Website Feedback: May 25, 2009

My mom was 61 yrs old and had a rare form of dementia which affected her ability to do tasks. Her memory was great and she could carry on a conversation well. She was very excited about my upcoming wedding this summer and would talk to many about this. She lived at Capital Care Norwood. She was recently (2 months ago) having some paranoia, always involving staff, and at my request was being moved. She had been put on Seroquel (in March) by Dr. Brown, her doctor but it was not making a difference.

At Norwood they decided to have her go to the Glenrose for a reassessment and medication assessment (this is where she was originally diagnosed) however there were no beds available so she was moved to a different floor at Norwood, one she had previously been on and been happy at. Unbeknownst to me, she was put on Zyprexa on Apr.24/09 (the day she was moved to the other floor). Her regular doctor did not see her as he was away.

According to Norwood, it was their medical director who made this decision. Nobody told me she was put on a new drug, only that they would do a medication assessment at the Glenrose. Over the weekend, she appeared very tired, often falling asleep while sitting in her chair. I had to request her dinner in her room on Monday as she just seemed so out of it. I was there a lot over the weekend and staff rarely came into her room. I told the nurse about my mom not being herself and having a rough time, so tired, but was just given the dinner and I fed her. Not knowing she was put on any new medication, I just thought her tiredness and behaviour was from all of the previous stress, the move etc. The next morning (Tues.Apr.28) I received a call from Norwood advising she is being rushed to Royal Alex as she was found to be rigid, delirious and had a temp of 103.

I raced to Norwood and went with the ambulance. The treatment there was another terribly incompetent story. In the ER we were told her symptoms were either a result of sepsis, meningitis, or medication related. They did testing for sepsis and meningitis and we were told they were stopping all medications in case that was the cause. She was moved to an active treatment floor at 4:30am (Apr.29) and for some reason was given the zyprexa again twice on Apr.29. Unknown to us at the time. With some investigation I learned from calling Norwood that she was given zyprexa starting Apr.24 from the head nurse.

I then called Royal Alex to ask what medications she was being given and was told zyprexa. This drug is not approved for elderly patients with psychosis related to dementia. In vain I tried to speak to her Dr. from approx. 9 pm that night until approx. noon or 1pm the next day ( Apr.30) when I was finally allowed to speak to her Doctor. My mom passed away on May 1, 2009 at 12:12 am. Her doctor had assured me that day that she was improving (the zyprexa had been stopped due to the fact I refused it for her that morning).

I repeatedly questioned him about her breathing as it did not sound right and she looked like she was having trouble. I asked him if there was a problem with her breathing and said exactly “there is no chance she will stop breathing or anything tonight is there” He told me no, that is not a concern with this (neuroleptic malignant syndrome was the possible diagnoses as all test results were clear). We stayed until 8 pm that night and she was finally resting (they had given her Dantrolene) for the NMS.

She had not slept for 3 days, had been delerious and so much more. It was horrible. There was no nursing care, I had to wet her mouth and had to search the er ourselves to find swabs. We had called the nursing station at 11pm to check on her and were told she was fine, still resting. An hour and a half later the Doctor called me from his home telling me she died, he didn’t know why. When we went to the hospital right away that night, the nurse just said she didn’t hear her breathing, didn’t feel a heart beat, called the head nurse, then she took a breath and they could feel a heart beat so they tried to sit her up and then she stopped breathing again and there was not pulse.

After requesting an autopsy and medical records from both the royal alex and Norwood, I received a call on Wed. May 7 from the administrator of Norwood, Penny. She wanted me to come in to meet with her and Dr. Faulder on Monday. I advised her that was not possible as I would be in Ontario having my moms funeral. She said to me that she understood I would be in on Fri.May 9 (this is when I was scheduled to pick up the records), I told her I would and she asked if I could stay for half an hour longer to meet with them. I didn’t know what this was about and had so much to do to prepare to leave the province I told her I was not sure if there would be time, maybe I could see her when I return. She was quite adamant I see her before I left and gave me her cell number to call if I could make time at any point in the next two days.

I called her Thurs. night and told her myself and my sister would be coming there Fri. at 11:00 am. She advised she will meet us then and asked if anyone else would be coming. I told her my fiancee. We met and she told us that after my mom passed away, she was going through all of the charts etc. she noticed an error regarding pharmacy and nursing.

She said that starting Fri.Apr 24 pm, my mom was mistakenly given double the dose of the newly prescribed zyprexa for three days, once on Friday, twice on Sat., twice on Sunday and then it was noticed Monday morning so they skipped that dose and gave her the regular dose Monday pm. I asked her why we were not told, why the ambulance was not told or the hospital. She just said “I don’t know, I’m sorry”. The medical examiner advised us that the autopsy did not show a cause of death, she was healthy.

They had to send brain tissue and blood away for analysis. This is so horribly outrageous, I don’t know what to do or where to begin. I took a video of my mom in the hospital as she just looked sooooo bad and nobody seemed to care or act like it was that bad.

According to many professionals, she should have been in ICU with constant monitoring and on an elective ventilator. She wasn’t even on monitors. Please advise me what to do not only so that people are held accountable for this but so that this may not happen to someone else.

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