Whistleblower urges more medical inquests

An ex-coroner has claimed that the public is being denied information about deaths caused by medical mistakes. Kathleen Stephany, formerly the coroner in charge of special investigations, told the Georgia Straight that this is because the office of the chief coroner won't order inquests into medical-related deaths.

Stephany said that she was fired and her former department of medical investigations, which once had 12 employees, was eliminated in 2003 with "no real justification". Since then, the Coroners Service of British Columbia hasn't ordered a single inquest into a death linked to negligence by a physician or hospital.

"How can the care providers change their practice of care if they're not even aware what they did wrong?" Stephany asked.

Chief coroner Terry Smith was away, and nobody else from the office of the chief coroner responded to Stephany's allegations by deadline. The coroners service reports to John Les, Minister of Public Safety and Solicitor General. Stephany has filed a lawsuit in connection with her dismissal; she declined to discuss this litigation with the Straight.

The last medical inquest was held in December 2001 into the death of Christena Constible, a 20-year-old Abbotsford heroin addict who died of a methadone overdose. The coroner's jury determined that the death was caused by respiratory failure from a mix of antidepressants and methadone that were prescribed by her physician. Earlier this month, Dr. James Swanney, now a resident of Scotland, was charged with criminal negligence causing death.

The Straight reported last month that there were 14 medical inquests held while the NDP was in power from 1991 to 2001. Coroners service spokesperson Tej Sidhu claimed last month that a judgment of inquiry report, which is written by a coroner after an investigation, achieves the same result as an inquest.

Stephany, a registered nurse, said the public can only obtain a judgment of inquiry report if they know the dead person's name. She said that in an inquest, a jury examines evidence, hears testimony, and the public may attend hearings. "Inquests are a very good venue for educating the public," Stephany said.

Dr. Morris VanAndel, registrar of the College of Physicians and Surgeons of British Columbia, told the Straight that the coroners service sends about 20 reports of medical-related deaths per year to his office. He declined to comment directly on Stephany's specific allegations.

"We have a very good relationship with the coroners office," VanAndel said twice during an interview.

VanAndel acknowledged that individual coroners and coroners' juries sometimes draw conclusions that are "not medically valid", even though they're acting in good faith. "Coroner's juries, for example, are lay folk who look at a particular case and make recommendations, which may or may not be doable," he said.

In 2004, the Canadian Medical Association Journal published a report that suggested medical errors are quite commonplace. It estimated that 7.5 percent of people admitted to Canadian hospitals in 2000 suffered an "adverse event", which was defined as anything causing death, disability, or an extended hospital stay; almost 40 percent of these were preventable. The study also estimated that there were between 9,250 and 23,750 "preventable deaths" in Canadian hospitals that year.

Stephany also claimed that the coroners service has cut back on investigations of child and adolescent suicides since Vancouver Mayor Larry Campbell stepped down as chief coroner in 2000. Stephany, who is doing an academic dissertation on suicide, alleged that Campbell wanted every child and adolescent suicide investigated, unlike his successor, Smith, a former RCMP superintendent.

She said that since her department was eliminated, the office of the chief coroner has hired two people to work in the medical-investigations department: an experienced coroner with a medical background, and a junior medical investigator with laboratory experience.

The spring edition of the College Quarterly newsletter, which is distributed to doctors, mentioned an anonymous coroner's conduct in connection with the sudden death of a 72-year-old woman. The coroner persuaded an unnamed surgeon to sign a death certificate citing cardiac problems as the cause of death. She had recently undergone an abdominoplasty and liposuction in hospital.

According to the College Quarterly, the woman had a minor ECG abnormality and mild hypertension: "Since the death occurred two days after surgery, the surgeon had no way of really knowing the cause of death."

VanAndel told the Straight that the physician should not have signed the death certificate. He added that the surgeon was acting in good faith and was given "remedial instruction". His name has not been released. VanAndel added that he discussed this case with the chief coroner and would not criticize the coroner's conduct.