decubitus ulcer on his back, and therefore the gauze bandage was placed tightly across the colostomy opening. Or did they attempt to close of the opening of the colostomy?

On numerous occasions, we found the colostomy bag empty, there was no apparent flatulents.

His left foot was swollen. The severely ulcerated area on his swollen foot is a pressure sore (bed sore); the result of neglect. We were told that the flesh on his left foot had become necrotic, and had to be debrided, causing the heel bones to be exposed. He also exhibited severe footdrop, and some positional deformity, particularly in his left foot. He also suffered contractures of his legs.

October 26/00 10:35AM: After Mr. Bain had eaten, food remained in his mouth because he was so excessively medicated he could not stay awake long enough to swallow it. Lynn Olenek, RN (Director of Nursing Care and Pastoral Care), attended with another tall blonde person, whom we believe to be the Protection for Persons in Care Act (PPCA) investigator. Ms. Olenek introduced herself, but did not introduce the person who was with her. Ms. Olenek inquired who I was, and then they both immediately left the room. They looked briefly at Mr. Bain but made no attempt to address him, nor did he seem to be aware of them.

Mr. Bain was on a pressure bed. Sometime he was given thickened fluids, and sometimes liquids. This indecisive process was evident on his meal trays. We have since learned from the lawyer for the Office of the Public Guardian that there was an Order Not to Feed on his file. Nevertheless, we were never notified of this, there was no sign on the bed. Whenever we or others were to feed him, meal trays appeared.

November 12/00: He was being chemically restrained.He could not eat ice cream on that day. He said he wished to have some, but could not stay awake between mouthfuls.

He was also being physically restrained. He was tied to his bed and chair.

November 16/00 9:30PM: We exposed the twisted, neglected limbs to the Chief Executive Officer, Marilyn Snow, RN. We questioned her on whether she was aware of Mr. Bain’s neglected condition. She replied a number of times that she was totally aware of everything in the facility.
November 17/00: A guard was posted at the door of his room. Friends and advocates were denied access. Ms. Pat Henderson, Counsel for the Public Guardian’s Office, and Ms. Colleen Freese, Public Guardian Representative, Mr. Les Hills, Trust Officer, Mr. Richard Hreczuch, Trust Officer, Ms. Doris Bonoroa, Counsel for St. Josephs Auxiliary Hospital, made presentations to the court that this blind, ninety-year-old man could instruct staff and that he did not need a guardian. The statement was also made that the Protection for Persons in Care Act investigator had found no evidence of neglect.
November 21/00: A priest was denied entry.

November 22/00 12:00PM: Mr. James Bain dies.
Even in Death, his nails are not trimmed.

In nursing homes, neat, clean, white bandages deceptively hide horrific secrets. His left foot was swollen.

This is a picture of someone who has an infected heel, similar to that of Mr. Bain’s.