Report to the Minister of Justice
and Solicitor General
Public Fatality Inquiry
WHEREAS a Public Inquiry was held at the
in the
City
of
(City, Town or Village)
on the
Fatality Inquiries Act
Law Courts
Edmonton
, in the Province of Alberta,
(Name of City, Town, Village)
2nd
day of
April
,
2013
, (and by adjournment
year
on the
3rd and 4th
day of
April
,
2013
),
year
before
Larry G. Anderson
into the death of
of
, a Provincial Court Judge,
Shantha Rasiah
26
(Name in Full)
(Age)
Edmonton, formerly of Grande Prairie, Alberta
and the following findings were made:
(Residence)
Date and Time of Death:
Place:
February 6, 2010 at 02:36 o’clock
Royal Alexandra Hospital, Edmonton, Alberta
Medical Cause of Death:
(“cause of death” means the medical cause of death according to the International Statistical Classification of
Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose
and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).
Hypoxic brain injury caused by cardiac arrest caused by a combination of pneumonia and
proliferative glomerulonephritis
Manner of Death:
(“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable
or undeterminable – The Fatality Inquiries Act, Section 1(h)).
Natural
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Circumstances under which Death occurred:
Overview and Scope of Evidence
Shantha Rasiah died at 02:36 on February 6, 2010 at the Royal Alexandra Hospital in Edmonton. She had
been on life support since approximately 6:55 a.m. on January 28, 2010 due to a severe brain injury
caused by the deprivation of oxygen to the brain. The brain injury occurred while she was a patient at the
Sturgeon General Hospital in St. Albert. The evidence in this Inquiry focussed primarily on events in the
hours leading up to that injury, specifically between the time that Ms. Rasiah attended at the emergency
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department of the Sturgeon General Hospital shortly before midnight on the evening of January 27 , 2010
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through to approximately 7 a.m. on January 28 , 2010.
Seven witnesses testified before the Inquiry, six of whom are doctors. Extensive medical records, the
Medical Examiner’s Report and Certificate of Death were also received into evidence.
The doctors who testified were:
•
•
•
•
•
the two Emergency Room doctors who treated Ms. Rasiah, first Dr. Thompson and later Dr.
Mangan;
Dr. Norris, who was in charge of the Intensive Care Unit (“ICU”) at Sturgeon General hospital and
was consulted by phone but was not on site at the material time;
Dr. Lalic, who was on site and worked under the direction of Dr. Norris;
Dr. Murtha, a doctor in the ICU of the Royal Alexandra hospital, into whose care Ms. Rasiah was
transferred after the critical events; and
Dr. Bannach, a forensic pathologist, who performed an autopsy and authored the Certificate of
Death.
The Inquiry also heard from Ms. Cindy McVicar, a Registered Nurse and Program Manager at Sturgeon
General. She reported on the recommendations coming out of a quality assurance review following Ms.
Rasiah’s death.
Events Prior to January 28, 2010
On January 22, 2010, Ms. Rasiah attended upon a family physician after experiencing a cough and fever
for over a week. The doctor ordered that blood be taken for testing. An x-ray was also taken. Following the
results of the x-ray, Ms. Rasiah was diagnosed with pneumonia and given a ten day prescription for an
antibiotic called Bioxin. She was advised to go to an Emergency Room if symptoms persisted. She also
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appears to have had a follow-up appointment scheduled for January 29 , presumably because the lab
results would be ready by that time.
Records show that the lab results were ready and sent to the doctor’s office in the late afternoon of
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January 27 in time for the scheduled appointment. The lab results were forwarded with a covering
opinion noting an irregularity that the sender opined could be due to a number of possible causes including
kidney failure.
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By that same date, January 27 , Ms. Rasiah’s condition had not improved; the symptoms appear to have
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worsened. She followed the doctor’s advice and in the late evening of January 27 she attended at the
hospital emergency ward of the Sturgeon General Hospital in St. Albert.
It was later established through autopsy that the family doctor’s diagnosis of pneumonia was accurate. Ms.
Rasiah did have bilateral pneumonia but, unknown to anyone at the time, Ms. Rasiah also had a second
condition in her kidneys, described by Dr. Bannach as ‘’proliferative glomerulonephritis’’. This infection had
caused her kidneys to shrink and they were not working. Dr. Bannach concluded that these two conditions
together constituted the underlying cause of Ms. Rasiah’s death. The lack of kidney function resulted in a
build-up of acid which only compounded the effects of the pneumonia because the body’s natural response
to an acidic build-up is to produce more carbon dioxide which requires heavier breathing.
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The First Four Hours In Hospital
Ms. Rasiah attended at the Emergency Room (“ER”) of the Sturgeon General Hospital with a friend just
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before midnight on the evening of January 27 . At 23:55, she was assessed by a triage nurse, who
assessed her distress level at the second highest level on a scale of one to five. She was described as
being in ‘moderate respiratory distress’, complaining primarily of increased shortness of breath. Staff were
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made aware of the diagnosis of pneumonia made on January 22 . Ms. Rasiah was formally admitted to
hospital at 00:01. According to the nurse’s notes, Ms. Rasiah was then seen by a second nurse at her
bedside about five minutes after midnight. She was described as alert but pale, with a regular pulse but
laboured breathing, taking 30 breaths per minute. She was put on oxygen at 00:15 at a rate of 2 liters per
minute.
Over the next several hours, Ms. Rasiah was monitored regularly in the ER. Vital signs were taken each
hour by nurses. She came under the primary care of Dr. Thompson who, apart from nursing staff, was
assisted by a resident or intern, Dr. Xu. Neither the hospital records nor the memory of the witnesses who
testified establish the precise times that the doctors attended upon Ms. Rasiah but records do show that
Ms. Rasiah was seen by one or both of the doctors at about 00:30 and I accept Dr. Thompson’s description
that the doctors were frequently in and out over the next several hours with some of the contact noted and
some not.
At 01:00, a number of tests were ordered including an x-ray and bloodwork. Based on nurses’ notes and
the collection times appearing on later lab results, the samples were taken between 01:06 and 01:10. The
x-ray was done at about 1:20 and the lab received the blood samples at 01:22. The tests were ordered
because Dr. Thompson suspected there may have been more at play than pneumonia. Given Ms. Rasiah’s
deteriorating condition and lack of response to the earlier prescribed antibiotics, the doctor was not
prepared to reject the diagnosis of pneumonia but neither was he content to rely upon it as the sole source
of the problem.
At the time the x-ray was taken, Ms. Rasiah told staff that it was getting harder to breathe. A short time
later, when her vitals were taken at 1:50, Ms. Rasiah’s rate of breathing had increased to 32 breaths per
minute, a rate described in the evidence as ‘very concerning’ and symptomatic of a build-up of acid or
metabolic acidosis. As a result, the amount of oxygen given to Ms. Rasiah was increased from two litres to
either three or four – the evidence is unclear.
Dr. Thompson was anxious to receive the results of the blood tests and the x-ray although the evidence is
unclear as to when those results were obtained. There was no specific note in the hospital records and the
testimony on this point was very vague. It was probably in the range of 02:00 to 02:30. Although Dr.
Thompson had no specific memory of the time as of the date of the Inquiry, he did recall that when he
received the results, he promptly paged Dr. Norris, the head of the ICU at Sturgeon General, to consult.
He would have paged the doctor and later received a call back and he recalled that they spoke at length
about the pros and cons of different options, including whether or not to prescribe a broader spectrum
antibiotic. The records show that the antibiotic was either ordered or administered at 02:45, which suggests
that Dr. Norris probably responded to Dr. Thompson’s page around 02:30. It is unlikely that the test results
would have been received more than half an hour before the end of that conversation.
The blood work showed that Ms. Rasiah had an extremely high level of creatinine, which Dr. Thompson
recognized as a sign that Ms. Rasiah’s kidneys were not functioning. This is a conclusion with which all of
the doctors called in this Inquiry agreed. Having concluded that Ms. Rasiah’s kidneys were not functioning
properly, Dr. Thompson ordered that Arterial Blood Gas (“ABG”) be collected and ordered that a catheter
be inserted to measure urine output. The ABG was ordered at 02:50 and the catheter inserted at 03:00.
I am satisfied that the two doctors discussed the results of the blood tests ordered at 01:00 and further
discussed what to do in light of the fact that the Sturgeon General did not have the capacity to do dialysis
and clearly Ms. Rasiah was in need of dialysis. It was agreed between Drs. Thompson and Norris that Dr.
Thompson should contact a nephrologist (kidney specialist) at one of the three Edmonton hospitals with
the capacity to do dialysis. It was also understood that Dr. Thompson would contact Dr. Norris after
speaking to a nephrologist.
Before leaving the issue of what time this conversation between Dr. Thompson and Dr. Norris occurred, I
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am mindful that the discharge summary, dictated later in the morning by Dr. Norris, states that he was
consulted at 02:00. I do not find this reconstruction accurate, however, as it also refers to blood gas results
being known at that time, results that correspond with a test that was not ordered until 02:50.
I am satisfied that following the conversation with Dr. Norris, Dr. Thompson immediately requested that a
nephrologist be paged although no witness has a memory of who decided which of the hospitals with a
nephrology department would be contacted or, for that matter, whether more than one hospital was
contacted. A nephrologist did respond to the page, although the time is again unclear. The fact of the
conversation is noted and Dr. Thompson has a recollection of the gist of the conversation but the length
and specific content cannot be reconstructed.
The nephrologist with whom Dr. Thompson spoke was Dr. Deved, from the Royal Alexander Hospital
(“RAH”). Based on the sequence of events before and after, the conversation probably took place between
02:30 and 03:30. Although Dr. Thompson did not purport to have a clear memory of all of the conversation,
he was confident that he provided all of the relevant information at his disposal to Dr. Deved and that the
nephrologist had a good understanding of Ms. Rasiah’s condition as of the time of the conversation. Given
the totality of the evidence in this Inquiry, I am satisfied that Dr. Thompson would have provided a thorough
account of the information at hand as of 02:30 to 03:30 although Ms. Rasiah’s condition was changing and
it is not clear what information was available. As of 03:35, a nurse’s note refers to a Respiratory Therapist
attending “post ABG”, which suggests that the ABG results were known by that time. It is unclear if those
results were known to Dr. Thompson at the time that he spoke to the nephrologist.
The upshot of the conversation with Dr. Deved, as recalled by Dr. Thompson, was that Ms. Rasiah should
be transferred to the Royal Alexandra, though not necessarily immediately. Dr. Thompson’s understanding
was that, based on the information at hand, Intensive Care would not be required. The Royal Alexandra
would make room for Ms. Rasiah on the nephrology ward later in the morning. It is unclear whether either
doctor had an understanding as to what time such a transfer would occur, nor by whom it would initiated.
A nurse’s note could be interpreted to suggest a transfer time of 10:00 although the timing, authorship and
meaning of this note remains unclear.
By 03:35, Ms. Rasiah’s breathing had deteriorated further. The saturation of the partial pressure of oxygen
in her lungs (Sp02) was varying. A Respiratory Therapist is noted to have been on scene at this time,
which suggests that her condition was seen to be deteriorating. Dr. Thompson increased the oxygen intake
to 4 liters per minute at that time. This is the last written record of the involvement of Dr. Thompson.
At some point, but it is unclear when, Dr. Thompson handed primary care of Ms. Rasiah to Dr. Norris of the
Intensive Care Unit.
Immediately after Dr. Thompson spoke to the nephrologist, he paged Dr. Norris as planned. He
undoubtedly related that the Royal Alexandra would be prepared to receive Ms. Rasiah later in the morning
although it is not clear as to whether a particular time was discussed and it is not clear what else they
discussed other than who would be responsible for Ms. Rasiah’s care pending the transfer. It was Dr.
Norris’ opinion that Ms. Rasiah did not meet the criteria for admission into the ICU but he did agree that the
ICU would accept primary care of Ms. Rasiah pending her transfer to the RAH. Both doctors understood,
however, that Ms. Rasiah would remain in the critical care room within the ER, where she was already
situated.
Dr. Thompson considered that by the end of that conversation, Ms. Rasiah was formally under the care of
Dr. Norris and the ICU, although he also described that this would not mean that he would cease to be
involved. If the patient needed care, the ER doctor would not ignore the patient’s needs; the ER doctor
would respond.
Dr. Norris had a different understanding in that he understood that the patient would not be formally under
the care of ICU until an ICU doctor had assessed the patient and confirmed acceptance. Dr. Norris was not
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at the hospital in the early morning of January 28 but a different ICU doctor, Dr. Lalic was. Dr. Norris
phoned or paged Dr. Lalic following the second conversation with Dr. Thompson to advise that ICU would
be caring for the patient pending a transfer to the different hospital and Dr. Lalic responded to the call by
going down to the ER. Like Dr. Norris, Dr. Lalic did not consider that she was the primary physician before
doing an assessment and getting Dr. Norris’ express approval to accept care but she did go down to do an
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assessment, then spoke to Dr. Norris and I am satisfied that by 05:00 at the latest she had accepted
primary care.
There is again no specific note as to the time of the second conversation between Dr. Thompson and Dr.
Norris but on all the evidence, I would estimate that the time was likely between 03:30 and 04:00. Dr.
Thompson was noted to have ordered the oxygen increase at 03:35, which would not likely have been
done without consultation if he understood care had been transferred, and Dr. Lalic was noted to have
been on scene by 04:15. Dr. Lalic recorded the time of her initial assessment of Ms. Rasiah as 05:00
although I am satisfied that note more probably reflects when she formally accepted care of the patient
rather than when she attended in the ER, a suggestion which she conceded may be correct on being
pressed. The hospital registration record shows admission into the ICU at 04:19.
In the final analysis, there is a period of time from approximately 03:30 to 05:00 when there remains a
question as to who was responsible for primary care, an issue that has not gone unnoticed by Ms. Rasiah’s
family. On the other hand, I do not find any evidence that the differing perspectives as to who was in
charge had any material effect on the nature of care provided. There is no suggestion, for example, that
anyone hesitated or failed to make decisions out of uncertainty as to who was in charge or that there were
any lapses in care during this time due to confusion as to who was the primary physician. It appears that
the care was very much a team effort from the time of admission and the evidence suggests that this
continued throughout.
The Hours Preceding the Brain Injury
As of the time that Ms. Rasiah was assessed by Dr. Lalic, which I find was likely around 04:20 to 04:45, the
doctor considered Ms. Rasiah to be in a stable condition although diagnosed with ‘respiratory failure’ and
‘acute renal failure’. Vitals had been taken each hour from the time of admission, which along with other
indicators, showed that breathing was becoming more difficult. This concern had been addressed by
increasing levels of oxygen but, prior to 05:00, the vital signs had not shown any dramatic change and
based on her vitals, she was considered by all of the doctors involved, rightly or wrongly, to be in a stable
condition.
At some point between the increase in oxygen flow to 4 liters at 03:35, and the time that Dr. Lalic examined
the patient, the oxygen flow had been increased to 5 liters per hour. This increase is also reflected in the
nurses’ notes as of 04:00. However, Ms. Rasiah’s breathing rate had remained at 32 breaths per minute
each time the vitals had been taken commencing at 01:00.
When Dr. Lalic checked the breathing rate, she recorded the breathing rate at 24 – 26 per minute, which
she felt was slightly elevated but not extreme and she found Ms. Rasiah’s oxygen saturation of 95% on 5
liters of oxygen was reasonable. It is not clear as to whether or not Dr. Lalic was aware at that time that
her assessment of Ms. Rasiah’s rate of breathing was markedly different from the rate that had been
consistently recorded during the preceding several hours.
At 05:00, Ms. Rasiah’s breath rate was again recorded as 32 breaths per minute but over the next half
hour, there were signs that Ms. Rasiah’s condition was changing. At 05:30 Ms. Rasiah reported that her
chest would not let her breathe. Her chest would not expand. The oxygen rate was increased to 10 liters.
According to the Neurological Vital Sign Sheet, vitals were then taken at 5:40 and the respiratory rate had
jumped to 38 breaths per minute (first noted as 28). At 05:46, oxygen was further increased to 15 liters
and the return of a Respiratory Therapist is noted in the Nurse’s Record. Ventolin was ordered by Dr. Lalic
at 05:50. According to the Team Notes, Ms. Rasiah’s blood pressure was dropping at that time and Ms.
Rasiah was not speaking.
At 05:55, Dr. Lalic noted that she had contacted Dr. Norris and he would be coming in to assess the
patient. At 06:00 Dr. Lalic ordered more Ventolin. Ms. Rasiah was still not speaking, her blood pressure
was down to 109/92 and the respiratory rate was at 38.
It was likely around 05:45 when Dr. Lalic engaged the assistance of Dr. Mangan, who was the most
experienced Emergency doctor on shift following Dr. Thompson’s departure after 03:35. Dr. Mangan’s
Consultation Report shows that he was consulted for an opinion at 5:45. Soon after , he was called upon
to assist with an intubation. According to the Team Notes, authored by a nurse who is described as
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extremely attentive, at 06:12 Dr. Mangan was called to assist Dr. Lalic in preparing Ms. Rasiah for
intubation. Ms. Rasiah’s pulse was noted to rise, but at 6:15 her pulse was noted to be dropping rapidly to
60, then 30, then the nurse’s note reads, “Continued attempts; Dr. Lalic unable to intubate-Dr. Mangan
attempting”. The next team note is at 06:50, noting that the patient had been successfully intubated. In the
meanwhile, a Code Blue had been called.
Based on the notes on the Code Blue Sheet, Ms. Rasiah was intubated at 6:28 to a depth of 22 cm.
However, at 6:35, Ms. Rasiah lost her pulse and she was noted to have been without a pulse until 6:42. By
6:50 she was noted to have had a strong radial pulse and was on a ventilator.
Dr. Mangan could not recall times, but did recall being asked by Dr. Lalic to intubate Ms. Rasiah and
recalled the procedure in vivid detail. Most notably, Dr. Mangan recalled that when asked by Dr. Lalic for
assistance with intubation, he was in agreement that intubation was appropriate. He assessed what
equipment he would need and ordered Fentanyl (a fast acting narcotic medication), Gravol and
Rocuronium (a muscle relaxant). He then attempted to insert the tube he selected but was unsuccessful.
He accidentally hit the esophagus. Using a different stylet, he tried again and was successful. According to
the medications log, the three medications were dispensed at 6:20, 6:22 and 6:26 respectively.
Once Ms. Rasiah was placed on a ventilator, she was transferred to the Royal Alexandra hospital where
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she remained on mechanical ventilation until her death on February 6 after the ventilator was removed.
She had suffered a severe hypoxic brain injury from which there was no prospect of recovery. This
resulted from the deprivation of oxygen to the brain.
One of the avenues of inquiry in this hearing was how long Ms. Rasiah’s brain was without oxygen and in
turn why the brain injury was so severe.
It is clear from the evidence that Ms. Rasiah’s brain was not getting oxygen for at least the seven minute
period between 06:35 to 06:42 while there was no pulse. However, the evidence points to a longer period
during which the flow of oxygen to the brain was at least severely diminished, probably commencing at
06:15 when her pulse dropped sharply to 30 and possibly lower.
The evidence of Dr. Bannach was that the changes in Ms. Rasiah’s brain could have resulted from oxygen
deprivation during a time frame of three to five minutes although the doctor clarified that there is no direct
correlation between the length of time that the brain is deprived of oxygen and the amount of brain damage
that can result. It appears that science cannot yet answer why there is not necessarily such a correlation.
In the final analysis, the evidence suggests that Ms. Rasiah’s brain injury could have resulted from the
seven minute period during which there was no recorded pulse. It seems clear, however, that the brain
was deprived of oxygen for a longer period, possibly for as long as half an hour. Logically, while not
scientifically verifiable, it is probable that the injury was the result of both the complete deprivation of
oxygen for seven minutes and the severely curtailed flow of oxygen for a much longer period.
Recommendations for the prevention of similar deaths:
The scope of a fatality inquiry is limited by law. It is beyond the scope of an inquiry judge to determine fault
or offer normative assessments, either favourable or unfavourable. The scope is limited to finding facts.
However, the Act does allow a judge to make recommendations that might prevent similar deaths from
occurring in the future.
With hindsight, it is not difficult to opine as to probable outcomes if things had been done differently. For
example, if Ms. Rasiah had attended at a hospital that had dialysis equipment, things may have turned out
differently. If, upon discovery that Ms. Rasiah had renal failure, she had been sent or gone to a hospital
with a nephrology department, things may have evolved differently. If Ms. Rasiah had been intubated
sooner, perhaps things would be different. However, in determining whether recommendations should be
made, the judge must be careful to refrain from simply second-guessing judgment calls with the benefit of
hindsight. The judge must look at what policies or practices, going forward, might prevent a similar death.
The judge must recognize the risk of unintended consequences, particularly when assessing practices in a
professional discipline in which the judge is not trained but may have gained a little knowledge. In short,
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judges should not be afraid to make recommendations where appropriate but they must be satisfied that
any recommendation will be objectively supportable and will do more to advance than hinder the intended
objective.
In this case, I am unable to make any recommendations that are likely to prevent similar deaths in the
future.
The Inquiry was presented with evidence around the internal review that followed Ms. Rasiah’s death and
the recommendations that came out of it. Whether those recommendations will have the effect of
preventing similar deaths in the future remains to be seen but they do appear to constitute positive steps
that can only help to improve quality of care generally. They reinforce the importance of open lines of
communication, improve processes promoting clarity around the transfer of primary care and reinforce the
importance of ensuring accurate note-taking. That said, while these are very important, and while the
circumstances of Ms. Rasiah’s death only punctuate the importance of attentiveness to these concepts,
these are not new concepts that need be set out in the form of a judge’s recommendation, nor can I be
satisfied that the issues identified by these recommendations were actual contributors to Ms. Rasiah’s
death.
One issue not addressed in the internal review relates to whether or not changes should be made to the
practices or protocols surrounding the transfer of a patient from one hospital to another. This is a very
important issue. However, I am not satisfied that there is sufficient evidence to make any kind of
recommendation one way or another. There was vague reference to limitations in the resources of
hospitals, bed space and the demands upon transportation services but it was very imprecise and, in any
event, it appears that the delay in transferring Ms. Rasiah more promptly was less an issue of resources
than a question of medical judgment assessing need.
Ms. Rasiah’s death is such a tragic loss. It cries out for answers. It calls for accountability. It reminds us
all of the fragility of life. However, the law does not permit a judge to address accountability in a Fatality
Inquiry. It allows only for a finding of facts. It is hoped that this Report serves its intended purpose – to
provide an objective reconstruction of a difficult truth.
DATED
at
November 28, 2014
Edmonton
,
, Alberta.
Larry G. Anderson
A Judge of the Provincial Court of Alberta
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