Yukon North Of Ordinary

News archive for December 11, 2013

Cause of death will never be definitively known

The results of an external patient safety review regarding the death of nurse Teresa Scheunert at the Watson Lake Hospital last summer suggest the 47-year-old did not die of mixed-drug toxicity.

By Ainslie Cruickshank on December 11, 2013 at 4:08 pm

photo

Photo by Vince Fedoroff

CAUSE OF DEATH CHALLENGED – Dr. Robert Robson, seen this morning on the right side of the video conferencing screen, conducted a patient safety review following the death of Teresa Scheunert (below) at the Watson Lake Hospital in June 2012 at the request of the Yukon Hospital Corp. He believes she died of a cardiac arrhythmia associated with obstructive sleep apnea, not of mixed-drug toxicity, as the pathology report originally indicated. Also seen are Jason Bilsky, the CEO of the hospital corporation, centre, and Warren Holland, the hospital corporationsʼ initiative co-ordinator, left.

The results of an external patient safety review regarding the death of nurse Teresa Scheunert at the Watson Lake Hospital last summer suggest the 47-year-old did not die of mixed-drug toxicity.

Instead, Dr. Robert Robson believes she succumbed to a cardiac arrhythmia associated with obstructive sleep apnea.

Robson is an emergency room doctor with extensive experience conducting similar patient safety reviews.

He was hired by the Yukon Hospital Corp. to conduct the safety review following the release of the Yukon coroner’s report into Scheunert’s death.

Over the course of a week spent in Whitehorse in October, Robson spoke with 28 individuals involved in Scheunert’s case, including her health care providers and three of her family members.

He told local reporters this morning via video conference from Alberta that he also reviewed clinical, patient, and pharmacy records, the coroner’s report, and the autopsy.

Following his investigation, he found the medical treatment Scheunert received was not a significant contributing factor in her death.

“So the principal finding, I suppose, is a non-finding,” he said.

He qualified his comments by adding that the finding doesn’t mean every element of Scheunert’s care was perfect.

However, the doctor noted that the purpose of the review is to determine contributing factors to Scheunert’s death, not to assess the competence of her health care providers nor assign blame.

Robson acknowledged Scheunert was prescribed significant levels of pain medication.

However, Robson said, nothing in her clinical presentation was consistent with mixed-drug toxicity.

For instance, an hour before she died, a nurse noted she was sleeping peacefully with a normal respiratory rate, which would be inconsistent with an overdose of medication.

While the physician said he cannot prove Scheunert died of cardiac arrhythmia, he believes it’s an explanation more consistent with sudden death.

In her report, the Yukon’s chief coroner listed Scheunert’s cause of death as mixed-drug toxicity based on the findings of a toxicology report.

The blood samples used in the toxicology report were drawn four days after Scheunert’s death.

Robson said it’s well understood that levels of fentanyl particularly can increase in the blood following death, which, he suggested, could impact the reliability of the toxicology findings.

He also noted that while the levels of pain medication prescribed to Scheunert could be lethal to an average healthy person, her body had adapted to handle higher doses over the course of her treatment for chronic back pain.

Cardiac arrhythmias are electrical currents causing irregular heartbeats and would not be detected by an autopsy, Robson said.

They are also frequently associated with sudden death.

Scheunert, he said, exhibited a number of characteristics that make obstructive sleep apnea a plausible contributing factor to her death.

He couldn’t say for sure, however, that she suffered from the disorder and specifically noted there was nothing to signal to her residing doctors or nurses that she should be monitored to determine whether she did indeed suffer from obstructive sleep apnea.

He determined that it was possible the nurse had sleep apnea because there were references to loud snoring from time to time. But, he added, not everyone who snores suffers from the disorder.

Robson explained that he began searching for an alternate cause of death because a number of Scheunert’s health care providers commented on the suddenness of her death.

He argued she didn’t present with symptoms consistent with an overdose of narcotics.

“We will never know with certainty what the ultimate cause of death was,” Robson said.

“I think that the pathologist proposed a cause of death which seemed to be supported by the evidence, and what I’m saying to you is certainly the clinical presentation and the descriptions of those caring for her are not consistent with that explanation.”

Robson also provided the hospital corporation with a number of recommendations.

Those include developing and strengthening legislation and dedicating more resources to reviewing and reporting patient deaths and other incidents, and conducting more robust and timely patient safety reviews.

He noted that he didn’t find the hospital corporation was particularly worse in its reporting of serious incidents than those in other jurisdictions in Canada; incidents are underreported across the country.

Robson also recommended the hospital corporation continues to improve its medication safety policies.

He noted that several initiatives have been undertaken. Those include the review underway of pharmacy function and the institution of a tele-pharmacy system for hospitalized patients in Watson Lake.

“By making this recommendation, I want to underline that I am not suggesting any elements of the present policies contributed to Teresa Scheunert’s death,” he said.

Jason Bilsky, the CEO of the hospital corporation, and Robson met with members of Scheunert’s family Tuesday to discuss the findings of the patient safety review.

Earlier this fall, the family called for a judicial review of Scheunert’s case, citing unanswered questions about her care and the existence of two coroner’s reports.

The chief coroner announced in late November she would hold a public inquest into the deaths of Scheunert and Mary Johnny.

Johnny also died following treatment at the Watson Lake Hospital in the summer of 2012. The inquest will be held from March 24 to April 4 of next year.

CommentsAdd a comment

ralpH

Dec 12, 2013 at 9:44 am

Ho hoocky,Going with the Coroner.

watson res

Dec 12, 2013 at 10:15 am

??? How does Nancy Thompson get away with headlines like ” Teresa Scheunert died from being given a toxic mix of drugs”?  People in healthcare cannot comment…they are not unwilling to comment…they are bound by confidentiality conditions and morals.  Something Nancy should aspire towards!

mike madder

Dec 12, 2013 at 11:09 am

Wow, this whole review was just a ruse to try and put doubt in peoples minds that the victim died of something other than doctors neglect by over prescribing narcotic pain killers and then not monitoring her usage and in fact ignoring her usage.
Watson Lake Hospital has had numerous unexplained deaths over the years like this and still nobody is held accountable. How can anyone not think this when a persons medical files disappear regarding her prescriptions and the miles and miles of excuses given. It is insulting to anyone to just accept the opinions of this board because it is based on nothing but speculation and not fact.
This is 2013 and we still don’t get the truth or facts as to how this nurse passed away or the numerous others who have died due to the neglect or misdiagnoses of these hospital staff.
Shame on the board who minimizes ones death and justify the neglect. I hope that the Federal Government will finally look into a lot of these deaths because they are not just suspicious they are criminal in nature.

watson res

Dec 12, 2013 at 1:52 pm

Ralph, I don’t see a MD behind the coroners name do you?

ralpH

Dec 12, 2013 at 3:58 pm

NO!! But the person that did the autopsy does. the coroner included those findings in her report.

Groucho d'North

Dec 13, 2013 at 4:24 pm

As more of this sad and unfortunate case comes into the public view, the fuzzier the alleged facts become. The one thing I do see clearly is the government and Yukon Hospital Corporation’s less than diligent focus to provide any clarity to what happened in this case. Now we learn pertinent information from a patient safety review is being withheld from the family after it was said the report would be provided to them. The expert doctor who conducted the patient safety review has only succeeded in adding more confusion to this situation by suggesting another cause of death, with the qualifier, that he cannot be certain his opinion is accurate; moreover he didn’t even consult with the doctor who performed the autopsy.

Minister Graham repeatedly points to the system as a means to resolve these issues -  it’s the same system the Coroner says failed Ms. Scheunert.

Perhaps it is the system at fault and it should be investigated to determine what failed, when and how. Then examine the system for how well it serves the needs of grieving families and similar interests, and how it better serves the various players to keep them from accountability and providing accurate information to grieving families.  It appears more time, effort and money is invested in covering asses than finding the faults and correcting them.

I do have faith in the medical professionals who treat me when I have been admitted to WGH. I do not have faith in the bureaucracy (system) used to govern the administration of Yukon healthcare services. Who is accountable?

Add a comment

In order to encourage thoughtful and responsible discussion, comments will not be visible until a moderator approves them. Please add comments judiciously and refrain from maligning any individual or institution. Read about our user comment and privacy policies.

Your full name and email address are required before your comment will be posted.

Commenting is not available in this section entry.

Comment preview