"LIVES WERE DESTROYED AS A RESULT OF MEDICAL ERRORS BY ANOTHER ONTARIO DOCTOR, THE NOW-INFAMOUS CHARLES SMITH. HE WAS A WELL-RESPECTED CHIEF PEDIATRIC PATHOLOGIST AT TORONTO'S HOSPITAL FOR SICK CHILDREN BETWEEN 1982 AND 2003, WHO SPECIALIZED IN GIVING EXPERT TESTIMONY IN CRIMINAL COURT CASES INVOLVING CHILD ABUSE. BUT THE EVIDENCE HE GAVE WAS FLAWED, RESULTING IN THE WRONGFUL CONVICTIONS OF SEVERAL PEOPLE. LIANNE THIBAULT, FOR EXAMPLE, WAS FOUND GUILTY OF KILLING HER 11-MONTH-OLD SON NICHOLAS BASED LARGELY ON SMITH'S EVIDENCE. SHE WAS EVENTUALLY CLEARED, BUT NOT BEFORE ANOTHER CHILD WAS TAKEN FROM HER AT BIRTH AND HER NAME WAS PLACED ON A LIST OF KNOWN CHILD ABUSERS. THIBAULT ENDURED AN UNSPEAKABLE NIGHTMARE. WITH MEMORIES SO FRESH OF THE SMITH CASE, IT IS ENCOURAGING TO SEE PROVINCIAL HEALTH OFFICIALS RESPONDING QUICKLY TO THE WINDSOR DEBACLE."
EDITORIAL THE NATIONAL POST;
-----------------------------------------------------------------------------------
PUBLISHER'S NOTE: During the past two years, this Blog has reported on a crisis in Canadian pathology indicated by serious breakdowns in hospitals in Newfoundland, New Brunswick, Quebec, Saskatchewan and elsewhere in the country. The purpose, beyond seeking review and reform, is to show that the wide-ranging problems with pathology in Canada were not limited to the criminal sector - and that serious errors, sometimes lethal, were being made in reading test results on living patients. In short, that there was a crisis in Canadian pathology. The following Ottawa Citizen editorial makes a compelling connection with Dr. Charles Randal Smith - who was found to have made serious errors in his analysis of tissues from living children at the Hospital for Sick children in addition to his forensic flaws - and reminds us the irreversible harm that one physician can cause when the requisite checks and balances are not in place.
-------------------------------------------------------------------------------
"It is difficult to imagine many things worse than a cancer diagnosis, but Laurie Johnston can," the National Post editorial published earlier today under the heading "Healers who hurt," begins.
"After a biopsy, the Leamington, Ont. resident was told by Windsor surgeon Dr. Barbara Heartwell that she had breast cancer. She underwent a mastectomy, the amputation of her breast," the editorial continues.
"That was in 2001. Only later did she learn she never actually had cancer.
The case is one of two that have come to light alleging Heartwell performed unnecessary mastectomies.
Windsor's Hotel-Dieu Grace Hospital is investigating Heartwell's performance. The hospital is also investigating cases of flawed pathology reports, which may be connected to some of Heartwell's surgeries. The hospital has suspended a pathologist named Olive Williams, and indeed the province has stepped in to help review the botched operations and questionable pathology reports.
The external review -- by people from outside the hospital where the doctors worked -- is a good place to start understanding what went wrong and how extensive the damage is. That it should be done by people who are not colleagues of the physicians in question is just common sense.
Whether a result of human error or something else, such medical mistakes have far-reaching, often devastating, results.
Lives were destroyed as a result of medical errors by another Ontario doctor, the now-infamous Charles Smith. He was a well-respected chief pediatric pathologist at Toronto's Hospital for Sick Children between 1982 and 2003, who specialized in giving expert testimony in criminal court cases involving child abuse. But the evidence he gave was flawed, resulting in the wrongful convictions of several people.
Lianne Thibault, for example, was found guilty of killing her 11-month-old son Nicholas based largely on Smith's evidence. She was eventually cleared, but not before another child was taken from her at birth and her name was placed on a list of known child abusers. Thibault endured an unspeakable nightmare.
With memories so fresh of the Smith case, it is encouraging to see provincial health officials responding quickly to the Windsor debacle. The Ontario College of Physicians is also involved. The medical establishment seems to understand that hospital errors are unlike errors in most other workplaces where the consequences are usually measured in time or money. In medicine the stakes are higher. The women who unnecessarily had their breasts removed will never be made whole.
Whatever the explanation for the errors, the Windsor horror makes clear that safeguards need to be implemented to limit the damage that any individual health worker can do. Medical errors can happen due to bad luck, incompetence or gross malpractice. A proper safety system has checks at every gate, so to speak.
As it happens, the province has been working toward this. Beginning in April, no operation will take place in the province until all the players in the operating room go through a checklist. This 32-point surgical checklist requires a double-check of the biopsy report.
About a year in the making, the checklist was the result of a worldwide study involving hospitals in Toronto and other parts of the world that found the checklist reduced the risk of errors or mistakes in surgery by about 30 per cent.
The development of more stringent error prevention strategies comes too late for the Windsor women who were done a terrible harm; their ordeal is a reminder to all physicians that just as they have the ability to repair bodies they also have the power, in an instant, to damage them."
The editorial can be found at:
http://www.ottawacitizen.com/health/Healers+hurt/2620615/story.html
Harold Levy...hlevy15@gmail.com;
