The following is a list of things that I had no
idea of until after Josh died and I received his hospital records.
It was supposed to be all of them although there seems one very
important one is missing, even though it was only 6 days after he died.
1. On June 6/12 at 10:45 am the internest discontinued the antidote
because the blood work from earlier (about 8:00 am) showed his ammonia
and valproic acid levels to be down to almost normal. At 2:20 pm
the psychiatrist tried to interview Josh and could not get any sense out
of him. At 3:15 pm just 35 minutes later the internest "medically
cleared" Josh. At 3:35 pm ten minutes later he was given the blood
work results taken at 1:00 pm. This showed his levels rising
significantly again. When he was shown this he said, "doesn't
matter, patient is still medically clear."
However,they did not contact Poison Control for treatment
Despite his rising levels, the Dr. still medically cleared Josh. This
means he was left with no medical treatment for the high valproic acid
and ammonia levels in his system.
Then Josh was accepted to the Mental Health Unit by the same
psychiatrist who could not get any sense out of him one hour before.
At 6:00 pm Poison Control contacted the hospital to inquire as to what
was going on with Josh. When they found out that his levels had started
rising earlier in the day, they were very concerned for his well being.
When the doctor that previously cleared Josh was contacted by hospital
staff about this, he clearly stated that he “stuck by his decision,
patient is medically clear” even though it was quite evident that my son
was deteriorating quickly.
He let him go from 10:30 am, when they discontinued the antedote, until
after 8:00 pm when he became delirious. Also Poison Control told
them not to give Josh "Haldol" but he was prescribed it twice that day by two
different doctors (psychiatrist and internest). I believe this may have contributed to his
deteriorating condition as it can cause "Neuroleptic Malignant Syndrome"
as well as other serious conditions. The hospital says, Yes, Josh
was prescribed this twice but since there is conveniently no Pharmacy
record for this they maintain that he never received this. However
on the bottom of the doctors orders it shows that it was faxed to the
pharmacy. Given the events that led up to him being restrained in ICU, I
am certain that he received this and they pulled the record to cover
2. Violated the “Consent to treatment Act”.
On June 6/12 Josh was unable to speak for himself from 8:00 pm on, and
they never called me until after midnight. When someone can not speak
for themselves, they are supposed to contact the next of kin to get
signed authorization to treat the patient. They treated him without
written or verbal authorization from me (next of kin). I was never
consulted during the whole time he was in the ICU unable to speak for
himself. Why did it take over 4 hours to contact me?
3. Violation of the “Minimal Restraints Act.”
Only the doctor in charge can order physical restraints and they are
supposed to closely monitor this and keep records. The doctor in charge
now claims she does not remember him being in restraints even though you
can clearly see them in the picture above and I have signed
statements from witnesses regarding this. She also did not get my
permission for this. Josh was physically restrained the whole time he
was chemically restrained for over 4 days. This put him at great risk
for the DVT he developed. I am now aware that the reason for
keeping him physically and chemically restrained for over 4 days is
because according to the doctor every time they tried to wean him and
bring him around he got agitated. Anyone waking up in this
situation would naturally be a little confused and agitated if they were
restrained, especially if they had no idea how they got there. I
told the nurse I would like to be present for this because I know I
could have helped to calm him, but this was totally ignored.
Instead they kept him immobilized for over 4 days increasing his risk
for blood clot. The College and the doctor claimed there was no
time to contact me and since it was an emergency situation, they had
every right to physically restrain him. He was not restrained
until around midnight, so why could they not have contacted me 4 hours
earlier when he started deteriorating?
4. He had all the symptoms of the DVT (blood clot) he developed which
led to Pulmonary Embolism and caused Cardiac arrest which killed him.
Pink sputum,sweating constantly, fever, high heart rate, trouble
getting his breathing regulated.
The doctor claims she was treating him for aspirated pneumonia even
though an Xray revealed he did not have this. She never even looked at
any other reason for his symptoms. I thought when one thing is ruled out
you naturally would look at another cause for the symptoms. Why did she
not do this? I believe he had developed the DVT on the evening of
June 6/12 when he ended up in ICU since he had the symptoms from that
until he died (over 4 days). If this is the case it is likely that only giving
him heparin would not help. It is a preventative measure and does
little good after the DVT has developed. This doctor is supposedly
certified in internal medicaine so how could she miss this as it is
quite common given the circumstances of immobility and Josh being at
high risk. Since his heart rate was over 130 bpm for over 4 days I
wonder why a cardioligist was never consulted.
5. When I found my son in distress on June 12 at 3:40pm, I pushed the
call button and got no response from anyone. About 5 minutes later I
pushed it again, and about 1 ½ minutes later the nurse finally arrived.
The nurse now claims she answered both calls. Why would I push it
twice if she came after the first one? When my son started turning colour she left the room instead of pushing
the code blue as is protocol. It was
not until after she returned and Josh passed out that she finally pushed
the code. I witnessed this. This nurse wasted over 10 minutes from start
to finish of my son’s last minutes of life and we will never know if the
call had been answered promptly the first time and the code had been
pushed sooner if this would have saved him. By the time the team arrived
I know in my heart he was already gone as I seen his eyes roll back and
heard him defecate just before the code was pushed.
Interstingly enough, this particular nurse is no longer with the
hospital. I wonder why?
6. The coroner states the cause of death as “suicide”. Although he took
an overdose this is not what he died from. He was hospitalized for
almost 8 days and the medications he ingested were long gone out of his
system. He died due to Deep Vein Thrombosis (pulmonary embolism) which was most
certainly caused by the events of the evening June 6 and then being restrained in ICU for over four days.