PUBLISHER'S NOTE: In a previous post, (link below) CBC Journalist Richard Cuthbertson, noted in his report on the disastrous pathology debacles in the U.K. and Canada centered around Doctor Dick van Velzen, of Alder Hey scandal infamy that: "There is the Ontario inquiry that examined the work of Dr. Charles Smith, whose autopsy mistakes led to wrongful convictions. There is Cameron report into erroneous breast cancer screening results in Newfoundland, and the Creaghan inquiry into faulty cancer diagnoses in Miramichi, N.B. "I have them all, and I keep trying to convince residents to read them," said Dr. Erica Schollenberg, the office's current occupant." To fill out the historical record a bit, here is some background on Newfoundland's erroneous breast cancer 'scandal', in the form of a CBC (Canadian Broadcasting Corporation) story New Brunswick's botched cancer diagnosis disaster.
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PREVIOUS POSTS IN THIS SERIES:
PART 1: (Dr. Dick van Velzen: The Alder Hey scandal. U.K. and it's Canadian connection): https://www.blogger.com/blog/post/edit/120008354894645705/6420637297647506632
PART 2: The faulty cancer debacle. (New Brunswick); https://www.blogger.com/blog/post/edit/120008354894645705/5496055087502819610
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PASSAGE ONE OF THE DAY: "In Menon's case, Schollenberg's call to the Miramichi Hospital resulted in staff digging through the pathologist's files to see if there was any reason for concern. There was. "Miramichi's other pathologist, Dr. Darius Strezelczak and Jeff Carter, the hospital's director of risk management quickly compiled a list of five suspect cases, including four missed cancer diagnoses. The fifth case involved a cancer diagnosis Menon made for a patient whose identity somehow became lost. "Dr. Menon had indicated on different occasions that the report could belong to two different patients." Jeff Carter said. According to Carter, it eventually took Menon 60 days to sort out exactly who the cancer diagnosis belonged to. Tip of iceberg; The findings alarmed the hospital and its chief of medical staff, Dr. Carl Hudson, officially alerted regulatory authorities on Jan. 29, 2007. The college suspended Menon's medical licence eight days later. Following the suspension, the college of physicians undertook its own review of Menon. It sent two pathologists who were not from N.B. into the Miramichi hospital to check his work. Dr. Rosemary Henderson from P.E.I. and Dr. Bruce Wright from Nova Scotia made a one-day visit to Miramichi in April 2007 and came away concerned about Menon's abilities, stating simply in their written report that Menon "fails to meet the current standards of surgical pathology."Henderson then agreed to do a more thorough review of Menon's work for the hospital itself. She pulled 227 of his breast and prostate cancer cases from 2004 and 2005 and went over them in detail. The results, released in February this year, were alarming. In 18 per cent of the cases, the diagnoses were deemed incomplete and in three per cent, they were said to be wrong. Within the week, the health minister announced there would be an inquiry."
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PART 3A: STORY: "A Miramichi pathologist under the legal microscope," by CBC Reporter Robert Jones, published on May 12, 2008. "Robert Jones has been a reporter and producer with CBC New Brunswick since 1990. His investigative reports on petroleum pricing in New Brunswick won several regional and national awards and led to the adoption of price regulation in 2006."
The daughter was upset at the treatment her mother received by the attending emergency room physician and her letter asked that his conduct be reviewed.
But that's not what caught Schollenberg's attention.
Almost in passing the letter also mentioned a Dr. Rajgopal Menon. Menon had conducted an autopsy on the woman's mother following her death and made an odd finding in his report that she had been "a heavy smoker."
That was not true, the daughter wrote. She questioned whether the entire autopsy report might be a work of fiction.
Schollenberg read the complaint and was concerned. He picked up the phone and called the Miramichi hospital and told senior medical staff there he thought they might have a problem.
"Sometimes little things can suggest a bigger problem," Schollenberg told CBC News later. "I thought it was a situation they might want to look into."
Name rang a bell
Schollenberg's instinct for trouble proved uncanny. His phone call to Miramichi unleashed a series of events that over the last two years has shaken confidence in New Brunswick's health-care system.
Menon, a doctor for 45 years, was stripped of his right to practise medicine by the N.B. College of Physicians and Surgeons just six months after that August complaint hit Schollenberg's desk.
Triggered by that suspension, a deeper look into Menon's work has left hundreds, if not thousands, of residents of northeastern New Brunswick asking questions about the quality of health care they have been receiving over the past 13 years, questions that are now the subject of a formal commission of inquiry.
New Brunswick's commission of inquiry into pathology services at the Miramichi Regional Health Authority began hearing from witnesses May 5, 2008, and is tasked by the government to report back within six months.
The one-man commission, headed by Justice Paul Creaghan, is sorting through what has become the wreckage of Rajgopal Menon's medical career.
The inquiry is trying to establish whether Menon misdiagnosed serious cases and only partially diagnosed others and, if so, why no one at the Miramichi hospital ever double-checked his work or abilities.
A catch
Separate from Creaghan's inquiry but on a parallel course is another investigation at a lab in Ottawa where 23,782 diagnoses that Menon made over his career in New Brunswick are being painstakingly reviewed for errors.
"It's very upsetting," said Miramichi family doctor Jeff Hans after learning of the inquiry and the serious concerns with Menon's work. "It certainly impacts on many of my patients and so it leaves me worried if there were some misdiagnoses."
In the early days, Miramichi must have felt lucky to get Menon. Pathologists are in high demand in Canada. They hold down a critical station in any health-care system, analyzing tissue samples, blood and bodily fluids to detect the presence of disease.
Most cancer diagnosis start with the analysis of a biopsy sent to a pathologist. Mistakes, as Newfoundland is finding out as well with its own provincial inquiry, can be disastrous.
Rajgopal Menon was born in Singapore in 1934 and earned a medical degree in Scotland in 1961 from the University of Glasgow. In 1995, late in his career and at the age of 61, he began what became a 12-year stint in Miramichi as a pathologist for the region.
Edmund Schollenberg has been Registrar of New Brunswick's College of Physicians and Surgeons for two decades, has degrees in both law and medicine and has developed an unhappy expertise in the area of problem doctors.
He had seen Menon's name on another letter of complaint from Miramichi four months earlier and although neither it nor the second complaint focused primarily on Menon, Schollenberg didn't like seeing the pathologist's name appear twice in two unrelated cases in such a short period of time.
In Menon's case, Schollenberg's call to the Miramichi Hospital resulted in staff digging through the pathologist's files to see if there was any reason for concern. There was.
Miramichi's other pathologist, Dr. Darius Strezelczak and Jeff Carter, the hospital's director of risk management quickly compiled a list of five suspect cases, including four missed cancer diagnoses. The fifth case involved a cancer diagnosis Menon made for a patient whose identity somehow became lost.
"Dr. Menon had indicated on different occasions that the report could belong to two different patients." Jeff Carter said. According to Carter, it eventually took Menon 60 days to sort out exactly who the cancer diagnosis belonged to.
Tip of iceberg
The findings alarmed the hospital and its chief of medical staff, Dr. Carl Hudson, officially alerted regulatory authorities on Jan. 29, 2007. The college suspended Menon's medical licence eight days later.
Following the suspension, the college of physicians undertook its own review of Menon. It sent two pathologists who were not from N.B. into the Miramichi hospital to check his work.
Dr. Rosemary Henderson from P.E.I. and Dr. Bruce Wright from Nova Scotia made a one-day visit to Miramichi in April 2007 and came away concerned about Menon's abilities, stating simply in their written report that Menon "fails to meet the current standards of surgical pathology."
Henderson then agreed to do a more thorough review of Menon's work for the hospital itself. She pulled 227 of his breast and prostate cancer cases from 2004 and 2005 and went over them in detail. The results, released in February this year, were alarming. In 18 per cent of the cases, the diagnoses were deemed incomplete and in three per cent, they were said to be wrong.
Within the week, the health minister announced there would be an inquiry.
"It's a shocking event," said Murphy. "There's no sugar-coating this."
Meanwhile, in Miramichi, suddenly anyone who ever had a biopsy done had serious concerns. Roger and Romuald Vautour, whose father recently died of cancer, immediately wondered if his case was one that might have been mishandled by the hospital.
"My dad was going to the emergency for a few years complaining about his stomach pains and different stuff," said Roger. "Every time, he would go to the emergency they were doing tests and they would say 'no, it's just your nerves. Go back home, Mr. Vautour.'"
That kind of worry and suspicion touched hundreds of families in the area and as the inquiry began the big question was why the hospital had no system in place to catch problems sooner.
Justice Creaghan said he wanted to know that as well."
The entire story can be read at:
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3B: JUSTICE CREAGHAN'S REPORT: Under the heading: Canadian Press This is a portion of the Canadian Press unattributed story: The entire story can be read at the link below: "The head of an inquiry into pathology services at a hospital in northern New Brunswick says Dr. Rajgopal Menon should have lost his licence in 2005, two years before he was suspended from working.
Justice Paul Creaghan says in his report released Wednesday that there has been no program of quality control in the pathology lab at the Miramichi Regional Hospital since 1994.
Menon worked at the Miramichi hospital from 1995 until early 2007, when his licence was suspended following complaints about incomplete diagnoses and delayed lab results.
An audit of Menon's work earlier this year found 18 per cent of 227 breast and prostate cancer reports were incomplete and three per cent were incorrect.
In a lengthy three-volume report, Creaghan says Menon's work at the hospital was flawed.
"Overall, we found that his service was unsatisfactory in terms of both attention to his duties and to the level of his performance," Creaghan wrote.
He also pinpoints a litany of systemic problems within New Brunswick's health-care system and found that the Department of Health had no idea whether pathology labs in the province were operating at acceptable levels of quality.
"The commission found no meaningful peer review of Dr. Menon's work while he was employed at the hospital," Creaghan says in the report."
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3C: COMMENTARY: Author Sam Solomon's incisive commentary in the 'National Review of Medicine." April, 2008, Volume 5 No-4, is aptly headed, "Canadian pathology mired in crisis,' as it concludes that, "Three deadly scandals expose gross failings in training, oversight."
| GIST: Sir William Osler famously said, "As is our pathology so is our practice... what the pathologist thinks today, the physician does tomorrow." If Dr Osler — a pathologist himself — was right, then Canada's entire medical system is in deep trouble, says Canadian Association of Pathologists president Dr Jagdish Butany. "Over the last 20-plus years, we have not paid enough attention to laboratories and pathology and pathologists," he says. "[The healthcare system has] relegated pathologists to the basement and given them that same priority." The result of that chronic disregard is now becoming readily apparent: Canadian pathology is in crisis. SYSTEMIC PROBLEMS As a result, an expert panel of leading medical authorities are now in the process of setting up a comprehensive review of the current deficiencies in pathology in Canada. The details of the review haven't been finalized yet, says Royal College of Physicians and Surgeons of Canada CEO Dr Andrew Padmos, but the report will have another goal as well: to restore the public's severely shaken confidence. The three scandals have done grievous damage to the profession's reputation. "They've given us a black eye," Dr Butany admitted to the National Post last month as he and Dr Padmos dutifully denied a crisis exists and reassured reporters across the country that Canadian pathology is indeed trustworthy and can be repaired. In conversation, however, cracks appeared in the veneer of their everything's-under-control exhortations. After explaining that Canadian health human resources problems are having a particularly acute effect on the field of pathology — "We are concerned the problem is going to become worse and more widespread and we don't have in place an effective pan-Canadian action to stop it" — Dr Padmos quickly sought to quell any possible anxiety. "Is it an absolute knockdown crisis? Of course not. What they need is some hope and some planning." The shortage of pathologists and lab technologists is already putting pressure on the system. "People are working too long hours, or past your threescore and ten, even," says Dr Butany, "so that makes for an increasing potential for mistakes. You don't have time to critically analyse previous work, to sit back and think." But the real culprit in all three scandals appears to be a lackadaisical approach to quality assurance and training. ONTARIO But that trust was misplaced. Dr Smith is now at the centre of a public inquiry into the entire field of pediatric forensic pathology in the province. Many child murder convictions that Dr Smith helped resolve have been thrown into question and the provincial Chief Coroner's office is now suggesting a total of 142 cases be reviewed. Although Dr Smith made a dramatic apology to his victims at the inquiry, he wasn't actually on trial. In fact, there's one thing he and his victims seem to be able to agree on: the balance of the blame should go to the pediatric forensic pathology system itself and the lack of oversight, training and quality assurance. The inquiry's closing arguments wrapped up April 1. Justice Stephen Goudge is due to submit his final report and recommendations to the government by September 30. NEWFOUNDLAND AND LABRADOR Again, the absence of standardized quality assurance — a problem that still persists today, says Dr Padmos — appears to have contributed significantly to the errors. There have also been suggestions that a St John's lab may have misinterpreted the results of a now-outmoded method of immunohistochemical testing on biopsy tissue; a 2003 internal memo by pathologist Gershon Ejeckam called the lab's technique "unreliable and erratic" and said diagnoses based on those tests "will surely jeopardize patient care." Amidst allegations of a politically motivated coverup, some have called for Health Minister Ross Wiseman's resignation. The inquiry's final report is due no later than July 30. NEW BRUNSWICK Already, Dr Menon's lawyer, Mel Norton, has employed the same tactics that Dr Smith's have in Ontario, blaming the pathology system and the lack of oversight. "[It's] too convenient just to aim the gun at one person," he told the Telegraph-Journal in February. The government has ordered reviews of all 24,000 of Dr Menon's cases, from 1995 until 2007, and the RCMP has also been asked to consider charges of criminal negligence against Dr Menon. Retired judge and former provincial Tory health minister Paul Creaghan, who is heading the inquiry, is due to submit his final report by August 22." The entire commentary can be read at |
https://www.nationalreviewofmedicine.com/issue/2008/04/5_patients_practice01_4.html
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PUBLISHER'S NOTE: I am monitoring this case/issue/resource. Keep your eye on the Charles Smith Blog for reports on developments. The Toronto Star, my previous employer for more than twenty incredible years, has put considerable effort into exposing the harm caused by Dr. Charles Smith and his protectors - and into pushing for reform of Ontario's forensic pediatric pathology system. The Star has a "topic" section which focuses on recent stories related to Dr. Charles Smith. It can be found at: http://www.thestar.com/topic/charlessmith. Information on "The Charles Smith Blog Award"- and its nomination process - can be found at: http://smithforensic.blogspot.com/2011/05/charles-smith-blog-award-nominations.html Please send any comments or information on other cases and issues of interest to the readers of this blog to: hlevy15@gmail.com. Harold Levy: Publisher: The Charles Smith Blog;
SEE BREAKDOWN OF SOME OF THE ON-GOING INTERNATIONAL CASES (OUTSIDE OF THE CONTINENTAL USA) THAT I AM FOLLOWING ON THIS BLOG, AT THE LINK BELOW: HL:
https://www.blogger.com/blog/post/edit/120008354894645705/4704913685758792985
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FINAL WORD: (Applicable to all of our wrongful conviction cases): "Whenever there is a wrongful conviction, it exposes errors in our criminal legal system, and we hope that this case — and lessons from it — can prevent future injustices."
Lawyer Radha Natarajan:
Executive Director: New England Innocence Project;
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FINAL, FINAL WORD: "Since its inception, the Innocence Project has pushed the criminal legal system to confront and correct the laws and policies that cause and contribute to wrongful convictions. They never shied away from the hard cases — the ones involving eyewitness identifications, confessions, and bite marks. Instead, in the course of presenting scientific evidence of innocence, they've exposed the unreliability of evidence that was, for centuries, deemed untouchable." So true!
Christina Swarns: Executive Director: The Innocence Project;
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YET ANOTHER FINAL WORD:
David Hammond, one of Broadwater's attorneys who sought his exoneration, told the Syracuse Post-Standard, "Sprinkle some junk science onto a faulty identification, and it's the perfect recipe for a wrongful conviction.
https://deadline.com/2021/11/alice-sebold-lucky-rape-conviction-overturned-anthony-broadwater-12348801
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MORE VALUABLE WORDS: "As a former public defender, Texas' refusal to delay Ivan Cantu's execution to evaluate new evidence is deeply worrying for the state of our legal system. There should be no room for doubt in a death penalty case. The facts surrounding Cantu's execution should haunt all of us."
Congresswoman Jasmine Crockett; X March 1, 2024.
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