Crystal Thomas and
First of all we would like to thank the coroner’s service and their council for their efforts during the inquest into the death of Teresa Scheunert. They have made this inquest publicly accessible, and open. We were also grateful for the expert witnesses that came to testify.
What we were surprised by, however, was how adversarial the process became. We found that strange since an inquest is designed to not find guilt or blame. We did find, however, that there are certainly numerous ways to improve public safety.
There was no clear care plan for Teresa’s main symptoms causing pain and discomfort, (problems with her abdomen, spine, numb and tingling legs, swelling, possible infection, anemia, edema, etc.). Patients in hospitals should have clear care plans.
We regret there seemed to be considerable focus by hospital and physician lawyers on making Teresa look bad rather than learning from the “system gaps” about improving care.
A physician testifies that Teresa had alcohol on her breath. This is hearsay, and the physician did not document it. If prescribing narcotics, the presence of alcohol should be documented. If alcohol was suspected, extra vitals and monitoring would have been warranted. There was no alcohol detected in the autopsy.
We think Teresa’s death is an issue of public safety.
There was no clear treatment plan, lack of consistency with standards of care, poor charting, (some by exception, some things not noted at all, only recalled later) and doctors’ notes were almost non-existent. The few doctors’ orders for vitals and blood sugar levels for diabetes were supposed to be done four times a day, yet those orders were never done four times a day, and several days not done at all.
There was inadequate charting and monitoring of Teresa’s symptoms of back pain, abdominal distention and numbness and there was no plan at all for monitoring the side-effects of the several opioids she was prescribed and administered in hospital.
Hospital policies for fentanyl were not followed. They did not document where the patch was applied on the body, or if and how the location was changed. The proper protocol for disposal of high potency narcotics was not followed, and disposal was not documented on the medical administration record or anywhere else in Teresa’s chart. This is an extremely unsafe practice by both physicians and nurses in Watson Lake’s hospital.
Watson Lake had access to a 24-hour on-call pharmacist, but the available pharmacist was not called, nor consulted, regarding the multiple sedating opioid medications prescribed and administered in hospital. Doses of narcotics, or any interactions or adverse effects they may have on one another, were not reviewed by a pharmacist. We discovered that physicians and nurses at the hospital did not seem to see the importance of pharmacist oversight in their facility. We feel that was an extremely important and dangerous oversight.
Policies in place that stated medication should not be left at a patient’s bedside were also not followed or enforced. Indeed, witnesses appeared to have no awareness of several policies they should have been following.
We also feel that there was a conflict of interest having a fellow staff registered nurse as a patient in hospital at that time, and Teresa was too compromised to leave on her own.
There was no investigation of Teresa’s elevated heart rate, nor her bloodwork that had suggested she may have infection or inflammation.
We found it troublesome that instead of immediately ordering for Teresa the MRI and subsequent tests (ultrasound, a better CT scan) she required, the doctor first blamed WCB, and then testified she advised Teresa to seek her own treatment in the private sector and pay for her required tests out of her own pocket.
Regardless what the final outcome of this inquest may be, there are still many issues that need to be fixed.
All Yukoners are entitled to consistent, safe care that this inquest shows Teresa Scheunert did not receive in Watson Lake Hospital.
We hope that whatever the outcome is, that there will be recommendations not only made, but enforced for the
safety of all.
Thank you very much,
The family of Teresa