The Black Rod

The origin of the Usher of the Black Rod goes back to early fourteenth century England . Today, with no royal duties to perform, the Usher knocks on the doors of the House of Commons with the Black Rod at the start of Parliament to summon the members. The rod is a symbol for the authority of debate in the upper house. We of The Black Rod have since 2005, adopted the symbol to knock some sense and the right questions into the heads of Legislators, pundits, and other opinion makers.

Location: Winnipeg, Manitoba, Canada

We are citizen journalists in Winnipeg. When not breaking exclusive stories, we analyze news coverage by the mainstream media and highlight bias, ignorance, incompetence, flawed logic, missed angles and, where warranted, good work. We serve as the only overall news monitors in the province of Manitoba. We do the same with politicians (who require even more monitoring.) EMAIL:

Wednesday, January 07, 2009

#38. Incompetence killed this woman at Seven Oaks General Hospital

The day after Christmas 2007, a woman was taken to Seven Oaks Hospital.

She was 89, approaching the end of her life, and her family couldn't care for her at home anymore.

Their only choice was to take her to the hospital where she would be looked after while they tried to find a nursing home for her. They assumed that a hospital was a safe place for their elderly mother, a place she would get the proper medical care she needed in her final days, and that she would be treated with dignity and respect.

It was the biggest mistake of their lives.

The woman was admitted to palliative care on the fifth floor of Seven Oaks Hospital. Her children visited her daily.

The first time they noticed the bruises on their mother they naturally were alarmed.

Imagine what they felt when they were told that severe bruising was considered a normal part of life for the elderly at Seven Oaks General Hospital.

Old people are frail; they need help walking, help going to the bathroom; without that help, they can fall. And repeated falls, with the bruises they cause, are to be expected, the kind nurses at Seven Oaks told the woman's family.

The hospital has a no-restraint policy. And the nurses are just too, too busy to assist all the old people who need help. They just weren't too busy to attend the pre-strike meetings which frequently denuded the ward of any nurses.

The shocked family redoubled their visits, staggering them through the day and evening, staying longer each time.

But the bruising continued and soon her whole body was covered in blue. The family began taking pictures to document their mother's suffering. And after each fall there was another excuse which usually boiled down to 'not enough staff.'

Hire a private nurse, they were told.

One evening, as one visiting daughter was about to leave, she pleaded with the nurses to put her mother to bed. It was late, she was sleeping in her chair. The nurses refused. It wasn't time for bed, they said. They would keep an eye on her.

The next day the daughter noticed something unusual about her mother.

A bone near her neck was obviously sticking up where it shouldn't. She called a nurses aide. Hmm, said the aide, it looks like she's got a broken collarbone.
She probably broke it when she fell under the watchful eyes of the nurses a half hour after the daughter left the night before.

The aide called a nurse. The daughter insisted her mother get an X-ray. I'll ask the doctor, said the nurse--- TOMORROW, when he comes in.

So the bruised and battered 89-year-old woman suffered with a broken collarbone all night until the doctor saw her. She's got a broken collarbone, the highly educated medical practitioner announced when he finally examined her.

The family's agony matched their mother's. One day a daughter arrived to find her mother almost naked in bed, her bedclothes pulled up around her shoulders, freezing, helpless, no blanket and no dignity.

They couldn't imagine how it could get worse.

Then, one day in January, one of the daughters noticed that the curtains were drawn around the bed nearest her mother's and a hand-written sign had been pinned on.

"Contagious. MRSA." read the sign.

The daughter knew what 'contagious' meant. She needed a nurse to tell her what MRSA was -- the antibiotic resistant Superbug ( in this case more properly referred to as HA-MRSA, as in hospital-acquired.)

Why, she asked, was a woman with a contagious infection being held in a room with five other patients? Shouldn't she be in isolation?

Oh, the isolation ward is full up and there's nowhere else to put her, a nurse said.

And anyway, she's only suspected of having the Superbug. The tests aren't in yet. The family kept visiting their mother until one day the patient behind the curtain disappeared.

The tests were in. She WAS contagious. Who would have thought?

You can guess the rest.

Everyone in that room came down with the Superbug, including the 89-year-old woman.

As her lungs filled with water and she fought for breath, more and more people on the ward were testing positive for MRSA,
until one day the hospital closed off the entire ward.

In February, 2008, the 89-year-old woman mercifully passed on. She was finally free of the tortures of staying at Seven Oaks Hospital.


On Tuesday, the Winnipeg Regional Health Authority spewed out a barrage of numbers.

* They reviewed all 2,577 deaths in city hospitals last year.
They flagged 60 as "worrisome."
* They deemed 37 were "critical incidents
", doctor-talk for
'the patient died because of something we did or did not do for him/her.'

We don't know if the 89-year-old woman made the health authority's Top Forty. We don't think so.

Her (mis)treatment was considered so normal, we don't think anyone at Seven Oaks even put her on their "worrisome" list.

She was old. She was dying. She fell. It happens.

It's not our fault she caught the Superbug. Oh, yeah, maybe it is our fault she caught the Superbug.

No, it's her fault. If she was healthier she would have fought off the infection. Right?

File closed.

Except it's not.

37 is a number.
60 is a number.

And each time you read those numbers, remember that they stand for people who suffered needlessly in hospital and died because the system failed them.

And remember the treatment inflicted on an 89-year-old woman at Seven Oaks Hospital.

And ask yourself -- how bad does the system have to get before your mother's case warrants the attention of the health officials?

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