Thunder Bay Regional Health Sciences Centre
Thunder
Bay Regional
Hospital - Case Study of Mrs. Squitti
"To error is human.... "
Too many different doctors, on
a day to day basis in hospitals ?!
Not enough family doctors ?!
Not enough specialized doctors ?!
Not enough nurses, and too many patients per nurse ?!
Conclusions:
Most importantly, Canada's
Health Care system
lacks accountability and an objective and effective quality control
system.
While most believe it is a
public system, (a half-truth) it is merely publicly funded, with most
services provided by 'private sectors.'
The one critical systemic flaw
in the payments to family doctors, is that the financial payment system
(a fee per visit and specialists) rewards volume, it indirectly rewards
chaos, complications, referrals, complexity and poor health; there are
many winners to this system except good health and most often the
patient. In the case of a payment for a procedure, the
effect is not as negative although there is an incentive for volume.
The payment system penalizes
prevention, good nursing, good
doctoring, and most importantly good health.
This basic systemic flaw makes
victims not only of patients, but also doctors and
nurses and staff who must deal with this financially promoted
"organized chaos" ; the devil is in the details!
Caesar J. B. Squitti
July 26, 2010
The
Health System and Nursing
in Ontario
July
12, 2007
The
conditions in which nurses work in is unacceptable. Too much
work, not enough support staff, and management that is unable to
regulate the conditions, nor deal with 'renegade' staff, that makes it
difficult on the whole system.
If
one critically examines the health system in Canada, you will note that
it is a half-truth, that is it is merely publicly funded, with most
all services provided by private enterprises, not that is a problem in
of itself, except for the current payment system that rewards repeat
visits, inefficiencies, ineffective treatments, and disease. The
payment system is the needle in the haystack, the devil in the missing
detail that motivates the system away from the best of cures;
prevention. It is a payment system that victimizes good doctors
and
especially nurses, who would appear to bear the brunt of a system
in
chaos.
I
would like to include some observations concerning nursing in Ontario
that I must include
to give a more balanced approach to the health system in Ontario, since
I
have put it under the microscope.
Nursing
is one of, if not the most important and basic fundamental
service in the Ontario
Health System. A truly most demanding and important service that is
highly unappreciated and I say that because of the total lack of
importance given to them in the hospital setting.
For
one, while investigating the hospital board system in Thunder Bay, it
was noticed that on all boards there was only one nurse on the quality
control committee, and the position was non-voting. TRULY
UNACCEPTABLE.
Any
school of management suggests that your front line workers, are those
most able to offer important advice to the health system. It is
obvious the 'boys' club of hospitals in Ontario treats the nurses
profession with a lack of respect.
I was
quite pleased to hear that the CBC aired one of my letters on this
issue several months, ago and shortly thereafter the nurses association
announced that they would be taking a more political involvement in the
health system. Good for them.
Nurses
have seen management give them raises on the one hand, and then on the
other, management has decreased full time jobs to save on the benefits
extended to nurses, which make it difficult on the nurses and patients;
too much short shifts, increases the change in the environment.
It is
important to understand that most 'nurses' are salaried positions, and
do not benefit from an increase in 'chaos' within the
system. That is why they are so important a source of
information to make the system more efficient and effective.
The
importance of having more nurses, one from each field involved in the
board operations of each hospital is paramount.
In
sofar as the health and hospital systems are concerned the public
has
lost control of the purpose, the intent and direction of them.
The Truth will set us
free ?
April 19, 2002
By reading the editors page, "No exception to the Golden Rule" on fair play in the media, the new Editor to the Thunder Bay Post, Ann Zaza speaks about some important concepts regarding the need to have a free media. A free media willing to print The Truth, and not a freedom to print what "they" believe is politically acceptable. The Truth is sometimes difficult to accept.
The deaths at Wakerton, should show to the people of Canada how systems can fail, and it is important to deal with the important issues of the problem, not ignore them.
Case in point. After several bad experiences within the Thunder Bay Regional Hospital, we decided to expose the cover-ups, the stonewalls within the medical system in hopes of bringing to the attention of the people what was the risks within our troubled hospital system.
We decided to take out an ad in the Thunder Bay Post, in 2001, prior to Ann Zaza's arrival at The Post, via a sales rep by the name of Dale Pumphrey, and The Chronicle Journal. The copy was checked over by legal council in Toronto and following some minor changes the legal advice that there should be no problem in running the ad.
Originally both account reps from both print media's said they saw no problem with the account of events that occurred to our Mother in the Thunder Bay Regional Hospital. Problem was that both papers decided that they would not run the ads. Why? There was no reason given. They could have verified the information with Mr. Saddington from the Hospital. No, they declined to expose to the public of Thunder Bay, what was happening in the City, and in my opinion jeopardized the health and well being of those who use the hospital.
I disagree with the bottom line written
by Ann Zaza, the new editor at The Post, that in this case the media,
as
represented by The Chronicle Journal and The Thunder Bay Post did not
play
fair with us, nor the people of Thunder Bay.
Caesar J. B. Squitti
Thunder Bay, Ontario
References:
CBC INVESTIGATIVE REPORT - 2004
Last Updated Mon., 24 May 2004 15:15:52
TORONTO - Thousands of Canadians die every year because of mistakes in their treatment at hospitals, a new study shows.
About 185,000 patients suffer an accident in surgery or a medical oversight every year, 40 per cent of which are preventable, according to the study published in the Canadian Medical Association Journal....see link below for full story !
Chronicle Journal December 1, 2000
Thunder Bay Regional Hospital Emergency Department in a State of Crisis
Chronicle Journal December 6, 2000
Thunder Bay Regional Hospital -Specialist questions ER report
Chronicle Journal December 6, 2000
Thunder
Bay Regional Hospital - Hospital leaders fret over leak
A CRY FOR JUSTICE !
Thunder Bay Regional
Health Sciences Centre ?
This page is set-up to bring to light some of the unfortunate negative situations that have happened at the Thunder Bay Regional Hospital in Thunder Bay, dealing with Mrs. Squitti over the years.
If you know that some of the details here are incorrect, please contact the writer. I am Caesar Squitti, a wrighter of sorts, and I have taken this avenue to pursue The Truth regarding Mama Squitti and her incidents at the local hospital in Thunder Bay.
Let us all appreciate that many great and positive things have also happened over the years, at these facilities, by dedicated nurses and doctors.
This is however and examination of
the
negative incidents that are the potential of creating much positive
reform
within the hospital system, based on a appreciating that we are all
human
and that unfortunate situations occur some in part due to forces beyond
our control.
1. The first incident 1996, Mrs. Squitti was brought into the emergency department of the Port Arthur Hospital, at 1:00 A.M., following a severe leg infection, perhaps a minor stroke. She was admitted to the hospital and 12 hours later, had not been seen by a doctor, was not given any oxygen and was not given any medication. The hospital has now closed this emergency department after 9:00 PM due to a lack of staff.
By the early morning she was in a great deal of pain, and disoriented. My sister had been with her all this time. One nurse called some other staff to restrain her, including a cleaning lady. My sister was told to leave the room. Moments later my sister heard her mother screaming and a loud crack. When she entered the room, Mrs. Squitti was unconscious and a staff member had her sore leg in her grip, without realizing she had a problem with her leg and a heart condition.
When I arrived on the scene, I did not know this had happened, and my sister was probably in shock. My mother came to, telling us that she wanted to leave and we left the hospital.
The next morning, Mrs. Squitti developed
bruises on her body, and Police were called. Pictures were taken, and
the
investigation went nowhere. I did learn later that one of the
individuals
involved was connected to a local police force, and ponder the question
if there was cover-up. The individuals involved included one
nurse, a staff member, and some cleaning staff.
We later learned that one of the people involved had connections that probably resulted in the investigation being shut down.
We now were at home, and mother was in
worse condition. Teresa took mother to her family doctor, one who does
not have privileges at the local hospital and she advised us to go to
Saint
Josephs Emergency Department. We waited three days in the emergency
ward
for the internal specialist to show up. NO one did, except for a
passing
through intern who asked if Mother perhaps had a stroke. Poor mother
was
somewhat disorientated and now complaining of a pain to her ribs.
We waited three days in the emergency, 24
hours a day. I even slept in the car in the parking lot,
waiting for doctors to treat o examine mother. We eventually left
the emergency department. What is more alarming that one evening
while we both slept by mothers bed in the emergency room, Teresa woke
up, after being hit on the back of the head by a board. The nurse
explained that she was taking the board off the wall, and it
accidentally slipped. Was this in retaliation for calling the police
into
the first incident at the Port Arthur General. Teresa had to go
see her doctor because of bleeding to her ear.
The nurse in question was not working at St.
Josephs the last time I saw her, but she is still within the hospital
system. I sent a letter of complaint to the hospital, and
the nurses profession regarding this incident and nothing came of
this. We know allot of great good nurses, but there appears to be
some select few who may be "renegades' making life difficult not only
for patients but for all the good nurses and staff in the
hospital. ( I expect with the amalgamation of the two
hospital facilities in Thunder Bay, McKellar and the Port Arthur
General, ( McKeller which was excellently staffed and operated,
according my observation, and the Port Arthur General, that appeared
mismanaged) that there is going to be some serious problems for
management, the hospital and the good staff. A few bad apples
will
spoil the whole barrel.
Mama Squitti was never really treated and with time she just improved.
RECOMMENDATIONS:
1. The hospital board did not have in place floor supervisors. Therefore some patients fell through the cracks. When I learned that the hospital had been operating without floor supervisors, I learned that they had not had them in over 8 years. When I contacted human resources the person on the phone told me they had them, when I asked since when, the response was "they are starting next week."
2. Qualified specialized nurses, ie
those dealing with the elderly- geriatric nurses , are not being hired,
because they warrant a higher pay schedule.
3. It appears the good
name of
nursing, as in all professions, must be critically examined and
controlled, the Nurses Association may have lost control of some its
members.
This site will explore many of the unanswered questions surrounding the near death experience of our mother during her stay in the Thunder Bay Regional Hospital, in 1998, in hopes of shedding some light on avoiding these types of incidents in the future.
Mother was placed into the Intensive Care Unit of the Thunder Bay Hospital, following complications with Bronchitis. We were concerned that some of the staff would retaliate for the previous incident where police were called.
It was bad enough we had to wait THREE
DAYS, to have Mrs. Squitti's specialist see her, because the doctor was
not informed that Mrs. Squitti was in the ward. In fact the specialist
was within 20 feet of Mrs. Squitti when she entered the emergency ward,
and the doctor was never contacted. Why was not the
doctor notified ? I have learned since, that one of the nurses
put into the ICU during our stay was the head of the nurses union; who
had problems walking let alone looking after patients.
Early one morning Teresa say Dr. H come and go, without being contacted
to see Mother. So Teresa went to the nurse and asked her why Dr.
H did not come over, to which the nurse responded, ‘go get her if you
want'.
The next morning Teresa waited at the door, for Dr. H. At 7:00
o'clock Dr. H was making her rounds at the ICU and Teresa met
her. Teresa explained that she was trying to contact her for
three days. Dr. H stated that no one had contacted her. The
Dr. said she saw Teresa in the ward, but thought she was visiting
someone.
By the time the specialist saw Mrs. Squitti, she was in very poor
condition, and her lungs were drained, it appeared her kidneys had gone
into shock due to some medications given to her earlier. We
were watching Mother who was in bed for three days with water
accumulating in her system, in part because the heart specialist was
not contacted. When Dr. H. gave Mother some medication for her
kidneys the response was immediate.
Mrs. Squitti was put onto a respirator after having her lungs drained,
and what happened next is of major concern.
Late one night, the attending nurse, asked Teresa Squitti, to leave and
Teresa responded that she would not and that if she wanted her to leave
that she contact security.
I can only assume that a negative relationship developed between this
particular nurse and Teresa. Several hours later, this nurse, the head
floor nurse gave orders to a junior nurse to have Mrs. Squitti injected
with some drugs, Morphine and 2.5 mg of Valium. Mrs. Squitti does not
take Valium but a much weaker drug, Ativan, .25mg. A pharmacist
confirmed that this was over medication. My concern was why
Mother was given these drugs in the first place, she was not in pain.
Mrs. Squitti was put on a respirator at 11:00 at night on to drain the
liquid out of her lungs. The condition that developed the next morning
is that Mrs. Squitti was not waking up and the heart specialist was
concerned why she was not waking up. I believe had a cat scan performed
to see if there was any brain damage.
At this time Teresa informed Dr. H that mother had been injected
one night with Morphine and Valium, saying that the doctor had
prescribed it. One morning Teresa asked Dr. H had she prescribed
the drugs. Dr. H said no, and then Teresa asked Dr. H, if it was
all right for her to ask Dr. H in front of the nurse about the
injection;
the Dr. agreed.
So the next morning, in front of that nurse, Teresa asked Dr. Hessian
in front of the nurse who had said that Dr. H had prescribed the drugs,
‘did you Dr. H prescribe the drugs, morphine and valium?" and the Dr.
responded no. The nurse said nothing.
Dr. H. decided to perform a cat scan on a Friday, to see if any
additional strokes could be the cause of Mother not waking up.
She told the Intensive Care nurse, that she would be on-call for Mrs.
Squitti only. If there was anything of concern, to contact her
she was wearing a beeper.
On Friday night, mother started to develop fever, and attempts were
made to contact Dr. H, or so we were led to believe. Mother temp
rose to 103 degrees and we thought that she might pass away.
Teresa was praying for help. On Sunday night Dr. H. walks in the
door, unexpectedly. She said that she was at a function,
and she was driving by and thought she might check in to see Mrs.
Squitti. We told her that the nurses were trying to get
in touch of her for three days. She said that no one contacted
her.
Dr. H. then phoned the nurses registry and ask that a full report be
issued on the incident, and then gave mother some much needed
anti-biotics.
A few days later Dr. H the cat scan reports came back and
Dr. advised Teresa that Mother did not have any additional
strokes. Later that morning, an internal specialist came
into the room one morning and stated to Teresa that Mrs. Squitti was
basically dead and that from reading the cat scan reported that Mrs.
Squitti had suffered another stroke. Teresa told me that
she found it strange that the doctor, was lying because Dr. H had told
her that mother had not had another recent stroke. So I became
very suspicious of this.
The specialist Dr. H, decided to have tests conducted to
determine what drugs were in here system. The same nurse who had
authorized the student nurse to give the drugs, replied that nothing
would be found in her blood. Dr. H. responded that she was
not looking to do blood tests, but urine tests.
For three days, the urine tests, were not conducted, and the doctor
had repeatedly ask for the tests. Eventually the doctor
asked that she was going to stay until the tests were performed.
The tests showed that mother had high levels of morphine and valium in
her system.
So for weeks, Teresa and I and Josie Roti, took turns watching mother,
24/7. Mother was on the respirator. One
day Dr. H. came in and gave mother some "albumen"
(albumne) a special in
the feed tube, to return in one hour, and advised Teresa that she could
keep mother on life support for as long as she wanted. Within
that hour, the head of critical care came into the intensive care unit
, and starting to pick at mothers' ears. She turned to Teresa and
said, "she's deteriorating, you know you are making her suffer'.
Teresa responded, "you don't know my mother and you don't know
me'. The critical care rep then walked out.
Teresa was being bullied by the head of critical care to take mother
off the respirator and she did not know what to do. In despair
she tells me that she prayed to God, "God
show me a sign, so that I know what to do". Seconds later,
Mother, started to move around, she then sat up, opened her eyes,
starred at Teresa and then went back down in the bed and went back to
sleep and continued to show foot and hand movement. The nurse saw
this and her response was, ‘this happens sometimes'.
Dr. H came back and asked the nurse has there been any changes.
The nurse responded no and then looked at Teresa. Teresa then
showed the doctor her notes, of all the improvements that Mother had
made in the last hour. She then told the nurse if
there is any slight change to call her.
Dr. D. was quite upset with Teresa and verbally attacked her saying,
"You don't leave someone on life support for 26 days', "there is
nothing left here but nerve endings". Teresa responded, ‘there is
a human life here' and "watch what you say, there is a human life here,
she could here you".
One afternoon, that internal specialist Dr. D, who had stated t hat
Mrs. Squitti had another stroke, called a meeting to discuss the
condition of Mrs. Squitti; there was going to be a meeting with a
medical student in the Port Arthur Hospital at 1:00. What
happened next was somewhat beyond probability.
I was at the shop waiting to go to the hospital, when Nick Prsa, came
into the shop. He was cleaning out his TV repair shop and came
across two tape recorders, and since he did not need them both, decided
to bring one over for me. Was this a message from God, that
I should record the meeting ? So minutes before this
meeting with the specialist, Dr. D. in walks a person to give me a tape
recorder. I took it as a sign.
At the meeting Dr. D. suggested that there was some problems with Mrs.
Squitti something to do with her metabolism.
Well Dr. D. went on to explain that Mrs. Squitti was in a bad situation
it was a problem that related to her metabolism. I
did not believe him, in fact it was a half-truth, so I asked about the
drugs she was given, "MORPHINE AND VALIUM, in fact 2.5 mg of Valium. I
told the doctor that Mrs. Squitti does not take Valium but Ativan. The
doctor replied that 'they were the same drugs'. "Really" I said and
then the doctor corrected himself, 'the same family of drugs'. Mrs.
Squitti was very sensitive to drugs, and would take on occasion .25 mg,
that 1/4 mg of Ativan, not 2.5 mg of Valium that she was given. Not
only is 2.5 mgs of Valium 10x more that .25 mgs of Ativan, Valium has a
longer half-life and will remain in the system longer.. It appeared to
us that the Doctor was trying to cover up the impact of the 'morphine /
valium ' combination. Why ? ...my suspicion was that 'these two
drugs'
in combination were responsible or partly responsible for the coma
conditions.
We sat with Momma Squitti for many days, night and day, worried that
something wrong would happen. The nurses, two of them, one who injected
and the other who had authorized the younger nurse to administer the
drugs was being very attitudinal and uncooperative. One of the nurses,
the one who had directed the student nurse to administer the drugs in
question did not want us to touch Mrs. Squitti. We asked
the doctor and she responded, "do whatever you want to get Mrs. Squitti
to wake up".
One day we placed a set of earphones on
Momma Squitti with music from a portable music player, and one of the
nurses, the one involved in the original injections, seemed to object
to this and I became very upset with her attitude. I came in one
morning and feeling the stress levels in the room quite high, I quickly
turned to her and asked point blank, " are you afraid that
she will wake up?...." She looked at me and said "yes !".
I turned away. Interesting response from this person toward a
patient in a coma, don't you think ? We were trying to get Mother
up, and this nurse was worried.
It took a few weeks to get Mrs. Squitti off the respirator, 'weaned
off' and Mrs. Squitti was fed through a feeding tube. Eventually Mrs.
Squitti showed signs of responding to us, but it took a few weeks. In
part due to the great strength Momma Squitti had prior to being
admitted.
What was really strange, was after Momma
Squitti had regained herself and was able to walk with assistance she
would say to us that "they had killed her !". Odd for a person in a
coma, don't you think ?
The complaint with the Thunder Bay Regional Hospital that
followed, complaints against the doctor involved with the apparent
cover-up and the hospital. The hospitals response was the following
"records indicate the doctor had ordered them." Not much of an
investigation if you ask me. This would suggest the doctor lied. I
believe the records are lying. It is my opinion that if it was not for
the dedicated work of one specialist, some compassionate staff, and the
24 hour care by Teresa, that Mrs. Squitti would have surely died.
The doctors complaint went
all
the way to the College of Physicians and Surgeons, and an appeal to the
Health Services Board in Toronto, and 'not anything' came of it. The
initial response from the doctor was not accurate, but it seems when we
sent in a recording of the meeting with Dr. D to the College of
Physicians and Surgeons, they gave him the copy, or the information
contained on it, and he changed his testimony. The Toronto Star
contacted me and did their own investigation of the College of
Physicians and Surgeons and came to the conclusion that 'over 90% of
the complaints were pushed under the carpet; I can verify that in our
complaint they appeared to provide information to the doctor for his
own defense.
So I warn you about providing too much information to the College, they are a self regulating agency that appears to side with the doctors. Errors do happen, and we all should expect them, but we should not lie to cover up errors that might interfere with treatments. I for one can attest to the great many complexities that doctors must deal with, and as the saying goes, "judge not lest you be judged".
I remember the truthful response of the specialist, who came in one morning, and honestly stated, "perhaps we gave her too much drugs'. An honest accurate response that understands that each person is different and you cannot expect doctors and nurses to make perfect decisions; that is unreasonable. Honesty is the best policy. A simple statement, "maybe the drugs are not acting properly, or they may have, given the situation caused unforeseen effects, is all that was required.
In an unrelated incident, in the same hospital years earlier, Momma Squitti was almost given the wrong drugs twice, within hours, in fact her heart specialist witnessed the two events and could not believe it. Perhaps Momma Squitti was given someone else's morphine and valium ?
We must also give credit to Teresa,
who
remained with Mrs. Squitti, night and day, for some 30 days. In those
30 days, Mrs. Squitti remained in a coma, and one of the nurses, the one
involved in the drug injections, appeared to not want Mrs. Squitti from
gaining consciousness. Just like everything there is good and bad, even
in the angles. Why should a hospital be any different. There were those
staff that were helpful and those that weren't.
I will continue to update this
account, with more details.
------------------------------
In the meantime, a doctor in Ottawa,
was found guilty of killing some
10 patients with morphine overdoses.
In some cases where breathing
is
agitated, morphine is used to repress it rather than trying to treat
the problem, ie water build up ?
As of February 25, 2000, a
teenager who went into the Sick Children's
Hospital with a broken leg, died from an overdose of morphine; an
investigation has ruled it a homicide.
In England a doctor, Dr. Shipman,
murdered hundreds of elderly patients with
injections of morphine.
Is morphine, under the label of 'pain management' being used as a
tool of termination ?
( Do not resusitate orders is
another problem in the hospital system )
Morphine used to terminate
lives ?
------------------------------
(please note how a combination of morphine and valium, nearly killed Mrs. Squitti, and "some" of the professionals lied to conceal a possible mistake, or a murder.....???? By a miracle did Mrs. Squitti recover, but it relied on Teresa, her daughter sitting with her mother for some 3 weeks, 24 hours a day...in the ICU )
I have noted that Canadian hospitals, lack the respect of human life. Perhaps it is because they now perform abortions, or perhaps of our materialistic now culture, life is invaluable. It is ironic, because without life, in the long term materialism would itself die. Below you will find three separate incidents of how, a hospital in Thunder Bay, Ontario reflected this "attitude."
It is said that a chain is as strong as its weakest link and this simple analogy, gives great insight into a hospital system. No matter how great the intentions, how great the people, it is those little details, that will spoil the day, for all of us. The names of the doctors below are those that have in my opinion become pawns in a system that lacks critical control, and enough resources to be properly run. We all suffer. The staff, the patients, the administration, and the people of this city.
It is important that we appreciate that reality is flawed and that we must make the important decisions to correct the problems to avoid similar problems. To expect the unexpected and errors, is the beginning of discovery and improvement if we act on them.
To error is human, to forgive divine, to not learn from your past mistakes is unforgivable....
The decision for the Thunder Bay Regional Hospital to further restrict the hours of the Port Arthur Hospital, is perhaps a step in the right direction, but perhaps the entire department should be closed, ASAP.
MY RECOMMENDATIONS:
1. Morphine and other drugs are being used to sedate some patients. Throughout the world some patients are euthanised as was being done in England by a doctor.
2. Other sedative type drugs are being used with little knowledge or transference of this knowledge to the family.
3. Accurate investigations of patients who die in the ICU be undertaken to see if there are problems.
If a hospital and its
staff can kill healthy unborn children, incinerate them, and
rationalize
that, then euthanizing the elderly is easy.
Mrs. Squitti was suffering from a leg infection, for some two weeks. Although her family doctor operated a few blocks away and Mrs. Squitti was confined to bed, she refused to pass by the home to see Mrs. Squitti. The doctor drives a $ 75,000 4x4, we are not talking horse and buggy. Attempts to get blood tests at home failed. She suffered a mild seizure at home, and was taken to McKellar Hospital.
(You should not that Thunder Bay is restructuring its hospitals. Five years ago we had three general hospitals, and a psychiatric one, today we are moving to close them all and move to a new centrally located one.)
We had taken Mama Squitti to the McKellar site because of the unfortunate experiences noted above at The Port Arthur General site. We were told that Dr. N. could not attend Mama Squitti at this site, and we would have to transfer her to the Port Arthur Site with the understanding that Dr. N, her heart specialist would see her when she was transferred to the Port Arthur Site.
Upon arriving at the Port Arthur General, she was given to the wrong doctor, another doctor by a nurse.
The nurse LIED to us.
In the next three days, Mrs. Squitti saw, 4 different specialists. Three out of town replacements, since the Port Arthur General was having problems with doctors.
Mrs. Squitti passed from this physical life on March 26, 2000. Probably, complications, from inappropriate medications, and suffering again from a probable kidney shock, probably induced by an overdose of drugs, and a failure to note the negative effects on Mrs. Squitti . (160 mg of Lasix) I am certain Mrs. Squitti would be alive today if Dr. N had attended Mrs. Squitti, her heart specialist would have attended her when she first arrived.
It is my opinion, that the Port Arthur site should be closed as soon as possible. We have found the McKellar site better organized and driving a few minutes is not as critical as the important care and organization that one needs when one arrives at a hospital. All it takes is a few simple honest errors, and the game is over.
Mrs. Squitti, my mother, was a mother to all to all people, of all types, sick, well, and other....in her eyes, she only say children of God.
Mrs. Marianne Squitti went to a better world, Sunday, March 26, 2000. In a somewhat sureal set of circumstances.
As we sat beside the hospital bed holding onto the still warm body of Mamma, I turned on the Sunday Mass from Rome with Pope Paul II. After a few minutes the station aired Luciano Pavoratti singing in concert with his rendition of "Mamma".
The co-incidence was shocking but welcomed. I turned up the speakers and listened. I would like to believe that in this moment of transition, God had once again revealed his mysterious hand in the final page of the LIFE of a very saintly person: MAMMA Squitti.
MY RECOMMENDATIONS:
1. Canada's Health system ranks among the most expensive in the world, yet in terms of patient quality it ranks 24th, behind Columbia. The financial part of the health system rewards visits, referrals, and disease. Mistakes and treating symptoms rather than causes is rewarded under the current system. Put doctors on a salary, a fee per patient per year, and I am certain the focus on the system will change.
2. The College of Physicians and Surgeons is a failure in improving the health system. It is a success in protecting its members. The Toronto Star contacted me and then undertook a study of the College and found that the vast majority of cases are swept aside. With overwhelming evidence to the contrary, they protected doctors errors, rather than dealing with them. Shame on them !
3. The current doctor shortage in Canada is man made. Economics 1010 tells us that a restricted supply of a service will result in higher prices or as in this cases more income to those involved. There are many skilled doctors from other parts of the world that are not welcomed here, because they interfere with the supply and demand, that under the current system rewards a doctor shortage to the doctors in the system. In the long term the system may collapse as doctors, nurses and support staff are exhausted, and the health of the nation declines.
The current system rewards visits, referrals, testing and illness. Pay the doctors more, but place them on a salary.
We must replace the cliché, "an ounce of prevention is worth a pound of cure" with
PREVENTION IS THE CURE !
4. We can find new solutions, only
after finding the problems, remembering that we are all only human !
. (The ruby red rose in the desert of life)
* Mamma Squitti's
Recipes for Bread, Pizza and more !*
Investigating the investigators?
A recent statement made by the Chief of Police of Thunder Bay correctly suggests that we should "investigate the investigators" and I am surprised that we are not continually doing this in many areas of society. There is no doubt that investigators must be fair not only to the defendants, and complainants, but to general society as well. At times this delicate balance if not exercised properly, victimizes all concerned and most importantly "the Truth," if we can ever know it.
Just last week, I received a form from the Ministry of Health, advising me, that they had hired "an independent" agency to conduct an external audit of the College of Physicians and Surgeons; the unit that investigates Doctors. This after complaints directed towards these investigators were not doing their job properly.
On the one hand I have been personally witnessed, a 8 year complaint lodged with investigators of the College of Physicians and Surgeons, and have found the College unreasonable, unrealistic, manipulative, unobjective, non-critical, and ineffective with dealing fairly with a health complaint. It becomes obvious that at times, "investigations" can become political tools to attack or cover-up, rather than becoming important tools for learning from unfortunate incidents.
On the other hand, I have more recently witnessed to an unfortunate drugging of an elderly patient in one of the local hospitals, that left an elderly patient in a coma for some 4 weeks, by drugs, that appear to have been improperly and/or incorrectly administered. My letter of complaint to the local hospital board, has drawn an incomplete response to many concerns, together with the conflicting statement that "the doctor" ordered them, according "to the records."
* Case study of Mrs. Squitti *
First, this is in direct contrast to what the doctor has stated to us, and second the investigation does not even go as far as asking for the doctors opinion on this matter, even though we had told the hospital of the Doctors response. More importantly, I have been advised by the Hospital Board to pursue any complaints against staff through professional agencies, including, you guessed it, the College of Physicans and Surgeons.
With the recent government cutbacks in health care funding, one of my concerns, is that it is my opinion some patients are being "overly sedated" because understaffed resources cannot deal with the increasing and demanding workloads. In addition, I am afraid that investigations that could lead to important positive changes within the hospital are being hampered by ineffective investigators.
Another of my concerns, is that our hospital does not have in place an automatic and critical system of investigating the investigators that handle client concerns, to ensure that they are indeed effective. Mistakes happen, hindsite is 20/20 and I believe that administrative decisions are impacting negatively on staff. When errors do happen, the focus of investigations should be on ensuring the errors do not happen; ie increasing staff changing procedures. (I say this from the observations I have made. I would not want to be a nurse for the job is far too complex and demanding )
Let us appreciate that Thunder Bay, has one of the highest mortality rates, in the province, and that some of the problem lies within the hospital health system itself. From my own personal observations, we are not taking proper control of the situation. In any system, we should be doing all we can in the present to learn from the past, and make changes to improve our future in providing health care services.
As the cliche goes, "To error is human, to forgive divine," and I would like to add, to not learn from the past, is the unforgiveable mistake.
As a critical writer of sorts, being
able to correct the world definitions of "truth," " half-truth,"
and "lie" in 1994, these revisions have not been integrated into
the educational programs as I write this, let me say that perahps the
College
of Physcians and Surgeons, could use a change of name that reflects
what
I have observed of this organization in the last few years. The name
should
be changed to the College of Physicians, Surgeons and Stupid People.
Time
will hopefully change my beliefs of this organizaton.
Caesar Squitti
- 319 Bay Street - Thunder
Bay, Ontario 1-807-345-0461
You be the JUDGE !
On this very important date, October 21, 2004 I am posting what the 'official word' is from the Thunder Bay Hospital is.
As a former recording Secretary for various volunteer boards, I am truly disappointed in the lack of integrity by the "Hospital" .
I will keep you informed
of any changes.
"None of these reviews have determined that there is any substance to the claims you have made...and nothing further will be done !"
RON SADDINGTON
Any comments concerns or observations ?
The
Health System and Nursing
in Ontario
July 12, 2007
If
one critically examines the health system in Canada, you will note that
it is a half-truth, that is it is merely publically funded, with most
all services provided by private enterprises, not that is a problem in
of itself, except for the current payment system that rewards repeat
visits, inefficiencies, ineffective treatments, and disease. The
payment system is the needle in the haystack, the devil in the missing
detail that motivates the system away from the best of cures;
prevention. It is a payment system that victimizes good doctors
and especially nurses, who would appear to bear the brunt of a
system in chaos.
I
would like to include some observations concerning nursing in Ontario
that I must include
to give a more balanced approach to the health system in Ontario, since
I
have put it under the microscope.
Nursing
is one of, if not the most important and basic fundamental
service in the Ontario
Health System. A truly most demanding and important service that is
highly unappreciated and I say that because of the total lack of
importance given to them in the hospital setting.
For
one, while investigating the hospital board system in Thunder Bay, it
was noticed that on all boards there was only one nurse on the quality
control committee, and the position was non-voting. TRULY
UNACCEPTABLE.
Any
school of management suggests that your front line workers, are those
most able to offer important advice to the health system. It is
obvsious the 'boys' club of hospitals in Ontario treats the nurses
profession with a lack of respect.
I was
quite pleased to hear that the CBC aired one of my letters on this
issue several months, ago and shortly thereafter the nurses association
announced that they would be taking a more political involement in the
health system. Good for them.
Nurses
have seen management give them raises on the one hand, and then on the
other, management has decreased full time jobs to save on the benefits
extended to nurses, which make it difficult on the nurses and patients;
too much short shifts, increases the change in the environment.
It is
important to understand that most 'nurses' are salaried positions, and
do not benefit from an increase in 'chaos' within the
system. That is why they are so important a source of
information to make the system more efficient and effective.
The
importance of having more nurses, one from each field involved in the
board operations of each hospital is paramount.
In
sofar as the health and hospital systems are concerned the public has
lost control of the purpose, the intent and direction of them.
Caesar
J. B. Squitti
July 16, 2007
Dear Squitti family:
First of all, may I offer my condolences on the loss of your Mother.
I was a resident of Thunder Bay for many years and still have family there. I remember the store well and general news about the family.
I do believe that this whole health care system is a shambles. I am not surprised by the treatment that was received at the local hospitals, or the brush off by Mr. Saddington. Unfortunately, I too am victim of their unprofessional actions and downright abuse.
I hope that someday soon, someone will be brave enough in the system to say enough is enough and deal with these ongoing issues, instead of brushing them aside.
If you would like to publish my email for anything, that is fine, but please remove my name.
Thank you and may God Bless you and your
family.
Signed Anonymous
(Thank you for writing to us )
Dear Caesar,
I heard a few years ago that Mrs.Squitti had died, but I had no
idea the circumstances until I
came across the site.
I really have to
say I am shocked
and disgusted. I have many fond memories of her.
I used to walk down the lane from grandma's and if
she was out in the garden I would talk
to her and she would always
listen. She always gave me a treat when I went
into the store. She even taught
me how to knit.
Not many had the kind of
time
or patience she showed for a
five year old, but like you said, she was a
mother to all people and I hope
she will always be remembered as such.
Please accept my belated
condolances.
Amanda
(Thank you Amanda and God Bless !)
The Truth will set us free, or so the cliche goes.
In hopes of bringing 'common problems' to the attention of the public, we will include your incidents here.
If you want to continue with the current system then you want to know what is right with the system.
However, if you want to improve the system you want to know what is wrong with it.
Send us your comments !
(names will be ommitted)
References:
Chronicle Journal December 1, 2000
Thunder Bay Regional Hospital Emergency Department in a State of Crisis
Chronicle Journal December 6, 2000
Thunder Bay Regional Hospital -Specialist questions ER report
Chronicle Journal December 6, 2000
Thunder
Bay Regional Hospital - Hospital leaders fret over leak
End of Section 5
Front Page Index Sec 1Sec 2 Sec 3 Sec 4 Sec 5 Sec 6Sec 7 Sec 8
Your truths, comments, questions or suggestions are appreciated.
