The investigation of a serial and potentially catastrophic operating-room error, involving Ontario’s leading pathologist, is being reported as a closed-door proceeding that would otherwise justify the efforts of high-profile family members seeking more information.
Lawyers for three families who have believed for decades that similar accidents and problems have happened elsewhere in the surgical program run by the Dr. David Williams who, until his retirement last year, was the chief forensic pathologist in the province – say they are in the dark.
“We can’t understand how or why a very public agency such as the Ontario College of Physicians and Surgeons has failed to provide any information other than a single statement from its own lawyer,” said Joseph Cotroneo, a lawyer for one of the families.
The college reported last month that it has hired a law firm to conduct a “secondary investigation” in the matter of the errors.
In a 19-page statement from that probe, the college indicated that the professional body had “conducted a full and comprehensive internal investigation” into the mistakes that occurred with Williams in 2009, a year after he retired, resulting in seven patients dying and two others sustaining serious injuries.
Williams died in March from cancer. In retirement, he had refused a previous call for a new probe into the incident, asserting it was not his responsibility and that his communication in 2009 with the surgeon-in-chief at the hospital, including its senior physician at the time, were “incidental.”
But the college said its “internal investigation” found that there were 23 attempts at repairs to the surgical room failed or disappeared, the first of them in 1998, and the fact the room’s “cracking skin” could not be addressed through the “quality assurance process” was an area it investigated.
It is this information, said the college, that prompted the hire of the law firm.
The lawyers for the families have questioned that hiring and said they are sceptical of an investigation whose key witness had told a corrections hearing about the 2008 incident that occurred while a surgical team was trying to remove a cyst on a senior patient, but had not been heard from for more than four years. The panel on the hearing, including fellow pathologists and a board member, was holding a recess during a parade of friends and relatives who had believed that “these experts could make sense out of a 16-year-old, gut-wrenching chain of events,” Cotroneo said.
The lawyer is not only representing the families in the University Health Network’s third major investigation of a Williams medical error and care in a surgical room, but also Andrew Gruschenko, a prominent Toronto resident, who has filed a complaint with the college after a surgeon tried to remove a woman’s gallbladder with a closed, infected gall bladder after injecting a generic drug into it. A key hospital investigator is a former Ontario government medical education adviser, who has written that the college’s reporting of the incident shows the profession is facing a “culture clash” over transparency.
Dr Martin Makary, the doctor who was accused of that error and in an attempt to remove a patient’s gallbladder with an inside-out procedure, said he has been too busy to reply to messages left for him. “My background involves hospital administration, so I’ve got three litigations out there,” he said in an interview, about a lawsuit related to an equipment malfunction and two related complaints made to the college.
Makary said when he became head of the College of Physicians and Surgeons in 1999, three cases related to the office were under investigation. As a medical journalist, he investigated and reported about two of them.
It is unlikely, for instance, that either the changes made after the Canada Health Act requires annual reporting of deaths caused by medical errors, or of the 2008 mishap involving patients in the surgical ward at Western University hospital in London, Ont., which are now under investigation at the college, would have occurred with the doctors who were involved in both the report for one of the investigations, and were their personnel not in the room at the time, he said.
In addition, he said, the college’s power to impose a disciplinary sanction on a doctor comes only after an admission by a doctor to the college’s board of medical directors, rather than at the disciplinary hearing conducted by