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FLAWS UNDERMINE DOCTOR'S REVIEW, SAYS WATCHDOG GROUP

On Monday February 14, at 11:00 a.m., there will be a media conference held by Voices on Health-care Concerns and Accountability Inc. (VoHCA) at Queen's Park, Media Studio, Main Floor. VoHCA is raising serious concerns about the terms and conditions of the independent review of the College of Physicians and Surgeons of Ontario (CPSO), which the Ministry of Health commissioned to KPMG.  A barrage of public criticism of the CPSO's complaints process spurred the decision to launch this provincial review. Georgina Hunter, supported by VoHCA, led a national letter-writing campaign and held a media conference on June 9, 98.

VoHCA believes this review cannot deliver the desired outcome, articulated by the government, because of the constraints imposed on the review.

VoHCA's members have extensive experience dealing with the CPSO and are concerned about the CPSO's lack of accountability.  VoHCA believes that the independent review will not reflect the realities which patients have been experiencing. The following points highlight serious flaws that VoHCA urges the Minister of Health to rectify:

Failure to adequately inform past complainants; failure to hold a public forum; and use of flawed methodology which restricts the analysis of serious cases.  Also, the small scope of the review cannot reflect the enormity and the seriousness of the issues.
 

1. Failure to Adequately Inform Complainants of the Review
Inadequate measures have been taken to ensure that complainants and the public are informed of the existence of the review and the deadline for participation. The advertisements placed in various newspapers have proven unsatisfactory: Only a small percentage of potential participants saw the ads, an informal VoHCA poll determined. A more direct method of having the CPSO inform the complainants was repeatedly refused by the CPSO.  The Ministry has chosen not to hold a media conference that would have certainly alerted potential participants.

The review is flawed by the inexplicable and irrational decision to avoid the very people who can provide the data to achieve the outcome.

A vital function of this conference is to publicize the existence of the review to complainants who are currently unaware of the review and may otherwise miss the deadline tomorrow for participation.  At least 20,000 complainants over the past decade should be entitled to, and may wish to participate in this review.

To participate, contact KPMG at:  (877) 525-2776  or (416) 969-6559 by February 15th.
 

2. Terms Prohibit a Public Forum
VoHCA, along with other individuals expressed to the Ministry staff the necessity for a public forum.  Without a public forum, the media will be unable to report on the complainants' views, criticisms and concerns. Consequently, there will be no public education or public scrutiny of the CPSO during this review.
 

3. Methodology Ignores Serious Complaints
The methodology used to analyze the CPSO files will not guarantee a good representation of complaints.  Only two hundred files will be reviewed and they will be mostly restricted to those filed within the last year or two. This excludes many serious cases still unresolved filed before that date. (See background notes about an unresolved class action complaint filed in1994 with the CPSO regarding Dr. Christine Bloch.)

The review should focus on serious clinical errors resulting in death, disability, and family distress, which were not referred to discipline. Files where the CPSO failed to take adequate measures to prevent the error from being repeated by the individual physician involved and by other physicians in general should be examined. Instead, the analysis risks being watered down with those not related to serious clinical errors.

False conclusions risk being made about the CPSO's accountability due to flawed methodology. The potential for incorrect conclusions biased in the CPSO's favour means the Minister of Health and the public could be provided with false assurances about the CPSO's accountability.   This may place in jeopardy potential reforms.

4. Small-scale of Review Disproportionate to Magnitude of the Problem
Why was this review given such low priority, and why is it being done on such a small scale?

Why is the public exposure almost invisible considering this issue affects all of Ontario's heath care users? According to KPMG, there will be only three interviews regarding clinical errors.  Reducing the main source of data to a written questionnaire cannot adequately deal with the magnitude of the issue.

For further information or to arrange an interview, please call Georgina Hunter at:
(613) 730-0047 until February 11th and after February 12th.

Cellular:  (613)  795-5543 for February 12th only.
 

Index:

1. Telephone Numbers
2. Background Information
3. Examples of Serious Cases Which the CPSO Refused to Refer to Discipline
---------------------------------------------------------------------------------------------------------------
1. Telephone Numbers

College of Physicians and Surgeons of Ontario, Jill Hefley, Associate Director Policy and Communications, x 445 (416) 967-2600

Voices on Health-care Concerns and Accountability, Gordon Lever, Chair, (613) 389-0916

Ministry of Health and Long-Term Care The Honourable Elizabeth Witmer, Minister of Health (416) 327-4300

Berry Wilson, Press Secretary (416) 327-4300

Nancy Kelly, Senior Policy Analyst, Direct Payment and Regulatory Programs Policy Unit (416) 327-8893

Marilyn Wang, Manager Direct Payment and Regulatory Programs (416) 327-8888

Mary Beth Valentine, Director, Policy Program Branch (416) 327-8636

KPMG, Steve Lough, Policy Analyst (416) 969-6442

Francis Lankin, NDP Health Critic (416) 325-6904

Lyn McLeod, Liberal Health Critic (416) 325-6904
 

2. Background Information

Ministry Failure to Provide KPMG with VoHCA's Telephone Number, A Valuable Resource for Reaching Complainants

If the outcome of the review requires input from stakeholders why did the Ministry of Health fail to inform KPMG of VoHCA? Ministry staff assured VoHCA that they would inform the reviewer of VoHCA's desire to participate.
 

CPSO Protects Physicians Not the Public, Says Expert

"The current system [self-regulation] actually safeguards the professionals at the expense  of the public." says George Belza, a consultant who conducted a York University seminar on the ethics of self-regulation. Sun. Oct. 24, 99  Ottawa Citizen: "Health colleges under review amid criticism" by Hollie Shaw
 

CPSO Policy Protects Physicians Identity and Keeps Public Uninformed

"We look for ways other than discipline to remedy many clinical problems...we emphasize education and remediation" Dr. John Bonn, Registrar CPSO Members Dialogue July/August 1998 p. 26. These measures prevent the names of physicians involved in the complaint from being made public. By deviating  from discipline, the CPSO ensures that secrecy surrounds the outcome of these complaints. Consequently, the public cannot make informed decisions when selecting physicians.
 

CPSO Provides False Assurance of Cooperation to the Public

In a December 4, 1998 article in the Globe and Mail by Krista Foss,  CPSO director of public affairs and communications, Jim Maclean, said the College is prepared to cooperate.  "Our books are open" he said.
Reality:  The CPSO provides false assurance to the public that they will cooperate while later even refusing to alert complainants of the review by sending them a notice.
 

3. Examples of Serious Cases which the CPSO Refused to Refer to Discipline

Multiple Complaints about Dr. Bloch: 1992 -1993 at the Oakville-Trafalgar Memorial Hospital

The CPSO's failure to deal effectively with complaints filed against Dr. Bloch and a failure to do so under the legislated mandate to complete the investigation within 120 days.

Dr. Bloch:  CPSO Class-Action Complaint Filed in 1994 and Currently Unresolved.
At least five cases involve babies delivered by Dr. Bloch at the Oakville Trafalgar Memorial Hospital during a 14-month period in 1992-1993.

Elizabeth Monroe:  One of the complainants in the class-action:  (905) 827-1567
 

Jackie and  Douglas Houghton:  (905) 469-9170

In October 1993, baby Lucas died of a fractured skull due to a high-risk forceps delivery done by Dr. Bloch at the Trafalgar-Memorial Hospital. Dr. Bloch failed to call for the preparation for a C-section despite warning signs and opted to perform an emergency forceps delivery.  The extreme force of the forceps resulted in a brain hemorrhage leading to death.  Baby Lucas would be alive today had a C-section been performed at the first sign of heart deceleration 30 minutes prior to the point of crisis.

The Houghtons filed a complaint with the CPSO in December 1993. The CPSO announced Bloch would be referred to discipline in Oct. 97; this coincided with intense media scrutiny surrounding Bloch pertaining to another of her patients.  18 months later, the CPSO inexplicably reversed the referral to discipline, opting instead to have Bloch observed for a few days.  The CPSO have yet to provide the Houghtons with assurance that Dr. Bloch has been observed.
Reported in  P. A34, Toronto Star, Rita Daly and Lisa Priest: "Operating in the Dark: - The Accountability Crisis in Canada's Health Care System," 1998.

The CPSO deviated from their mandate to complete the complaint with 120 days.  Had this case been
dealt with within the legislated guidelines, the McGregor death, listed below, may have been avoided.
4
Hospital Recognizes Errors of Dr. Bloch

"An agreement has been reached, with legal guidance, that Dr. Bloch will undertake no further work at this or any other hospital and will not apply for reappointment." "Dr. Bloch is to undertake additional education, improve obstetrical skills, post-operative follow-up skills and to enhance awareness judgement.  All of this must be successfully completed ...before Dr. Bloch is allowed to apply for privileges at another hospital. One member expressed concern regarding the hospital's obligation to report the case to the College, which Dr. Bloch is anxious to avoid."  Minutes from the December 15, 1993 Oakville-Trafalgar Hospital Medical Advisory Committee.

This evidence shows that there were serious concerns about Dr. Bloch.  It is inconceivable that the CPSO refused to refer her to discipline
 

Andrew and Martha McGregor:  (519) 354-2131  Sydenham District Hospital, Wallaceburg, July 19, 1996

Dr. Christine Bloch conducted all pre-natal examinations and failed to pay heed to the mother's concerns that her baby was large, Ms. McGregor claims.  She failed to order an ultrasound, which most likely would have revealed that the baby would be 11lb at birth and that a vaginal delivery would be unsafe.   "Mrs. McGregor said she had three miscarriages then finally became pregnant through in vitro fertilization.  She purposely chose Bloch because she wanted an obstetrician to deliver her baby but Bloch, (the hospital's only obstetrician) left the hospital before McGregor went into active labour.  A family doctor delivered the 11-lb. baby boy and ran into trouble when the shoulders became stuck in the birth canal. Thomas ultimately emerged blue and unconscious" (and died 13 days later).  Operating in the Dark by Lisa Priest pp. 105-107

A complaint was filed with the CPSO in late 1996 regarding Dr. Bloch's judgement in leaving the hospital where she was the only obstetrician. The CPSO failed to refer this case to discipline in May 1997.  See also Toronto Star:  Oct. 18, 1997 by Rita Daly, Front Page: "Tragic Tale of a Baby Doctor and Two Hospitals:"  Full-page article on A34.

Note:  Dr. Bloch Continues to Practice Obstetrics at the Chatham hospital.
 

Peggy Harley:  (416) 762-6512

On December 8, 1993, Peggy Harley had her left lung punctured by a doctor in Toronto while performing acupuncture/trigger point therapy.  According to expert Travell's text, the position Ms. Harley was placed in put her at risk for a lung puncture.  The procedure resulted in the puncture of her left lung.  Her doctor sent Ms. Harley out of his office unattended fully aware that her lung could place her life at risk.  Subsequent emergency surgery resulted the following day.  Ms. Harley experienced pain for several years.  Scar tissue and loss of volume remain permanent side effects.   A complaint was filed with the CPSO in 1994 and in 1997 the CPSO refused to refer the case to discipline.
 

Georgina and James Hunter:  (613) 730-0047

"Notwithstanding the fact that we took her to two physicians and Ontario's only two pediatric hospitals over three days, Madeleine didn't receive an adequate diagnosis.  Because of these errors, little Madeleine died on September 30, 94.  Vital fluids -- a simple IV unit -- would have saved her.
 

The attending physician did not properly evaluate the nurse's assessment of moderate dehydration that is grounds for admission.  She did not properly consider the many red flags including a 12.5% weight loss.  The physician did not properly pay heed to a mother's fear that her baby was going to die. So sure that she was right, she chose not to connect my baby to the IV unit that the nurse had wheeled up.  She decided not to run simple blood tests that would have revealed the level of Madeleine's dehydration. She chose not to confer with a staff physician --although ER was empty at the time.   In my opinion, this was human error.  In my opinion, this was a tragic combination of arrogance and ignorance." Georgina Hunter.

The jury at the coroner's inquest decided after hearing evidence that it was necessary to issue 46-sweeping recommendations many of which dealt with physician education, re-training, recertification, and upgrading concerning the diagnosis and treatment of infant dehydration.   Coroner Ross Bennett, former chief coroner of Ontario, said he'd never seen a case where so many things went astray.   "An inquest into Madeleine's death prompted 46 sweeping recommendations aimed at Ontario doctors, nurses, and hospitals."    The former chief coroner of Ontario said he had never seen a case where so many things went astray.  "The College refused to refer the complaint to discipline hearings, after conducting a 2 1/2 year private internal investigation." Instead they wrongly attempted to avoid taking responsibility by wrongly blaming the parents for the death.  "An angry letter from the coroner's inquest expert witness, pediatrician, Andrew Lynk of Cape Breton Regional Hospital...stated that the decision of the college to place blame on the parents was: 'cruel, misguided and erroneous.'" Quotes excerpted from June 9, 98: Toronto Star "Doctor's accountability to be probed by Ministry" by Theresa Ebden
 

Agnes Spanieuse: (416) 626-0007

Ms. Spanieuse  filed a complaint with the CPSO in 1997 regarding breach of confidence against her GP.  She  became concerned after learning he suffered from a dual addiction-depression disorder for which he had been hospitalized.  Research indicated that he had a federal restriction on his prescribing privileges (no narcotics) and that he no longer had hospital privileges.  Ms. Spanieuse linked his erratic behaviour to his history of drug abuse.  Upon learning a complaint had been filed against him, he began harassing Ms. Spanieuse and her family. Pharmaceutical records revealed he had personally handled and possessed narcotics. The prescribing doctor of record for these drugs was his wife, a physician; however, she had never examined Ms. Spanieuse.  The CPSO were aware of the situation, but did not put such information on the doctor's record at the public's detriment.  The CPSO refused to acknowledge the seriousness of the situation.  Instead, they criticized the complainant for being unappreciative.
 

Kenneth Mesure: (519) 925-6729

Kenneth Mesure had hip revision surgery at the York Central Hospital in Richmond Hill, Ontario, on January 26, 1996 by his doctor.  During the operation the following problems resulted:  a vein was accidentally severed which required three bags of blood to replace; the leg was erroneously lengthened by at least 2.5 cm; the pelvis was erroneously bored through; damage was done to the sciatic nerve resulting in drop foot and loss of all control coupled with continuous pain in the right leg.  As a result the leg is irreparably damaged and is unusable.  Mr. Mesure requires crutches to move. A complaint was filed shortly afterwards:  685 days later, the CPSO noted in their report that the procedure was outdated.  However, they refused to refer the doctor to discipline.