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Family has mixed emotions about investigation results
Rozalynde McKibbin is bewildered and outraged at the results of a ‘care review’ conducted by the Winnipeg Regional Health Authority on the death of her mother.
"I still don’t understand how someone can look at what my mother went through and yet all that has really been done is a call for better records," she says.
McKibbin marked national elder abuse awareness day this year by meeting with Winnipeg Regional Health Authority officials to read a report about the starvation and death of her 98-year-old mother.
On June 15, Rozalynde McKibbin met with WRHA officials in an attempt to get answers from them about the death of her mother, Anne Rostecki, who died on Aug. 31, 2009 while being cared for at the Seven Oaks General Hospital.
Officials and McKibbin went over the findings of a care review of her mother. The review was based on Rostecki’s health records at Seven Oaks Hospital.
The report, signed by both Dr. Brock Wright, senior vice-president of clinical services and chief medical officer of the WRHA, and Lori Lamont, chief nursing officer and vice-president of interprofessional practice at the WRHA, says delays and inconsistent decisions regarding oral and tube feeding resulted in Rostecki receiving a lack of adequate nutrition for a two-week period.
McKibbin said her family had no reason to be concerned about her mother being admitted to Seven Oaks Hospital after a stroke until a nurse casually informed them that mother hadn’t been receiving nutrition for two weeks.
"What an understatement," says McKibbin.
"I asked a nurse how many calories was our mother getting each day, and the reply was ‘Zero’," McKibbin recalls.
"Our mother’s doctor didn’t even attend a meeting after our family discovered the starvation."
The review also found a complete lack of documentation regarding basic nursing care plans, such as bathing and other hygiene and skin care.
"…documentation consists mainly of flow sheets which do not provide evidence of ongoing assessment … Mrs. Rostecki developed skin breakdown prior to her death that could have been prevented," reads the report.
McKibbin says her mother didn’t receive her first bath until 36 days after being admitted to hospital.
The review also notes there was "limited evidence" that the health care team ‘regularly engaged Rostecki’s family in goals for care or day-to-day decisions’ regarding care.
McKibbin began requesting her mother’s medical files shortly after she died. She said she was disturbed by some of the information contained in the files.
McKibbin said despite her family’s attempts to discuss advanced care plans for her mother, no one saw a copy of the plan until January 2010. When she did see a copy of it, she was shocked by what it contained: a single piece of paper with three check marks, a signature, and instructions that CPR not be performed in the event of an emergency.
"Whoever signed it didn’t seek any family member input. A ‘team member’ got to determine my mother’s fate," she said.
"There was no spot or signature line on the form for any patient or family member comments or consent anyway, just lines for employees."
Last year, the WRHA released a pair of detailed reports calling for better communication between hospital officials, patients and their families when it comes to making end of life decisions.
Lamont said health authorities recognized there was a need for better communication with patients and their families. She said recommendations contained in the reports have since been introduced to staff.
WRHA spokesperson Heidi Graham said the care review and meeting with McKibbin likely ends the WRHA’s role in the life and death of Anne Rostecki.
"That’s likely it on our end," she said last week.
McKibbin said her family was unsure whether it will seek legal action against WRHA, but said she will continue to advocate for massive overhauls in the state of patient relations and health care in Manitoba at both the provincial and federal level.
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