Thank you, Mr. Speaker.
WHEREAS on Wednesday, November 4, 2009, Mr. Allisdair “Azzie” Leishman was brought by ambulance to the emergency department at Stanton Territorial Hospital suffering from hypothermia and experiencing a psychiatric episode;
AND WHEREAS while under the care and attention of Stanton Territorial Hospital, Mr. Leishman exited the emergency room and made his way to the kitchen, where he took a knife and inflicted serious injury to himself by stabbing himself in the chest twice;
AND WHEREAS Mr. Leishman remains in extended care at Stanton Hospital to this day;
AND WHEREAS this incident raises questions about how such an incident could occur within Stanton Territorial Hospital, and about the overall safety and security of patients and staff within the hospital;
AND WHEREAS Stanton Territorial Hospital conducted a confidential internal quality management review, or mortality and morbidity review of this incident which contained no recommendations to improve the system or ensure that no similar incident would be allowed to happen;
AND WHEREAS the family of Mr. Leishman have been requesting a comprehensive external investigation which would explain how a patient of Stanton Territorial Hospital could inflict such personal harm while under their care and make binding recommendations which would ensure that a similar incident could not occur;
AND WHEREAS the Minister of Health and Social Services and Stanton Territorial Health Authority continue to deny all requests for an external investigation into this incident;
NOW THEREFORE I MOVE, seconded by the honourable Member for Nahendeh, that this Legislative Assembly strongly recommends that the Minister of Health immediately order an independent, external investigation covering all aspects of the Leishman incident, with recommendations, as necessary, to improve safety and security for all patients and staff and improve the overall quality of care for all patients receiving care within the Stanton Territorial Hospital.
Thank you, Mr. Abernethy. The motion is on the floor. The motion is in order. To the motion. The honourable Member for Great Slave, Mr. Abernethy.
Thank you, Mr. Speaker. I rise today requesting that this government conduct an independent external investigation covering all aspects of Mr. Allisdair “Azzie” Leishman’s injuries which occurred while Azzie was a patient being cared for at Stanton Territorial Health Authority.
Mr. Speaker, it is critical that a horrible situation like this help us ensure that nothing like this ever happens again, that Azzie’s incident helps to improve the safety and security of all patients and staff within Stanton as well as help to improve the overall quality of care for all patients receiving care within the Stanton Territorial Hospital.
Mr. Speaker, November 4, 2009, was the day that the Leishman family will never forget. It was the day that Azzie, a helicopter engineer as well as a vibrant father, brother and son, was taken by ambulance to Stanton Territorial Hospital, reportedly suffering from hypothermia. Ultimately, we don’t actually know what was wrong with him. It could have been anything. Regardless, both prior to his arrival and once under the care of the staff of the Stanton Territorial Health Authority, Azzie was clearly experiencing confusion and disorientation. One person referred to it as a psychiatric episode. By all accounts, he was mentally distraught, disoriented, and not acting in a fashion consistent with his normal behaviour and demeanour. It is my understanding that, once he arrived at Stanton, he was put in a room with a door left ajar for monitoring. While in this room, he was monitored, walking in circles and mumbling to himself. At some point, Mr. Speaker, Azzie exited this room and left the emergency room. A short time later, Azzie appeared in the kitchen of the hospital and obtained a knife from somewhere in the kitchen. Non-medical staff was present in the kitchen at this time. Standing in the kitchen, Azzie took a knife and punched it into his chest, not once, Mr. Speaker, but twice. The second stab pierced his heart, severing blood flow to Azzie’s brain.
Mr. Speaker, many things could have happened at this point. A person experiencing psychiatric episodes is unpredictable. In this case, Azzie chose to inflict harm upon himself rather than inflict pain on others. Regardless, it is not unreasonable to assume that if a situation like this were to ever be repeated in Stanton, harm could be inflicted upon staff rather than onto the person with the knife themselves. As such, it is imperative that we understand how such an incident occurred so that we can ensure that it never ever happens again.
Mr. Speaker, at this time, I would like to recognize the incredibly hard work of all the competent and qualified doctors and nurses who jumped into action and did save Azzie’s life. I have no doubt that if they were not there, Azzie wouldn’t be with us today. Their dedication is truly appreciated. They did save his life.
However, as I have said previously, something bad did happen and it is important to learn from it. To learn from it, we must know what happened. We must have a comprehensive non-biased analysis of the event.
I have had a number of conversations with Azzie’s mother, Margaret, since this horrible incident. She has been Azzie’s primary advocate, and has taken it upon herself to be his champion throughout this ongoing ordeal. Margaret has asked continually for clarity on the events that took place in the hospital on November 4, 2009, and how in a place of healing this could have occurred. She wants certainty that it cannot happen again, Mr. Speaker.
Mr. Speaker, this is why we are having a discussion on this motion today. After an incident like this occurs, hospitals conduct internal quality assurance reviews. These are sometimes referred to as mortality and morbidity reports. This is the normal practice. After Azzie’s stabbing, one of these internal incident investigations was completed. These reports are completely confidential and content is protected by Access to Information. This protection ensures that doctors and nurses and other health care professionals have mechanisms where they can provide input into incidents and provide evidence without adversely affecting their position or professional bodies.
Although individual practitioners are protected, Mr. Speaker, the general findings and recommendations are supposed to be shared with immediate family members. I have talked to Margaret. This was done. In short, this is what she was told by Stanton after they completed the mortality and morbidity investigation into Azzie’s incident: all existing protocols and procedures that exist within Stanton and its emergency department were followed appropriately and no recommendations are required.
Mr. Speaker, let’s be clear. No recommendations are required. How is it possible that a system has learned nothing from this horrible incident? Mr. Speaker, I just don’t buy it. It doesn’t sound reasonable to me, not even a little bit.
Mr. Speaker, you may not believe this, given the fact that I am the one moving this motion, but I do believe that staff did nothing wrong. I have a huge amount of respect for health professionals throughout the system. They have one of the hardest jobs that I can imagine and provide a critical service in a complicated environment. The stress must be significant. Fortunately, they are professionals who continue to provide an incredibly high level of service, regardless of the challenges we face here in the North.
When the mortality and morbidity investigation claims it did nothing wrong and the staff followed all of the procedures and protocols within Stanton, I accept this. I believe this could be true. What I don’t accept, Mr. Speaker, is that policy, procedures and protocols accepted by Stanton meet the needs and potential situations that could arise, that no improvements can be made as a result of this horrible incident is unreasonable. If nothing else, Mr. Speaker, Azzie’s ability to stab himself in the heart in Stanton’s kitchen with Stanton’s knife while under Stanton’s care and treatment suggests clearly that there are some gaps in the policies, procedures and protocols utilized at Stanton Territorial Hospital. For this reason, the suggestion that no recommendations are required is nothing but insulting to the family and to anybody else who has a reasonable expectation that policies and procedures are expected to ensure safety and security of staff and patients within the facility.
Mr. Speaker, a mortality and morbidity quality assurance investigation is conducted by the institution on the institution itself. I am not sure that, in this case, the institution has demonstrated a subjective perspective. As such, it is imperative that an external investigation be conducted.
I and my colleagues have requested a copy of the quality assurance investigation. We have been told no. We have also been made completely aware of the confidential nature of these reports and the importance with respect to health providers for keeping these reports closed. I accept their arguments for keeping these reports confidential. As such, we are not actually today asking for the department to open these reports. Rather, we believe that an independent external investigation is what is truly required of this situation. We aren’t asking Stanton to conduct another investigation into themselves. That would be like asking a fox to take care of the henhouse. That has already been done. We all know how that turned out. Mr. Speaker, precedents exist from other jurisdictions for external investigations in similar situations.
To this end, I would like to draw a couple comparisons within other jurisdictions where incidents occurred within a health care system that requires independent, non-facility-based investigations to ensure transparency, enhanced public and employee safety.
Mr. Speaker, the first comparison is from Alberta. On Friday, September, 17, 2010, a 34-year old man entered into the Royal Alex emergency room. He told the nurse at the triage desk he was suicidal. He was put in a regular emergency room without tightened security. He was checked every 40 minutes. Every hour he came out and asked the staff for a counsellor. At noon the following day, he came out and asked for a pencil and a piece of paper. Later that day, 12 hours after he arrived, he was found hanging from a lamp in his room by a strap from his backpack, a note and a pencil by his side. To their credit, Alberta Health Authority, not the Royal Alex Hospital, completed a comprehensive investigation into the incident. In the end, they admitted mistakes were made. As a result of this review, recommendations for improvements were made within Royal Alexandra as well as across the entire Alberta health system. Mr. Speaker, the family went on record stating that they originally thought the government would do a complete cover-up. Instead the family feels that the government was very honest. The family was told that they would eventually receive copies of the investigation report. Honesty and transparency, Mr. Speaker, not cover-ups. The Leishmans would like the same level of respect.
Mr. Speaker, my second comparison, a double amputee from Manitoba with a speech problem was found dead in a wheelchair after waiting 34 hours for care at a Health Sciences Centre in Winnipeg. The man died as a result of a blood infection brought on by complications of a bladder infection caused by a blocked catheter. His death could have been prevented if the blood infection had been treated. Initially, the local Minister of Health in Manitoba and hospital administration indicated that the incident was unfortunate but as a result of the individual not registering at the admitting desk. In short, the individual was responsible for his own demise.
Many people raised concerns about the issue, including the man’s family. They wanted to know what happened. Ultimately, the man told a health authority refused to release much of the requested information. Afterwards, the incident was reviewed by the medical examiner. As a note, in the NWT, we don’t have a medical examiner. Instead we have a coroner. The medical examiner’s report indicated the man did check into the triage desk at the hospital, that patients and security staff within the waiting room attempted to bring the man’s pain and physical labour to the attention of staff, that regardless of the man registering in accordance with hospital policies and procedure, the man died in the waiting room 34 hours after checking in. The findings were radically different from the Minister and hospital’s original assertions that this was the man’s fault.
Why is this important to the incident currently before us? It shows that internal investigations don’t always result in the most comprehensive and accurate findings. That errors in perception can occur when you’re looking into your own affairs, that having external bodies assist with assessing situations in the best interests of the public as a whole help assure transparency. Without knowing what truly happened and how it could have happened, we don’t have the ability to make reasonable recommendations that will result in fixing holes in our system.
Another interesting fact of the case in Manitoba is that the family has filed a complaint with the Manitoba ombudsman’s office. They continue to try to learn more about the events leading up to the death of this man. Unfortunately it appears that although the medical examiner has provided his findings, the regional health authority continues to refuse to provide the family with information on the horrible incident, and it sounds familiar to me. Because Manitoba has an ombudsman office, their residents have a mechanism to raise concerns about government services. An ombudsman’s office will help this family find out what went wrong within the system and help the system ensure that it never happens again. In the NWT, we have no ombudsman’s office. The Leishman’s have far fewer opportunities or mechanisms available to them to help them learn the truth. They have fewer mechanisms to help them feel confident that the system, or Stanton in this case, has learned from this horrible incident and that staff and patients will be safer in the future.
Mr. Speaker, like in Manitoba, it is critical that we know how Azzie’s incident occurred. What holes exist in our system that allowed a patient to harm himself in such a significant manner? Without knowing the answers, how can we as politicians and the public at large have any confidence that the necessary changes to Stanton’s policies, protocols and procedures are being made to ensure that this never happens again? Better yet, how can our Minister and the Stanton Territorial Hospital have any confidence an incident like this will not happen again? If holes are identified and changes are made, they should share this information with us and give us confidence that the public and staff safety is a priority for this Minister and this authority. Public and staff safety must be of paramount importance to us all. Mr. Speaker, these examples are different from Azzie’s situation in one critical way: both of these men died; Azzie is still alive.
This leads me to my last point of consideration, which is often the most difficult to contemplate. Mr. Speaker, if Azzie had passed away as a result of his injuries, there would have been a coroner’s inquest here in the Northwest Territories. It would have been independent, it would have been external and it would have been an external investigation covering all aspects of the Azzie incident, with recommendations, as necessary, to improve safety, security for all patients and staff and help to improve the overall quality of care for all patients receiving care within the Stanton Territorial Hospital. There is little doubt in my mind that the coroner’s report would have identified some gaps in Stanton’s policies, protocols and procedures. I believe it would have made recommendations to help close these gaps in the best interest of the public and staff.
Mr. Speaker, transparency, openness and honesty are required in this situation. Both Margaret and I look forward to support on this motion from my colleagues, and let’s encourage the Minister of Health and Social Services to do the right thing. Thank you for your time and for your consideration.
Thank you, Mr. Abernethy. To the motion. The honourable Member for Nahendeh, Mr. Menicoche.
Thank you very much, Mr. Speaker. I am pleased to second the motion put forward by Mr. Abernethy here today to request an external and independent investigation as to what happened to Allisdair Leishman. I also support the mother, Margaret Leishman, a mother who just wants answers. I have seen her lobby efforts over the past year and I am really confounded that our system only gave her cursory answers and was unwilling to share any information with her.
I was involved in private industry for many, many years and anytime there was an incident, you always do an incident report or you do a post-mortem to learn from how to better yourselves, how it won’t happen again, how to prevent it, and in this case the system said yes, they’ve done it, but they’re not willing to share it with anybody else. In our government we should be more transparent and work together for the betterment of everybody and that’s all that motion calls for and that’s all the mother is calling for as well.
So, once again, I look forward to support from colleagues as we move this forward and once again it’s just calling for an independent, external investigation to get the answers out and I don’t know why we had to do it in the House like this, but here it is and we have to do the right thing, Mr. Speaker. Mahsi cho.
Thank you, Mr. Menicoche. To the motion. The honourable Member for Frame Lake, Ms. Bisaro.
Thank you, Mr. Speaker. I rise to support this motion. It’s a terribly tragic situation and one which deserves an impartial and an honest and external investigation. I find it impossible to believe that in this situation that there are not some policies, some protocols, some procedures at the hospital that should be amended so that this doesn’t happen again. I support my colleague Mr. Abernethy in his request that we have this investigation so that it does not happen in the future to anybody else, and it’s entirely possible that without any changes to what’s going on at the hospital at this particular time, that we will have harm to another person or another person will harm one or more other people. So I really feel strongly that this is a valid request and I would hope that the government would see to, and the Minister would see to, acceding to this request. Thank you.
Thank you, Ms. Bisaro. To the motion. The honourable Member for Yellowknife Centre, Mr. Hawkins.
Thank you, Mr. Speaker. I’ve known most of the Leishman family most of my life; actually and I grew up with many of them, including Allisdair.
I could not put into words in any way the feelings and emotions that the Leishman family are going through in this particular case, nor will I try. This is quite a powerful experience that they’re going through and let us try to imagine in a way how horribly this has changed their whole life forever.
Allisdair, I remember him well playing hockey and I still envision him with the smile and excitement and jest he’s had. He’s was a great guy. I knew his brother Ian extremely well, and who I always looked forward to seeing whenever I’d cross the ferry in Providence and I’d look forward to talking to him every time, and I know the family and I’d like to think that they’ve been good friends of mine for many years. I almost feel like hearing that the system has decided to deny them, perhaps, the truth, or the justice that they rightly deserve is not reflective of the values I believe in.
I think that with much consideration and concern, I’m worried about the impact of how this motion goes. I’m certainly worried about the impact that this has had on the family and I don’t deny that these are circumstances I probably could never comprehend.
Mr. Speaker, the primary message in this motion that I keep reading when I heard it -- and I thank Mr. Abernethy for bringing it forward -- is that people want answers. It’s hard to imagine that the mortality and morbidity review could come up with nothing. Mr. Speaker, no recommendations almost seems appalling. I mean, not even general ones, not even big ones, nothing. It’s hard to imagine that this type of incident could happen and no one could find one thing to improve in the system.
Mr. Speaker, I’m completely surprised; and surprise probably in no way puts the feelings of the family into perspective. I’m sure they’re outraged.
Mr. Speaker, speaking of outrage, you don’t have to look far into other examples. Mr. Abernethy mentioned about hospital examples about people reviewing themselves and the problems that can arise, but our country as a nation has swelled quite in an aggressive manner against police forces that review themselves and always the fear of it being biased or protectionist in some way and that that had changed and the lessons learned just from that alone of saying that people want a clear and objective review. I don’t think that’s in the context of saying that if you review your own agency, whether it’s a hospital or whatnot, you’ll make bad decisions or decisions to cover up. I think what it does is provide quality assurance that if you have clear eyes, you’re unfettered by any type of decision or outcome of those results that the families can be somewhat satisfied. They may not like it, but they can be somewhat satisfied that there was a clear effort to understand the situation and certainly make change.
The answers the family received -- I want to thank Margaret and Faith for coming to my office to talk to me the other day -- I think are left wanting. The more I think about it and the more I even try to comprehend the particular issue of how it happened, I can only imagine the family still feels a loss in the sense of trying to explain or understand the situation.
We need a policy that is reflective of our values. The motion is only a half step forward. We need a policy that reflects full disclosure so that families will be able to understand the situation, will be able to work to healing, will be able to work to understanding what happened. Again, as I said, maybe the results of full disclosure may not be the ones they want to hear, but honesty is something they will cherish for many years going forward.
It’s sad nothing will change this horrible accident. It’s a horrible thing. But how do we look forward? It’s difficult to look forward with no lessons learned in this particular situation. I view it as not necessarily a situation of just trying to find fault to pin blame on somebody. It’s also a situation of trying to figure out how we ensure that this doesn’t happen again. It’s been said already.
Undeniably many of us, especially myself, ran for office to change the status quo. I can’t imagine anybody here not feeling that way. I feel that the way this report is sealed and locked down and the family’s denied what I would say is the truth of the situation, by allowing that, we’re just protecting the status quo and I think that’s not why many of us, especially myself, made the challenge to come here.
In closing, I just want to say that I have lasting worry and concern for the strain that this family will carry. This is a grey cloud that had burdened their life back in November 2009. I think answers, true answers, honest answers, will bring some closure to this family as they go forward. I think the family deserves that.
Thank you, Mr. Hawkins. To the motion. Next I have Mr. Ramsay.
Thank you, Mr. Speaker. First of all I want to thank very much my colleague Mr. Abernethy, MLA for Great Slave, for his determination in bringing this motion forward. It’s not an easy thing to do and I think he has shown a lot of courage and conviction in bringing this issue forward to the House today in an effort to get some answers for the family. I couldn’t agree with him more in his statement that the family deserves answers.
Stanton has to be taken to task for providing answers. We owe it to the public that we serve to have answers provided to that family. It’s this family in this case and, God forbid, that an incident like this takes place again at that hospital. We have to make sure that we are doing the best that we can to provide not only safety for the patients at that hospital but for the staff that work there and for the public that go there.
The answers might not be easy to come by but I think the Minister certainly should order an external investigation into this matter sooner rather than later. To me it’s a shame that it’s come to this. The Minister and the government should have done the right thing: listened to the family. If the family wanted an external investigation into what happened to their brother, their son, they should have got that. They should have got that respect from this government. They didn’t. Again, I’m very glad that my colleague Mr. Abernethy has brought this motion forward today and I certainly will be supporting the motion.
Thank you, Mr. Ramsay. To the motion. Mr. Yakeleya.
Thank you, Mr. Speaker. I want to say a few words to this motion. I want to thank Mr. Abernethy for making this motion on the floor here for discussion. I want to say that I will support the family’s request to look at this incident and ask the government here to strongly consider an internal investigation into what happened. The family does want to know the truth of this and they want to make sure that this type of incident doesn’t happen anymore or doesn’t occur anymore at Stanton Hospital. To prevent it, they want to make sure that no other family could go through this if they can prevent it. That’s what they’re looking for.
I want to ask the Minister and this government here to give serious consideration to help the family, help the brothers, help the mother. It’s a very difficult time for the family, especially for the mother. The mother wants answers. Nothing worse than not getting answers for the mother. There are thousands of questions out there. Give some peace to the family and know that no other family in the Northwest Territories will be going through what the mother’s going through or the family’s going through. There’s no brain here. I think they want the answers. They want the truth. They want to prevent further incidents like this happening at any health centre in the Northwest Territories.
I have not yet heard the reason why government is denying this. I do not know why there were no recommendations coming out from the internal review. Something serious happened at one of our facilities. It’s a publicly run facility for everybody. Surely the family has rights and the people have rights in the Northwest Territories. They need to know it must be very hard on the family.
We should do the right thing, as my colleague for Kam Lake has said, and help this family and get this government to look at the truth of it. Is it us afraid of the truth? Is it the incident the family may be able to deal with the truth? We need to look at it and make sure this will prevent, God forbid, other families to deal with this type of incident with our government.
I want to again thank the Member. I will be supporting this motion.
Thank you, Mr. Yakeleya. To the motion. Mrs. Groenewegen.
Thank you, Mr. Speaker. I’ve listened, with interest, to all the comments of my colleagues and I do appreciate Mr. Abernethy and the support that’s being shown here for the Leishman family. However, I will support the motion because this incident does deserve to be looked into and deserves to have a report provided to the family. But for Member after Member who has stood up and suggested that there has been something untruthful happen here, I resent that. That is pre-empting the results of an investigation. If the Members all on this side of the House already think that somebody has done something untruthful -- I keep hearing it. The truth, the truth. From what I understand from Mr. Abernethy’s statement is the truth, is the patient was brought into the hospital, was put into a room for assessment, the door was not locked, the patient left the room, the patient went into the kitchen, the patient took a knife and injured himself. I understand that is the truth.
Now, what the hospital could have done differently to prevent something like that from happening, I’m not sure we can afford enough guards on the kitchen or on the door of the patients when they come to the hospital to ensure that something like that never happened. How many guards would it take?
I think that the family is deserved respect. I think they deserve full disclosure of everything that happened that day. But I do resent the insinuation of Members on this side of the House who think that this is a cover-up and that something untruthful has happened.
As I have stood in this House and said before, this is not unfamiliar to me. As I just said a few weeks ago, my own sister took a bottle of sleeping pills, went out in a vehicle without a seatbelt on and ran her car into a concrete abutment and killed herself, essentially. It took her five days to die, but she killed herself. That’s a very unfortunate circumstance. I don’t know what could have changed that, but I’m not blaming the health care providers, the psychiatrists, the in-hospital outpatient program she was going into that it didn’t help her. It’s a tragic, tragic thing. It’s horrible that a family has to go through things like this and live with this.
I am going to support Mr. Abernethy’s motion because, as I said, the family deserves the respect and full disclosure on this incident. What we do about that as a government and as a hospital I assure you that people could have come into the hospital with a knife and brought it with them. We don’t have guards there. We don’t have metal detectors. They could have brought a gun into the hospital for all I know. Anybody can walk in the front door of Stanton any time of day or night and there’s nobody to check you or see what you have planned or what’s in mind.
Anyway, I don’t know what the solution’s going to be. I guess we’ll leave that up... I will support the motion but, like I said, I resent the constant reference on this side of the House to something being untruthful in this matter.
Thank you, Mrs. Groenewegen. To the motion. With that, I will allow the mover of the motion closing comments. Mr. Abernethy.
Thank you, Mr. Speaker. I have in front of me here today a letter from Margaret Leishman from Kakisa Lake to the Members of this Legislative Assembly regarding a request for a public, external, independent investigation regarding the incident that took place on November 4, 2009, to Allisdair “Azzie” Murray Leishman. I’m going to read it for you.
On November 4th -- and these are Margaret’s own words.
On November 4, 2009, an incident took place in Yellowknife, Northwest Territories, Stanton Regional Hospital that changed the life of my son Allisdair Murray Leishman. This incident left him severely brain damaged and disabled for life. It is my understanding that the following occurred:
On the day that this took place he was seen shovelling snow in his driveway. It was very cold; at least minus 25 degrees Celsius. Later that day he was seen by another person inadequately dressed for the weather and acting strange. This person knew him and immediately called the RCMP. He later arrived at his cousin’s house. Upon arrival he was inadequately dressed for the weather and in an evident mental state of confusion. His feet appeared frozen and, in the absence of any smell of alcohol, his cousin immediately called an ambulance and then me to inform me to come as she knew instinctively that something was severely wrong.
When he was picked up by the ambulance attendants he was coherent and cooperative when he left with them. He was then taken to the hospital and left in the emergency room receiving area. Next he was put in a room without supervision and, because a door was left ajar, he left. He ran out of the hospital and the hospital staff called the RCMP. They were already looking for him because of an earlier call from another relative who had seen him and were concerned about his safety.
Azzie then returned to where he was on his own and asked for a glass of water. I don’t know which desk they were referring to. When the nurse went to get the water, Azzie apparently left again. He was gone when she returned. The nurse said he was running through the hospital. It is my understanding a few minutes later a Code White and a Code Blue were made over the intercom. He had made his way down the hall and into the kitchen part of the hospital through an unlocked door where they prepare food. There, in front of staff, he was able to obtain a knife and stabbed himself in the chest.
I was told that the hospital medical team was not hasty coming to the aid of my son, who was lying in a pool of blood on the floor in the kitchen. From what I was told and understand, apparently those who could have helped my son that day were in a meeting and did not hear the pages. The person that did answer the page was not part of the medical team. He was a maintenance man. This man took upon himself to get help that was being requested by the kitchen staff. It was also mentioned to me that, unfortunately, there were no security personnel in place that day. Again, this is my understanding and without a public external investigation I will never know, nor will my family know, exactly what took place on the day of November 4, 2009.
Twenty-five minutes after receiving the first call in Kakisa Lake, Margaret’s home community, a second call came. It was the call no family ever wants to hear. I was told my son was on an operating table fighting for his life. And she lives five hours away. He was later medevaced to Edmonton Royal Alexandra Hospital to be stabilized. He was there from the 4th of November to the 9th of December, and was transferred back to Stanton Territorial Hospital in Yellowknife and put on the third floor medicine ward where they treat communicable illnesses.
This was of great concern to me as he was in a very fragile and vulnerable condition. It is my belief that many felt he would not live. Regardless of this, he lived because of his strong desire and will to live. The hospital staff on the medicine ward were plagued with lack of equipment such as proper mattresses to prevent bed sores, broken lifts, no proper wheelchairs to hold his head or to prevent pressure sores on his arms. Also, there was a lack of much needed services on a daily basis that were necessary for a better recovery and they were unable to provide. With the rotation of doctors, lack of service and equipment and the need of consistent care was lacking, his care was sporadic and not consistent. To me it was totally unacceptable. He especially needed specialized care during those first months and he should have been receiving intensive rehabilitation and physical therapy several times a day to maximize his physical mobility. This did not happen.
He was kept here at Stanton Regional Hospital and only when I pleaded to the doctors and made waves was he given one doctor to oversee his care. Further pleading resulted in Allisdair being sent to a rehabilitation centre, the Halvar Jonson Brain Injury Centre in Ponoka, Alberta, where his needs were met. As a result, he made positive progress in a small way and was also in a positive and sound environment. His overall health improved greatly, but only for four months. Much to our dismay, unexpectedly, without consultation with me, he was shipped back to Yellowknife. Sadly, we questioned if this move was more about money than the immediate needs of Allisdair.
When he was transferred back, some of the medications were overlooked and, as a result of a mistake, he almost died. He had some very rough days due to the move. The transfer back to the North was a huge adjustment and impacted him in a negative way. The North, to date, does not have the equipment or services to make his life comfortable or meaningful. His health is not as good as it was when he was in Alberta. On his return he was placed in medicine ward and when they had a room, they transferred him to extended care. I chose this for my son as a temporary placement to get away from communicable illness being treated on medicine as I thought this would be safer for him with a fragile immune system. I was told by hospital staff his needs would be better met there because there were fewer patients. However, I did not understand that the majority of patients there were in palliative care and often have some sort of dementia. To date, things are not a lot better there and my son often seems fearful of others around him.
The whole matter has been devastating. It is a tragedy we feel could have, and should have, been avoided. There are no words that can express to those here in the Legislative Assembly and in this community or country as to the tremendous impact this has had on his daughter, our immediate family and extended family and friends. Nor does it reflect the impact of the fact that this situation has potential on our whole community for the future care of those going to the Stanton Regional Hospital if not corrected.
We are grieving not only for ourselves but for Allisdair’s daughter, known dearly as Boo, who will not know her father as we all have, nor will she have the comfort of being provided for in her lifetime by her father if he remains as he is today. We grieve for this government who has turned a blind eye to the lack of services that should be in place to protect all of us when ill and in need. We grieve the Members of this government who only think in terms of finances. We grieve for the Members of this government who make decisions on incidents while hiding behind closed doors and boards, with no accountability to those they serve.
It is my opinion that there has been no compassion in all of this. The actions around us seem to be made out of fear and about the need to save money. No one here can begin to understand the excruciating pain that this has brought to my heart nor can they know the financial burden it has put before us as a family presently and for the future. I am not a young mother; I am an elder. I may not live long enough to care for my son. Who will do that when I am gone? Who can I count on?
I believe a grave injustice took place at Stanton Regional Hospital the day my son was injured. Further to all of this, I am frustrated by the perpetuation of lack of services and what motivates that. My main and utmost concern is for adequate care and rehabilitation for my son’s brain injury and for care of his physical, spiritual, mental and emotional needs. It is my opinion it is not appropriate that my son is cared for on the extended care unit with dementia patients or palliative care patients. He shows fear there and is unable to protect himself. He is only 37 years old. He is unable to speak or eat but he is very alert and is aware of what is being said and what is going on around him. He is locked in his body. In short, he knows what is going on and his facial expressions tell it all.
I am the first to understand that full recovery may not be possible, but I do understand proper care and money is a factor in all of this. It is the opinion as his mother and legal guardian and that of those who support him, that my son is entitled to the best possible care for his condition. This government and this community owe it to my son to give him that. It is my opinion that the government, without compassion, is not doing justice for the people that they serve. We believe he deserves a chance to develop to his fullest potential. It is in the best interests of this government, monetarily speaking, for him to recover as much as possible. However, I know that this will not happen here at the extended care unit where he is presently placed.
Although I’ve been told an investigation was done by Stanton Regional Hospital’s internal review board, the Morbidity and Mortality Committee, due to legislation passed by the House of legislation, they do not have to reveal to myself, to the public what happened that day. Surprisingly, in light of these committee meetings in regard to the incident with my son, not one recommendation was revealed to me as to how things could have been prevented in an internal review. Personally, I am forced to question this lack of cooperation to prevent it from ever happening again. How is it that even upon request to the ATIPP NWT Information and Privacy Commissioner requesting details I am denied this necessary information to enable me to understand what exactly happened and how. I question what this hospital has to hide and what they fear in releasing information to me. What interest to the public necessitates this kind of hidden information? How can the Stanton Regional Hospital justifiably hide behind legislation from this Assembly? When this Legislative Assembly’s duty is to serve and protect the people of the Northwest Territories, why are they given a place to hide behind an internal secret review board? A public review of a situation like this should, in my opinion, be in the best interests of this country and its citizens. Why shouldn’t the hospital be subject to the full scrutiny of an independent, external public review board just like other organizations that serve the public? I adamantly feel it should be done to help prevent this from ever happening again to anyone.
If my son had died I would have been entitled to more information. However, to make it very clear, his life had been altered forever that day. In fact, his life as we know it did end that day. To date, every avenue that we have tried has fallen on deaf ears or they have either replied with placations or noncompliance. In one way or another, including the Department of Justice, the Workers’ Safety and Compensation Board and the Stanton Regional Hospital have not provided any comfort as to how this will never have the possibility of ever happening again.
As his mother and legal guardian, our family demands that we be given answers as well as accountability to the public. We further demand that his care be of the utmost importance and be met. I assure that his family and supporters will not cease to stop asking until we receive full explanation about what happened and how he can receive the best possible care. I am requesting that all information including the release of all files, video tapes, security reports and any other information be opened and provided an external public investigation.
We are also requesting that the Legislative Assembly will recognize and make concerted effort to meet Allisdair’s needs and to be placed where he can receive proper rehabilitation care. Proper care is necessary to enable Allisdair to reach his fullest potential. We request this in order to know exactly what did happen on November 4, 2009, and to prevent it from ever happening again. Mahsi cho. Margaret Leishman.
This is also cc’d to anyone and everyone who has an interest in justice being served.
