The Hospital, the College of Physicians and Surgeons, the Chief Coroner's Office of Ontario, the Health Professions Appeal and Review Board and the Death Investigative Oversight Council and the Provincial Liberal Party have all failed the citizens of Ontario. Patient Safety comes well behind their own selfish welfare and ambitions.

After reading this, if you feel compelled to express your views to your own MPP, please do so.  As well, you may also like to share your feelings with the following:

bbyrick@cpso.on.ca  Bob Byrick, President of the Ontario College of Physicians and Surgeons.

ahorwath-co@ndp.on.ca    Andrea Horwath, Provincial NDP Leader

tim.hudakco@pc.ola.org   Tim Hudack, Provincial Conservative Leader

dmcguinty.mpp.co@liberal.ola.org    Dalton McGuinty, Premier of Ontario (Liberal Leader)

dmatthews.mpp.co@liberal.ola.org  Deb Matthews, Health Miinister (oversees the College and Hospitals)

mmeilleur.mpp.co@liberal.ola.org)  Madeline Meilleur, Minister of Corrections & Community Safety (oversees the Chief Coroner's Office and the Death Investigative Oversight Committee)

dioc@ontario.ca     Death Investigative Oversight Council    (re: Kilby vs Chief Coroner's Office)

amarin@ombudsman.on.ca   Andre Marin, Ontario's Ombudsman

andrew.mccallum@ontario.ca   Andrew McCallum, Ontario's Chief Coroner

bert.lauwers@ontario.ca   Bert Lauwers, Deputy Chief Coroner at the time, investigating Terra's Death

My daughter's death 12 hours after being released from a Toronto hospital has never been truly investigated by: The Chief Coroner's Office of Ontario, The College of Physicans and Surgeons, the Hospital and the present Liberal Government. This government feels that all things are in place that a citizen needs to achieve transparency and accountablity but they are wrong and will not put an effort into dealing with the flaws within the system! Many Ontario citizens may not even be aware.

It is obvious that the Coroner's Office did not want negligence perhaps incompetence shown, which would involve a fellow member of the medical profession and certainly the standards were not met.

My 28 year old daughter is dead!!!!!!!!!  And no one within Ontario will supply me with answers to my very serious concerns; not even those people who supposedly investigated!!!!

During the year 2009 to Feb 2010 ---- six deaths at this same hospital involving the same department with very similar situations-- bled to death.    This same year a patient went in for a hysterectomy---was in her hospital room ---- started bleeding ---- bled to death before they could get to OR.----    Also, apparently an expert from a medical university was called in to assess the procedures within the operating room involving this same department team.    My daughter  bled to death 12 hours after being released from Humber River Regional Hospital.  The surgeon was Dr. Laz Klein, partner in MIS located in North York, Toronto.

Just think, if the Chief Coroner's Office had of granted a public inquest, or a regional coroner's review or have The Patient Safety Death Panel look into this matter it would have indeed saved lives. 

   For the entire story see this:   http://anangelinourlives-awk.blogspot.ca/   

The Chief Coroners Office of Ontario failed to: 

1. Conduct a death investigation in a manner that is effective and accountable.     

2. Conduct a high quality death investigation to ensure that no death will be overlooked, concealed or ignored. (By basing all of their decision on a medical expert consultant whose report omitted numerous crucial factors)   

3. To help improve public safety and prevent deaths in similar circumstances (apparently there were 6 more deaths by the bariatric department of this hospital during 2009 and up to Feb. 2020 under similar circumstances—it is almost impossible for me to obtain the details but the Chief Coroner’s Office and the hospital would have them-----these deaths may have been prevented if my daughter’s death was thoroughly investigated) by denying my request for my daughter’s death to go before the Patient Safety Death Committee and denying my daughter’s death be looked into by the Eastern Ontario Coroner through a review. (I know that legislation prohibited me from questioning the denial of a public inquest which I feel definitely limits a citizen’s right to appeal a wrong decision)  

  4.  Making sure the concerns and needs of grieving families are met as this office has refused repeatedly to answer specific questions and concerns I have had and relayed to them.  They have also refused to communicate with me via telephone, faxes, e-mails.  

They failed by:

5.   Overlooking, concealing and ignoring crucial factors related to my daughter’s care or lack of care which in turn did factor into her death 

Is it not incumbent for the Office whose finances are paid by the public purse to pursue and ensure patient safety is protected especially when the hospital refuses to answer the question from the grieving family?   As well, I’m sure the attorneys and committee members are aware of the dismal record of investigations by the Ontario College of Physicians and Surgeons.  The Chief Coroner’s Office has the authority through holding pubic inquests, utilizing the Patient Safety Death Committee and having Regional Coroner investigations to obtain these answers.

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This is an open letter to all citizens of Ontario:

Terra Dawn Kilby died 12 hours after being released from the Hospital (July 21, 2006)--- colon resection broke down and bled to death. (necrosis of the tissue surrounding the resection)  I have been trying to find accountability and transparency even since.  I have sent the following to every OCPS committee member.

Dear Ontario College Of Phys & Surgeons' Committee Member,

I realize that this may not be within your specialty but if you pardon the pun "It doesn't take a brain surgeon" to see very clearly that the College is not being truthful, not being accountable and have not treated myself, Terra's family, relatives and friends fairly.  They have placed the surgeon's reputation first, with very little regard to my daughter's death and thus they have failed all the citizens of Ontario.
You may very well be powerless, I don't know, but considering you are a member of the various committees at the College I would expect that your voice would be of some significance. (or are you merely a puppet whose strings are pulled?)

Of course, the College refused to released the names of the apparent 6 College surgeons who render yet another inept decision.  There is no way that this surgeon should have gotten away with the minor decision from the College --- "perhaps you should consider using anti-biotic prophylaxis in the future and your notes should be completed in a timely fashion".  With the feeble excuse that they fear me?   Yes, I may have contacted many of them while preparing my HPARB (Health Professions Appeal and Review Board) appeal. I had sent out over 3,000 e-mails mostly outside of Canada.  No one dares respond within Canada. I won my first appeal and have had to do a second one this past November.

Interesting to note:  I provided HPARB with over 100 named surgeons who stated that antibiotic prophylaxis is a must for the type of operation my daughter had.  The College's decision makers are anonymous.  The Surgeon's  lawyer stated that the HPARB panel should ignore my expert's opinions who are named, but they should accept the decision from 6 anonymous college surgeons????  Ontario citizens could look up this surgeon's name on the College's website and find a perfectly clear record.

The Chief Coroner's Office (quietly) shut down this surgical team and brought in an outside expert to look into the numerous deaths which occurred during 2009 and early 2010.  WHY was this not done when I made them aware of my concerns several years ago and WHY did the College not act on my first set of complaints?  Perhaps, lives could have been saved!

Chief Coroners Office

--refused my request for a public inquest

--refused my request for my daughter's death to go to the Patient Safety Death Panel

--refused my request for an Eastern Ontario Coroner's Review

--refused my request for the Chief Coroner to put panel together to access Deputy Chief Coroner at the time, all of his decisions

--way back refused MPP, now Senator Runciman's request to reconsider the public inquest                                                           

--refused OPP detective 's request to meet with me and answer my questions  

--refused Ombudsman's Office's request to meet with me and answer my question  

GEE, DO YOU THINK THEY ARE AFRAID THE TRUTH WILL BE REVEALED causing them some embarrassment & negative media.

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HPARB's Second Decision

Very disappointing, is all I can say.
The truth will be covered up at all levels.

SO, the DIOC will use this decision to eliminate my complaint against the Chief Coroner's Office. There is no way within Ontario that justice can be achieved by an ordinary citizen. All the so called ethical and just institutions the government proudly boasts of, are merely a figure head to be use to conceal the truth from the citizens of Ontario

I should note by carefully reading the decision by HPARB, that they did not consider any of the information that I provided prior to and presented at the meeting. You will notice they only comment on and accept whatever the College committee and their independent medical advisor states as fact.  No factual and relevant material is required to back up their opinions. Sorry, their opinions are treated as absolute truth!

It is a shame that all the work and contacts, medical surgeons, I made outside of Canada was considered absolutely irrelevant.

They will only accept a Ontario surgeon's comments.

Now, HPARB does find fault with regard to the administering of pre operative antibiotics. This is only because the College and their own medical adviser stated that this was neglected and that it is a standard practice. This contradicts the College and the adviser when they state the pre and post operative care was ok.

So, they sent it back. All the College has to do now is get a Ontario surgeon to state that this is not the standard practise and HPARB will be satisfied.

EVEN THOUGH, I HAVE PROVEN BY MY CONTACTS OUTSIDE OF CANADA (Hong Kong, Britain, USA, Europe and South America.) THE IMPORTANCE OF ANTIBIOTIC PROPHYLAXIS AND THAT IT IS A STANDARD OF CARE.

So, what ever the College and their experts state will not be questioned by a HPARB panel regardless of expert opinion outside of Canada.

So, basically citizens of Ontario, the medical profession is untouchable!!!!

Excerpts From HPARB Decision also quoting from the College's second decison:

The second point that remains is of the greatest concern to the Board. That is so because the Record includes conflicting information concerning the standard of care concerning the use of preoperative antibiotics.

The routine use of antibiotics prior to bowel surgery is an important aspect of care that was neglected by [the Respondent] in this case. The Committee would suggest that [the Respondent] consider the routine use of antibiotics in such circumstances. Having said that, we do not consider this oversight to have contributed to the unfortunate outcome in this case.

This passage appears to the Board to be contradictory. Although the Committee states that the "routine use" of antibiotics prior to surgery is an "important aspect of care" that was "neglected" by the Respondent, it does no more than "suggest" that the Respondent "consider the routine use" of preoperative antibiotics for future surgery. The Committee goes on to describe the Respondent's decision not to provide antibiotics prior to the patient's surgery as an "oversight", which suggests a failure of pre-operative care, regardless of whether the failure contributed to the outcome in the patient's case.

The second question related to whether perioperative antibiotics should have been prescribed. [The IOP] stated that he found no evidence in the record that anyantibiotics had been prescribed perioperatively. He staled that it is the standard of practice with bowel surgery to administer antibiotics, either orally or intravenously, approximately 2 hours prior to surgery so that the drugs are circulating before the incision is made. While it makes intuitive sense to administer antibiotics postoperatively, [the IOP] indicated that studies show it is the preoperative dosage that is most important, while postoperative dosing has been found to be "icing on the cake", [emphasis added]

According to this information, the IOP advised the Committee that the standard of practice required the administration of preoperative antibiotics. This appears inconsistent with the statement he made in his written opinion that the patient's "preoperative care, operative care and post operative care seemed appropriate". The matter is further confused, because in answer to the question: "Could this omission [of preoperative antibiotics] be a contributing factor to the defect in the anastomosis seen at autopsy?", the IOP answered "No".

The Board is left in some doubt as to the nature of the IOP's opinion and the Committee's decision concerning the Respondent's decision not to provide preoperative antibiotics. The IOP does not specify whether the standard of care to which he referred included laparoscopic surgery or open surgery, or both. Nor is it clear how, if at all, the IOP's advice, that the omission of preoperative antibiotics was not relevant to the anastomosis, relates to his more general advice on the standard of practice.

In these circumstances, it is necessary to return the matter to Committee for further consideration and clarification of its decision on this aspect of the complaint.

The Board's only remaining concern is with the question whether the Respondent met the standard of practice concerning the use of preoperative antibiotics.

The matter is being returned to the Committee solely for further consideration and clarification of this important matter.

DECISION
Pursuant to section 35(1) of the Health Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act, 1991, the Board returns the decision to the Committee and requires it to further consider and clarify its decision concerning the use of preoperative antibiotics and the standard of practice. The Committee's decision to counsel the Respondent on timely documentation of discharge summaries and to take no further action on the other aspects of the complaint is confirmed.

So basically, all the College has to do is to take back their recorded statement and state that anitbiotic prophylaxis is not mandatory (even though it is throughout the entire world) and HPARB will accept it. wWen I appeal the College's decision for a third time ,after winning twice, I will fail on the third appeal.;

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The Death Investigative Oversight Council

Dear Mr. Kilby: Thank you for your recent correspondences to the Death Investigation Oversight Council (the "DIOC"). This letter is to acknowledge receipt of your recent email correspondences that are listed in Appendix A, which have been added to your complaint file. In addition, thank you for a copy of the Health Professions Appeal and Review Board ("HPARB") decision dated June 7th 2012 (File # ll-CRV-0401) relating to your complaint matter that is before the College of Physicians and Surgeons of Ontario ("CPSO"). It appears that at this time your matter is complete or substantially complete in regards to your complaint with the HPARB and the CPSO. Your complaint file with the DIOC may be finalized in preparation for its initial review by the DIOC complaints committee in order to determine if your complaint, or aspects of your complaint, are within the mandate of the Council. Based on DIOC's legislative mandate, the purpose of the complaints committee is to review complaints with a goal of providing advice in order to help improve Ontario's death investigation system. As an advisory body, it is generally not within the committee's mandate to review or otherwise assess substantive medical conclusions or opinions with respect to the cause or manner of death. Consequently, and to the extent that your complaint before the DIOC may raise such issues, these aspects of your complaint may be outside the authority of the committee to consider. The committee is currently conducting a review of a complaint and once this review is concluded, the initial assessment of your complaint matter may begin. In addition to notification with respect to the status of your complaint, the complaints committee may also contact you if they require any further information or clarification. Sincerely AV Manager Death Investigation Oversight Council **************************************** ************************************************************
Some Day Soon We’ll Be Together, Again
April 22, 2012 at Terra’s Memorial Garden 1:00 pm   LOVE DAD

May visitors wonder why this is here?
Hearing your story they may shed a tear.
Your young life ended with much more to do.
A beautiful soul left us too soon,
Leaving behind in our hearts,  a very deep wound.

A symbol of negligence, a  reminder to all,
A warning for patients lest they befall.
A Memorial Garden dedicated to you.
 For your family and friends, ----this--- a symbol of love,
Thinking of you, looking down from above.

Still hiding the truth are those in the know,
Lacking transparency and not willing to show.
For surgeons and doctors you know what to do.
 Your patients require much more than your charm.
Remember “primum non nocere–first, do no harm”!

 A sister, a daughter, a niece and a friend.
All her love and friendship both did ascend
To those she met and to those she knew.
Was a compassionate , romantic and intelligent girl.
Enthusiastically giving all experiences a whirl!

The time will come when together we’ll be,
Reunited again with our little “Louie”.
Never more will we ever say “adieu”.
Our caresses and kisses we will certainly regain
Some day soon, ----we’ll be together again!      

There is no where for a citizen in Ontario to go to obtain transparency and accountability.

awkilby@hotmail.com