"THE ONTARIO MINISTRY OF HEALTH HAS LAUNCHED ITS OWN REVIEW OF MEDICAL ERRORS IN WINDSOR AND THE CPSO IS INVESTIGATING BOTH HEARTWELL AND WILLIAMS. THE CAUTION WILLIAMS RECEIVED FROM THE CPSO WAS NEVER MADE PUBLIC OR SENT TO HOTEL-DIEU, EVEN THOUGH THE COLLEGE ASSURED THE PATIENT'S FAMILY THAT A WRITTEN CAUTION "IS A SERIOUS OUTCOME FOR MEMBERS OF THE MEDICAL PROFESSION".......HOTEL-DIEU'S NEW CHIEF OF STAFF DR. GORD VAIL, WHO REPLACED INTERIM CHIEF DR. KEVIN TRACEY ON MONDAY, SAID THE HOSPITAL DOESN'T ASK ITS DOCTORS TO SIGN THE CPSO WAIVER, ALTHOUGH THEY ARE ASKED ABOUT THEIR CURRENT STANDING WITH THE COLLEGE WHEN REAPPLYING FOR HOSPITAL PRIVILEGES. VAIL SAID AS FAR AS HE KNOWS, WILLIAMS DIDN'T TELL HOTEL-DIEU SHE WAS CAUTIONED BY THE CPSO. HE SAID GETTING PHYSICIANS TO SIGN A WAIVER IS A RELATIVELY NEW OPTION FOR HOSPITALS AND HOTEL-DIEU IS LOOKING INTO IT. TOM CLOSSON, HEAD OF THE ONTARIO HOSPITAL ASSOCIATION, SAID HOSPITALS SHOULD KNOW IF A DOCTOR SEEKING TO HAVE HIS OR HER PRIVILEGES RENEWED HAS BEEN ISSUED A WARNING BY THE CPSO OR DISCIPLINED OUTSIDE OF A PUBLIC HEARING."
REPORTER SONJA PUZIC; THE WINDSOR STAR;
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BACKGROUND: 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.
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"A pathologist suspended from Hotel-Dieu Grace Hospital in January was quietly reprimanded by the College of Physicians and Surgeons of Ontario last fall after she misdiagnosed a patient who later died of cancer, documents show," the Windsor Star story by reporter Sonja Puzic, begins, under the heading "MD's error kept quiet: Pathologist missed cancer in patient."
"Dr. Olive Williams, who lost her privileges at Hotel-Dieu after a pathology review uncovered flaws in her reports, was issued a written caution by the CPSO in November 2009 after she admitted missing a tissue slide that showed the patient had an obvious tumour in her appendix," the story, published on March 2, 2010, continues."
"Williams reviewed only two out of three slides sent to the pathology lab and diagnosed the patient, a woman who was 80 at the time, with appendicitis. Williams's diagnosis was made in January 2007, shortly after the patient was rushed to the ER with a burst appendix, which was removed. The patient was properly diagnosed in London a year later and died in May 2008.
The patient's family, who asked not to be identified, filed a complaint against Williams to the CPSO, prompting an investigation by the college's inquiries, complaints and reports committee.
The family shared the results of that investigation -- which was not made public -- with The Star.
In a letter to the CPSO investigator dated Jan. 6, 2009, Williams said she diagnosed the patient with "acute appendicitis with perforation" after viewing two slides of tissue from her appendix. When she was told a year later that a London pathologist diagnosed the same patient with cancer that originated in the appendix, Williams went back to the slides and realized she had missed one.
"I am at a loss to explain how it is that I did not examine the third slide," Williams wrote, adding that she is "extremely diligent" in her practice and will ensure that "this mistake will not happen again."
"I sincerely apologize for my part in not picking up this tumour at onset," Williams wrote.
The patient's husband told The Star his wife's life could have been prolonged had she known in time that a tumour was growing in her appendix. By the time she was properly diagnosed, the cancer had spread through her abdomen and there was little doctors could do for her.
Hotel-Dieu confirmed Monday the misdiagnosed appendix tumour is one of the seven cases "of serious concern" it has uncovered so far in its review of pathology reports and the investigation into Dr. Barbara Heartwell, who performed two unnecessary mastectomies in 2001 and 2009. The two investigations overlap because some of Heartwell's other cases are affected by pathology issues.
The Ontario Ministry of Health has launched its own review of medical errors in Windsor and the CPSO is investigating both Heartwell and Williams.
But the caution Williams received from the CPSO was never made public or sent to Hotel-Dieu, even though the college assured the patient's family that a written caution "is a serious outcome for members of the medical profession."
"Such a disposition is used in circumstances where the committee is concerned about an aspect of the subject physician's practice and believes that the physician in question would benefit from some direction as to how to conduct himself or herself in the future," the CPSO wrote in its decision.
CPSO spokeswoman Kathryn Clarke said Monday the college is prohibited by law from disclosing complaints and investigations involving a doctor unless they warrant a public disciplinary hearing. Only disciplinary actions or practice restrictions handed down at the end of such a hearing are posted on the CPSO's public registrar, available online. Williams's profile on the CPSO website indicates she has a clean record.
The Regulated Health Professions Act sets out what kind of information about a physician is made public through the CPSO. Investigations and complaints that don't get referred to a public hearing are protected by the legislation.
Even hospitals can't get access to that kind of information unless they have their physicians sign a waiver authorizing the CPSO to share complaints filed against them and their outcome. Ontario doctors may be asked to sign those waivers when they're applying to have their hospital privileges renewed on an annual basis. But even then, the CPSO registrar discloses only information "deemed to be relevant" to the doctor's application for renewal of privileges, Clarke said.
"There is some discretion," she said.
Hotel-Dieu's new chief of staff Dr. Gord Vail, who replaced interim chief Dr. Kevin Tracey on Monday, said the hospital doesn't ask its doctors to sign the CPSO waiver, although they are asked about their current standing with the college when reapplying for hospital privileges.
Vail said as far as he knows, Williams didn't tell Hotel-Dieu she was cautioned by the CPSO. He said getting physicians to sign a waiver is a relatively new option for hospitals and Hotel-Dieu is looking into it.
Tom Closson, head of the Ontario Hospital Association, said hospitals should know if a doctor seeking to have his or her privileges renewed has been issued a warning by the CPSO or disciplined outside of a public hearing.
"I think that's a reasonable expectation," he said, pointing out that hospitals must inform the CPSO when they suspend a doctor's privileges."
The story can be found at:
http://www.windsorstar.com/health/error+kept+quiet/2630976/story.html
Harold Levy...hlevy15@gmail.com;
