Searching for meaning in baby’s death

An Anglican woman whose infant daughter died of dehydration a day after she was sent home from hospital says she does not want the licence of the doctor who treated her removed.

Instead, Georgina Hunter and her husband James want it publicly acknowledged that an error was made, they want the doctor’s name and details of the case registered so patients have access to the information and they want the case published for other doctors to learn from.

“That’s all we are seeking,” Mrs. Hunter said from her Ottawa home. “That’s not very much for a mother who has lost her baby. We are not seeking retribution.”

Mrs. Hunter has been a very public thorn in the side of the College of Physicians and Surgeons of Ontario since her seven-week old daughter died four years ago.

“From an Anglican point of view, from a spiritual point of view, I have felt called ever since Madeleine died to educate people.”

Mrs. Hunter also organized a baby memorial service at St. John the Evangelist Church, Ottawa, last year as a way for parents to grieve their lost babies, a service that was so successful it is being repeated this October.

In the days leading up to her death, the Hunters were worried that Madeleine was quite ill. She was sent home first from an Ottawa hospital and days later from the Hospital for Sick Children in Toronto. A day after she was discharged, Madeleine died. The autopsy attributed it to gastroenteritis and dehydration.

A coroner’s inquest was called and the jury made numerous recommendations. The Hunters then laid a complaint with the college. But the complaints committee released a report to the Hunters in March saying it will not refer to a disciplinary hearing the resident doctor who sent Madeleine home from Toronto’s Sick Kids.

In excerpts Mrs. Hunter released from the committee’s report, it notes that “a greater level of care” could have been provided to Madeleine but that the assessor did not believe care was below standard and that the resident’s inexperience explains why some of the subtle warning signs were not adequately heeded.

“The committee feels that any intervention in this matter should be educational, not punitive,” it concludes.

Mrs. Hunter said she has achieved her goals in convincing the Ministry of Health to look at the college’s procedures and in raising public awareness through a postcard and educational campaign. Now that a new group has started in Kingston – Victims of Health Care Abuse – Mrs. Hunter is satisfied other people will be keeping a close watch on the medical profession.

“I’ve done what I needed to do to ensure Madeleine’s death was not in vain. I feel I have accomplished my goal.”

At the same time, she is hoping the public will maintain pressure on the health ministry to make the Ontario college more accountable. She would like people to protest the college’s offering of alternative dispute resolution to resolve complaints sent to discipline, primarily because the doctor’s name is not made public during that process.

Based on research she has done by checking with colleges across Canada, Mrs. Hunter concluded the Ontario college has the lowest rate of complaints referred to discipline across the country, at just under one per cent.

Cases sent to disciplinary hearings are the only ones in which the doctors’ names are publicly revealed. Mrs. Hunter said that means doctors can be making all kinds of errors without patients finding out.

The college, however, says Mrs. Hunter’s statistical analysis compares apples with oranges since the laws vary by province and each college has different responsibilities. In addition, “It is not a mark of success to send every complaint we get to discipline,” college spokesman Jim Maclean said.

Instead, the college tries to resolve complaints through other means before it reaches the stage of a formal discipline hearing. Most complaints involve a lack of communication between patient and doctor, he said, rather than a tragic death. In those cases, a patient may be happy with a simple apology.

Alternative dispute resolution is offered in cases in which a complaint would otherwise be sent to a disciplinary hearing. It’s an option for patients who – like the physician – may wish to avoid airing their complaints in public.

At that meeting, the doctor may agree to take courses to upgrade his or her skills or to apologize, Mr. Maclean said. Patients who find the process is not working are free to terminate it and go off to a discipline hearing instead.

Due to privacy restrictions under the law, the college’s hands are tied in responding to some of Mrs. Hunter’s allegations, Mr. Maclean said. The college may reveal only if a doctor is facing or has been convicted of a charge of professional misconduct. He also noted that the Hunters are free to appeal that decision. A successful appeal would force the college to send the case to discipline.

Whether Mrs. Hunter is spreading information – or disinformation as Mr. Maclean charges – there’s no question she has achieved results.

She wrote articles in two parents’ magazines, attaching postcards to be sent to the ministry. She began an e-mail campaign and distributed postcards through two Anglican churches in Ottawa. The cards asked the ministry to investigate both the college’s refusal to send cases to discipline and what she charged was its general lack of accountability.

After a press conference Mrs. Hunter held in June, Minister of Health Elizabeth Witmer asked her professional relations branch to meet with the college to discuss concerns about its complaints and discipline process. Mrs. Witmer promised to review that and other information before responding to Mrs. Hunter’s call for an independent review of the college’s complaints and discipline process. (As of press time, no answer had been received.)

Mrs. Hunter believes pressure she put on the ministry is responsible for another positive outcome. The independent Health Professional Regulatory Advisory Council will be reviewing over five years the complaints and discipline process of all the professional regulatory colleges in the province.

That will include a “very specific focus on how complaints of a non-sexual nature are being handled by the colleges,” Mrs. Witmer wrote to Mrs. Hunter.

When she initially spoke to the council, Mrs. Hunter said, only sexual complaints were going to be investigated.

“I feel that is an achievement. That is an important first step.”

Meanwhile, Mrs. Hunter’s campaign is coming to an end.

“I feel there can now be closure in my life. I don’t think Madeleine would have wanted her mother to be a full-time advocate at the cost of our other kids. It is time to have closure on this issue and to focus on other things.”

Mrs. Hunter has given birth to two daughters since Madeleine died, the most recent in June.