John Klassen, 79, died in January 2004 -- three months after his health deteriorated from a heart attack.
An internal WRHA investigation into Klassen's case found he was not properly attended to by hospital staff when he first arrived at Concordia Hospital emergency in October 2003 complaining of chest pain.
The critical incident report said there was no evidence Klassen was monitored or that anyone documented his vital signs. It recommended guidelines be established to ensure emergency physicians document all treatment to prevent mistakes.
In a letter dated April 13, 2005, the WRHA told Klassen's family "an audit is being planned" to check that staff were keeping good patient records.
But two months ago, Klassen's daughter, Leslie Worthington, discovered the audit never happened. She received an e-mail from the WRHA's chief patient safety officer Dr. Rob Robson that confirmed her suspicion.
"The audit did not occur," Robson said. "I think there was some initial planning which revealed that this is a challenge in several other clinical areas -- in other words, not something that was restricted to emergency departments. There was a sense that an audit would not provide any useful information."
Worthington said the news is a slap in the face, and she is worried that the same medical mistake could happen again. "It's about using the recommendations and keeping patients safe," she said. "Other people have suffered, it doesn't make sense."
Heidi Graham, spokeswoman for the WRHA, said the health authority decided against doing an audit when they realized keeping up-to-date patient charts was a problem in areas outside the emergency room. Since then, she said the WRHA has launched several pilot projects to correct the problem.
The newly constructed adult and children's emergency rooms at Health Sciences Centre will soon be equipped with a tracking system that electronically records when a patient arrives and what tests have been ordered. At St. Boniface Hospital, a patient's full health record is now available electronically.
Graham also said the WRHA signed onto a national medical reconciliation project, to help remind physicians to look through a patient's medical history before prescribing medication.
"We recognize, and the emergency-care task force recognize, that there is a problem with physicians' charting," Graham said. "This is a problem that occurs in doctor's office, in other cities, everywhere."
Liberal Leader Jon Gerrard suspects some of the report's recommendations were never implemented and the audit should have been done to make sure.
Part of the problem, he said, was that the review was done internally. Gerrard said it's impossible for any body, including the WRHA, to review itself, and he is advocating for an independent provincial team that could investigate and make recommendations when medical mistakes occur.
"It's not good enough just to tell people to make changes," he said. "What is abundantly clear is we need to be able to change the process so medical errors are not made again."
Gerrard said the medical review process should be more open, so hospitals across the province could share information stemming from mistakes so they're not duplicated.
According to the WRHA's report, Klassen arrived at Concordia Hospital on Oct. 21, 2003, complaining of weakness, decreased memory and confusion. He was diagnosed with acute coronary syndrome -- a term that describes symptoms of blockages in the heart -- and was discharged three days later.
By Oct. 29, Klassen was rushed to Concordia Hospital emergency suffering from chest pain, shortness of breath and pressure in his head.
The report concluded no one treated Klassen after he received an ineffective dose of heart medication, no one monitored his vital signs, or treated him for having too much potassium in his blood until he was about to be transferred to St. Boniface Hospital.
Worthington said no one came to check on her father for 35 minutes, even though her father was yelling in pain and couldn't breathe. Eventually, she said hospital staff came in and gave him a drug that accidentally stopped his heart.
He was resuscitated, but after that day, Worthington said her father was never the same.
"He just rotted for three months," she said. "It was a joke."