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.