Kirkland and District Hospital Scandal
Gross medical negligence: Meningitis : IMC Victoria
KIRKLAND LAKE, ON
Missed meningitis is one of the most frequent lawsuits against emergency physicians, leading to large claims. Therefore, a high index of suspicion is needed and accurate charting of pertinent positive and negative findings is crucial.









Staphylococcal Meningitis





Less than 16 hours after Arlene Berry's admission to the Kirkland and District Hospital on May 23rd of 2000 her family was notified that she had just died meeting brain death criteria. She was administered Stemetil for "control of nausea". The record documents a PRECAUTION for a "RESISTANT BACTERIA". Stemetil was contraindicated to CNS depression, including an untreated diabetes and toxic conditionconsistent with infectious disease emergencies, at the onset. No diagnosis was made, and her physician failed to attend - he treated her over the telephone, unseen. She had a "resistant" bacterial infection. Stemetil exacerbated her condition resulting in sepsis followed by spontaneous meningitis. She died unnecessarily, the victim of a drug induced nightmare of unprecendeted magnitude.

CAVEAT:
Eleven percent of mass lesions in cancer patients are not metastases; mass lesions that can masquerade as brain metastasis include abscess (20%) and granuloma (less common and mostly associated with mycobacterial or fungal infection). The commonly observed deficits observed in CNS infection include weakness on one side of the body (hemiparesis), impaired speech production (dysphasia), visual field deficits (may or may not be present), and an inability to smoothly coordinate muscle movements, such as during walking (ataxia). Patients with a dioagnosis of primary or metastic brain tumor(s) associated with a CNS event should have a meticulous review of their history for possible iatrogenic causes.


The Stated Case

Arlene Berry developed "flu-like" symptoms suggestive of gastrointestinal illness within two weeks following Radiation Therapy. She died 10 days later.

The following information is taken from the medical record of the deceased, Arlene Berry who died suddenly and unexpectedly at the early age of 41, following her admission to the Kirkland and District Hospital on May 23rd of 2000.

Some 16 hours after the patient's admission to Kirkland and District Hospital on May 23rd of 2000 the patient's family were notified that Arlene Berry had just died meeting brain death criteria. No autopsy was done. A subsequent request for a formal inquest was denied.

The Regional Coroner, Dr. Barry McLellan concluded that Arlene Berry had died of "natural causes" due to "multiple metastatic brain tumors". The medical record for May 23rd and 24th of 2000 however, tells a very different story.

CAVEAT: Eleven percent of mass lesions in cancer patients are not metastases; mass lesions that can masquerade as brain metastasis include abscess (20%) and granuloma (less common and mostly associated with mycobacterial or fungal infection), Such infections can lead to certain inflamatory lesions, including meningitis which causes swelling of brain tissue and hampers blood flow, causing stroke symptoms that include paralysis. Some of them abscesses, may resemble and mimic brain tumor. When left untreated, inadequately or improperly treated meningitis of any etiology, but particularly pyogenic and granulatomous forms of meningitis may lead to widespread distruction of the brain.

Toxic shock syndrome accompanied by spontaneous meningitis with a sepsis-like picture is the highlite of this investigation.




Staph meningitis is an infection caused by the bacterium Staphylococcus aureus, also known as S. epidermidis, which causes an inflammation of the membranes surrounding the brain and spinal cord. In the very early stages of meningitis, it can appear like the flu. Meningitis caused by Staphylococcus aureus is an unusual illness that is often associated with bacteremia, or contiguous infection. Until recently, most cases were caused by methicillin-susceptible strains, but there are also reports of methicillin-resistant Staphylococcal aureus strains causing meningitis. Meningitis can also mimic the flu.


Symptoms resulting from brain abscess depend on the size and the location of the infection. Only 50% of patients with a brain abscess present with a fever and, when present, fever is often low-grade. In this case a low grade fever is confirmed. A brain abscess can also present with symptoms typical of any space-occupying mass within the substance of the brain (a focal neurological deficit). The commonly observed deficits include weakness on one side of the body (hemiparesis), impaired speech production (dysphasia), inability to smoothly coordinate muscle movements, such as during walking (ataxia), and visual field deficits may or may not be present depending on size and location of the abscess.

Multiple brain abscesses act as an intracranial expanding lesions characterized clinically by progressively severe intractable headaches that may fluctuate in intensity with evolution. Most patients will have headaches ranging from mild to severe. Constitutional symptoms are often mild, and fever is present only in about 10-20% of cases; however, weight loss is common.

Abscess of the brain can be an extension of a pre-existing or extremely fastidious bacterium in extra-intestinal viscera, or may be a direct hematogenous extension from the colon. Most often, brain abscesses are the result of mixed infections, typically with anaerobic bacteria in which Staphylococcal aureus is a common bacterium.


Irreparable harm can befall a patient when IV infusion is administered too quickly or too slowly. N-6 at 2330 hours documents "IV infusing well". N-4 documents incontinent blood tinged urine at 0305 hours. Incontinence is marked by
"impaired water excretion" resulting in "decreased urine output" due to "loss of bladder control," and is a very serious side effect of phenothiazine type drugs, eg. Stemetil/ prochlorperazine, and possibly first sign of a drug reaction.

A decreased urine output in the presence of continued water intake is the hallmark of "hyponatremia". N-3 documents a "large amount of dilute urine" at 0330 hours that is consistent with "fluid overload" due to overzealous IV infusion, which is a common feature of "hyponatremia". Hyponatremia is the result of "water intoxication". It is the opposite of dehydration. Hyponatremia is the most common electrolyte disorder which can result in brainstem malfunction due to cerebral edema.

Neutrophilia was first noticed in patients with gram negative sepsis and endotoxemia.
Endotoxins and other bacterial products appear to cause direct cellular injury while elicitinf cytokins that attract neutrophils which enhance hypersensitization, brain edema, and hypercoagulability with vascular inflamation from endotoxin that is a hallmark of the inflamatory effect in endotoxic shock. It is well described in the scientific literature that the presence of endotoxin is common in rapidly dividing bacteria at sites of localized infection and abscesses in the gut.







These are the facts:


On or about March 16th of 2000, Arlene Berry returned to Timmins where she underwent followup study and testing (at the same hospital), consisting of a CT scan, with mediastinoscopy and mediastinotomy as part of her post-operative examination. Following that testing, Arlene confided "I don't have AIDS or brain tumors, or anyting like that, but I might have a cyst". She also stated "I might have an infection", and also that "some people could be carriers and not even know it".

From that focus of a suspected infection, we now have an idea on what to look for, beginning with.a cyst, possibly in the pathogenic phase of abscess formation.

The cyst is a "suitcase" for infectious material inside. Most infected cysts, called abscesses contain the normal bacteria that are found on your skin. From this focus of infection the organism can be disseminated hematogenously even from the smallest abscess. Cysts of the central nervous system (CNS) are usually benign. If a cyst has the appearance of a small enhancing ring, differentiation from other granulomas such as tuberculoma, or from cysticercosis in a degenerating stage, or from abscess is impossible and a biopsy. is necessary.

On the second and third week of May of 2000 Arlene Berry was presumed to be suffering from a bout of the "flu" that is consistent with gastrointestinal illness. Her constilation of symptoms were that of a "flu-like illness" , marked by general malaise , loss of appetite, nausea, vomiting, and stomach pain accompanied by weakness (tired feeling), chills, low-grade fever, with evidence of brain involvement indicated by lethargy, and headaches that had become progressively severe.

A-23 of the medical record documents a "slurred speach" (dysarthria), a sign of "toxic condition" in which vertigo is a prominant finding in the setting of hydrocarbon toxicity, an invariable accompanyment of pulmonary infection, such as seen in cases of pneumococcal bacteria, including bacterial myocarditis and/or cardiomyopathy. A slurred speach is a most prominant finding in Toxic Shock-like Syndromes.

The medical record at A-22 of documents a "sedated" Cognative Perceptual Pattern (evidenced by a check mark in the lower left heading), a sign of cognative impairment that is a clinical feature of an altered mentation (altered level of consciousness or evidence of toxic condition, or coma) - goes to evidence of toxic condition.

OP-54 of the record documents a "haggard" appearance that is a an invariable accompaniment of a toxic or sedated appearance The same record documents that for "2 weeks had the flu". An accutely ill toxic appearance can be due to pulmonary toxicity secondary to a coexisting infection or toxic condition, which may suggest a lack of adequate oxygenation, the result of poor oxygen exchange.

Toxic condition denotes a state of being poisoned. No toxicology screening was done.

Further, patients who present with CNS effects due to pulmonary toxicity can be the result of hydrocarbon aspiration leading to hypoxia, leukocyte infiltration, and vascular thrombosis. Initial effects are similar to disinhibition observed in patients with alcohol intoxication, marked by dizziness accompanied by an indistinct or slurred speach, the result of poor oxygen exchange. A narcotic-like depression marked by a haggard appearance may also be observed. In some cases, euphoria may develop, as in alcohol or narcotic toxicity. Eventually, lethargy, headache, obtundation and coma follow. Seizures are uncommon but are believed to be due to hypoxia.

Lack of adequate oxygen due to poor oxygen exchange causes hypoxic damage to the nervous system because tissue cannot utilyze oxygen since there is a toxin or toxins present that prevents oxygen uptake by the cells. Thus the patient becomes obtunded. This is usually what happens in patients with Pneumoniae, which can be very serious because it directly interferes with your body's ability to exchange carbon dioxide and oxygen. Organ failure results from inadequate organ oxygenation due to poor perfusion.

Most people with pneumonia get better with antibiotics. Untreated, inadequately or inappropriately treated people can rapidly develop complications such as sepsis (blood poisoning), meningitis, and lung failure.

Klebsiella pneumoniae, a pathogenic "encapsulated soft tissue" Gram-negative bacillus, has gained an increasingly important role in adult meningitis both in community-acquired and hospital-acquired settings Patients with hospital-acquired *K. pneumoniae meningitis are reported less likely to have neck stiffness. Pneumococcal bacteria produce very potent toxins, and this is why pneumococcal meningitis is more likely to kill or cause brain damage than other types . Often, however, pneumococcal infection can appear first with a varying degree of fever with a very high white-blood-cell count (where almost all of the white cells are neutrophils or bacteria-fighting cells) and no obvious site of infection.

A-6 documents "This patient has come in with headache, vomiting, increasing head pain and some difficulty ambulating (ataxia) due to dizziness". The same record documents "mild diffuse weakness", which may also suggest a mild form of widespread illness, or can be the result of a "systemic infection".

Dizziness, a sign of poor ballance and uncoordinated movements is a common feature in toxic ataxia, but there were definite upper motor neuron signs in the legs causing this patient to pull to the right when walking, as evidenced by family and friends - "sedated patients are freequently ataxic".
CAVEAT: Dizziness, lethargy and ataxia have also been cited with adverse events of medications.

The commonly observed deficit in this case was one of weakness on one side of the body, such as seen in hemiparesis, (unilateral limb ataxia), vascular limb ischemia, or limbic encephalitis, the result of CNS infection. Further. hemiparesis or unilateral limb ataxia is almost always an indicator of focal posterior fossa abnormality, such as infarct, demyelination, or abscess.

A-5 documents the patient's presenting complaint as "headaches accompanied by severe stomach pain". The same record documents "abdominal pain ongoing for 2 weeks". Severe stomach pain is the result of alterations in GI function which can rapidly lead to gastric rupture, or perforated rupture. Acute onset of severe pain within the abdominal cavity requires immediate evaluation and diagnosis. There is nothing on record to suggest that the "severe stomach pain" had ever been adequately addressed, at that time or at all. A patient who presents with a "headache" and "severe stomach pain" concurrent with "UTI" and an "accutely ill toxic appearance" can suggest a "severe systemic infection" of "gut origin" as to mandate treatment in an Intensive Care Unit.. In this case the patient was simply treated as "routine".

Leukocytosis is a prominant finding in intestinal obstruction and strangulated hernia. We have a confirmed "leukocytosis"..


A-1 documents "She had been into the Emergency Department several times on the days before being admitted with a variety of complaints. This time she presented with headaches and severe stomach pain, vomiting, blood in her urine", to rule out delay by the patient in seeking treatment. Worthy of mention is that NO bloodwork was done on any of these visits.

CAVEAT: Multiple medications, restricted diet or poor nutrition causes gastrical intestinal lessions to gastrointestinal bleeding, which can become a breeding ground for infection.

Stomach pain concurrent with nausea and vomiting points to the abdomen as the source of the problem. History of medications suggest a number of medications which reduce gastrointestinal motility . MS Contin, Statex, Tylenol, Aspirin . Ciproflaxin (see Rx list): Compare Morphine with Ciproflaxin citations.

OP-53 documents "Here one week ago for UTI. Last period on 6th of May", can infer onset of menstral period closely related to illness in which symptoms result from production of toxin suggestive of S. aureus. Case reports cited primarily in women having period in which a blood-soaked tampon may provide an excellent breeding ground for bacteria. Staphylococci aureus bacterium, which can lead to staphylococcal septicaemia (blood poisoning, presumably the result of microabscesses in the kidney), can suggest clinical feature of the Toxic Shock Syndrome.

OP-54 documents a recent history of hematuria (blood in urine) for 3 days and a prescription for Ciproflaxin for "urinary tract infection". Cipro is an antibiotic indicated when "superimposed bacterial infection" secondary to a primary infection is present ie. ulcerative colitis (from radiation toxicity), for example. Rx Cipro goes to evidence of possible mixed infection.


Ischemic colitis is injury of the large intestine that results from an interruption of its blood supply. Further, low blood pressure, congestive heart failure, or diabetes; and abdominal radiation exposure, including ischemic colitis are all known causes of toxic megacolon.


Patients with toxic megacolon appear septic with lethargy; chills; tachycardia; and increasing abdominal pain.


BACTERIAL OVERGROWTH with toxic megacolon are at risk for perforation.
OP-54 of the record documents "large blood trace leukocytes", suggestive of "bacterial overgrowth".


Biliary tract infection is a common source of pyogenic liver abscess. COMPARE: Infections and Intoxications of the Intestines



CAVEAT: Ciproflaxin can potentiate existing renal insufficiency, and may enhance concomitant drug toxicity with enhanced potential for ototoxicity. Compare Ototoxicity in Constipation. See Morphine citations.

A-8 of the record documents "She had presented to the Emergency Department several days ago with vomiting and it was thought she had a UTI. She was given antibiotics and sent home", to rule out delay by this patient in seeking treatment.

According to the record, on May 23rd of 2000 "she returned" to the emergency department "with the very same complaints", as evidenced by the record at A-6. Submit that rapid evolution of illness or patient return within 24-48 hours suggests the severety of illness as to "mandate treatment in an intensive care unit". According to the record, Arlene Berry was simply treated as "routine".

The same record documents that for "two weeks" she had the "flu", including "migraines" (intractable headaches) which had "stopped this week" that can be explained by the antibiotics she had been given on the days before, with a reduction of her headaches seen with a "causal relationship to toxicity and infection". This is a classic feature of CNS infection.

OP-54 of the record documents "large blood trace leukocytes" what I take to be a "leukocyte estrace", a screening test used to detect presence of "bacteria in large numbers", ie., BACTERIAL OVERGROWTH, especially in UTI.

CAVEAT: Symptomatic urinary tract infection associated with inflamation and a urine WBC count higher than 8/ml can suggest Interstitial Cystitis in which pyuria leukocyturia (pus cells) is a prominant finding. Urine is usually hazy (purulent) on inspection. It mimics UTI, but bacterial cultures are negative and it does not respond to antibiotics, which cannot be ruled out. We have a confirmed WBC count that is substantially higher.

Further, submit that progressive headache associated with flu-like symptoms suggest clinical features of meningitis, cerebritis, or brain abscess.

OP-53 documents a history of "bloody bowel movements" for "4 days", a sign of possible diverticulitis, a condition associated with severe constipation in which passage of bloody stool is a prominant finding with concealed hemorrhage. There is nothing on record to suggest that a Stool O&P (ova and parasite) test or Stool Culture Test was ever done. The patient had been given scripts for constipation, evidenced by her Rx list, and we do know that she required extra laxative and tap water douches to help assist with stool evacuation due to very little action from the bowels, notwithstanding a great desire on several attempts of straining to evacuate stool. The symptoms were quite mild initilly, with constipation and diarrhea alternating, progressing to severe constipation, with an extra large difficult bowel movenent.on at least one occassion, giving rise to bloody bowel movements.

Caveat: Septic shock is often preceded by severe infection, often of the genitourinary or abdominal system. Septic shock due to bacterial translocation across the gut wall or due to local complications such as perforation or strangulation may also be caused, which in this case cannot be ruled out (We have a confirmed septic condition).

Abdominal pain can also be the result of "intestinal ischemia". The hallmark of intestinal ischemia is abdominal pain. Intestinal ischemia occurs when blood supply to digestive system is reduced. Intestinal ischemia due to mesentaric venous thrombosis is caused by a blood clot blocking a vein in the intestines which compromises the blood supply to the intestines giving rise to serious infection which can result in gangrene and tissue death leading to sepsis, or septic shock.

Other causes of intestinal ischemia include low blood pressure, congestive heart failure, and certain medications. Signs and symptoms of intestinal ischemia include abdominal pain, nausea and vomiting, and bloody stool. Undetected and untreated, intestinal ischemia can be fatal. The very same symptoms may also be suspicious for bowel obstruction, diverticulitis, and peritonitis. Clinical signs of biliary peritonitis include abdoninal pain, nausea and vomiting.

Ascites is an excessive fluid in the membrane lining of the abdomen, the peritonial cavity. Most cases of bacterial peritonitis occur as a result of ascites.

Leukocytosis is a prominant finding in intestinal obstruction and strangulated hernia. We have a confirmed Leukocytosis.

Once a patient develops severe constipation with a colon full of faeces, patient will lose their appetite and may even start vomiting. Lethargy and dehydration usually follows. If the constipation is secondary to another disease process, other symptoms relating to the primary disease may also be noticed. Other conditions may arise which cause the same symptoms to overlap.

CAVEAT:Constipation, fecal impaction and bowel obstruction are common problems for oncology patients. Further, interference with blood flow to the colon is the cause of ischemic colitis. The disorder mainly affects people over 50, but can affect anyone with a history of severe constipation.

Obstruction is blockage of the inside of the intestines by an actual mechanical obstruction. As blockage occurs gas and air distend the bowel proximal (closest) to the blockage. As the process continues, gastric (stomach), bilious (bile from the liver used in digestion) and pancreatic secretions (secretions from the pancreas used for digestion) begin to form a pool. Water, electrolytes and proteins accumulate in the area. This pooling and bowel distention decrease the circulating blood volume and the blood supply to the bowel tissue.

Toxic megacolon is a life-threatening complication of intestinal conditions, characterized by a very dilated colon, abdominal distention, and sometimes fever, abdominal pain, or shock. Vascular lesions of the intestine or colon can lead to gangrene and peritonitis

Strangulation of a bowel segment may cause necrosis (death of the tissue), perforation (a hole), and loss of fluid and blood. Since intestinal contents can't go downstream from the stomach, nausea and vomiting usually follows.



The severity of the pain usually far exceeds the physical findings early in the process. The WBC count may rise to 20,000 or 30,000/µL. Mesenteric venous thrombosis can be idiopathic.



Bowel obstruction secondary to constipation. .......... * Diverticulitis secondary to constipation is often marked by passage of bloody stool due to concealed hemorrhage. Diverticulae can rupture into the abdominal cavity giving rise to abscess formation. CAVEAT: The CBC may reflect peripheral leukocytosis with neutrophilia, indicative of infection. We have a confirmed leukocytosis with neutrophilia.

The majority of patients with *diverticula are asymptomatic. Peritonitis secondary to constipation or bowel obstruction.............*Evidence of peritoneal signs should immediately raise the possibility of fulminant colitis or *toxic megacolon and I will search toxic megacolon and see what turns up, but bowel obstruction in this case is a sure bet..

N-5 documents a "large queery bloody emesis reddish brown liquid" at 0255 hours (0245 hours written-over), which may suggest the presence of dark digested blood that is consistent with damage to the gut lining (blood turns brownish from lack of oxygen) possibly due to a stomach ulcer bleeding into the gut, or perhaps due to an obstruction related rupture. N-3 documents "suctioned orally thick secretions" at 0220 hours that IS suggestive of a more significant "backup of intestinal material" from the gut. The same record documents "suctioned down ET tube several times for small amount of brownish mucous" at 0330 hours.

CAVEAT: GI bleeding is a potential medical emergency. There is nothing on record to suggest purging of blood from the GI tract.

The Outpatient Record at OP-53 is totally devoid of annotation with respect to patient's bowel routine and urinary elimination pattern for toileting, marked by a complete abscence of nursing care plan, as further evidenced at A-21, and I find this to be significant in terms of quality of care. In the alternative it can infer deliberate omission.

The record at N-10 documents the patientÕs level of care as
routine, which showed little or NO concern for this patient. What I take to be a continuation of the same record at N-11 documents "vomiting, lung CA". There are NO further entries on that two page assessment. From that record it seems clear that NO follow-up was done.

Arlene Berry was admitted to the Kirkland and District Hospital on May 23rd of 2000. According to the record, she was admitted at 1845 hours by Dr. Spiller, the emergency physician. At the time of her admission, "her blood pressure was 115/70, with a pulse of 79 and regular" and a "respiration rate of 18". According to the record at A-6 , she was showing signs of "mild diffuse weakness:, otherwise she was found to be "allert and oriented", with "no focal deficits", which contradicts the outpatient record and shows incompetence on the part of the emergency department physician.

N-6 documents family in at 1915 hours. On seeing her, she was still responsive at that time and in fact she was able to reach and use for herself a kidney basin at her bedside table as she occasioned to vomit more of the usual flu-like "yellowish fluid" that she had done so many times on the days before. The record documents an emesis of upwards of "100 cc yellowish fluid", what is bilious vomit, also called bile.

CAVEAT: Bilious vomiting is the hallmark of suspected "intestinal obstruction".

The same record documents patient stated that she was then "feeling a little better", whereupon she was provided a cool cloth by one of the nurses and assisted to bed. The same record documents the patient complained of being "cold" (she had the chills (chills is a prominant finding in toxic shock-like syndromes), and so the nurses provided her with extra blankets. She also stated that she was "very tired".


N-9 of the record documents an "INFECTION CONTROL PRECAUTIONS" for a "resistant bacteria", evidenced by a check mark in the box. Healthcare providers should always be aware of a missed or changing diagnosis with oncology patients. Notably the particulars with respect to the bacterial identity of the resistant bacterium are omitted. Apart from that caution , NO precautions are reported because NO precautions were taken by any of the healthcare providers. It also seems clear that patient was NOT adequately educated or instructed to be on the alert or to quickly report GI illness (flu-like). Supportive Care & Symptom Control Regimens are absent, or have been omitted.

The facts of the case suggest that the healthcare providers who attended to Arlene Berry had been aware of a resistant pathogen, possibly of low virulance, associated with an occasional rash and disseminated disease (that can rapidly become pathologic if left untreated, or not treated in a timely manner), and which was was likely to affect a patient with a weakened or impaired immune function, but "failed in their duty of care" to take the necessary patient safety precautions, or any precautions whatsoever. Caveat: Pathogens with low potential for virulance can give rise to life threatening infections in the setting of impaired immune function.


A-12 documents a Physician's Orders for the concomitant administration of the following medications: Stemetil , MS Contin, Statex and Gravol, all of which are contraindicated to toxic condition, and to co-administration with each other = POISON. The signature on the order appears to be that of Dr. E. H. Jordan. Compare Anticholinergic syndrome - Anticholinergic Toxidrome. (Stemetil and *Gravol don't mix; Stemetil (prochlorperazine), and particularly morphine effects motility with constipating properties which can enhance ototoxicity, notwithstanding anticholinergic effects of mixing prochlorperazine (Stemetil) and dimenhydrenate (Gravol) concomitantly or concurrently - is a recipe for POISONING and I will gather the necessary citations to prove wanton and reckless disregard for patient safety.


SEARCH: *pneumococcal bacteria with S. aureus (mixed infection), "resistance" is a factor.


CAVEAT: Multifocal neurologic deficits can suggest a neoplastic etiology, but multiple brain abscesses may not cause any focal deficits to suggest their presence. The etiology ranges from acute afebrile disease to toxic condition to idiopathic.

Complications such as meningitis or brain abscess lead to toxic symptoms of headache, malaise, and fever may or may not be present.

Rx for "rash" given by oncologist during course of Radiation Therapy.

N-6 documents telephone orders received by the hospital from Dr. Jordan at 2030 hours on May 23rd for the drug Stemetil - 10 mg by IV 4 times daily for "control of nausea", given by the RN, as evidenced at A-11 of the medical record. Stemetil is an antipsychotic-antiemetic drug to be used with caution. Further, it seems clear that when antipsychotic medications are prescribed for "control of nausea", the underwriter is usually dealing with a significant underlying "psychotic disorder".

CAVEAT:
Stemetil is contraindicated to emesis in coma, trauma, toxic syndromes and in anyone with impaired airway reflexes and can result in POISONING. The antiemetic action of Stemetil may "mask the signs and symptoms of drug overdosage" and may "obscure the diagnosis and treatment of other conditions".


Page3


The duty placed on a doctor is to exercise care in all that is done for the patient which includes attendance, diagnosis, referral, treatment and instruction. It seems clear from the record at A-3 that this was not done and it is also clear that the physician elected to alienate and treat this patient unseen, at arms length, without his attendence and without any review of the patient's files.

CAVEAT: A physician's failure to attend, or to examine the patient, arrange follow-up, keep adequate records, or act with or convey the necessary degree of urgency is not without legal liability (Legal Liability of Doctors and Hospitals in Canada).

A-3 of the record, what I take to be the physicianÕs diagnostic sheet, is nothing more than a blank form. From that omission, it seems clear that NO diagnosis or differential diagnosis was made at that time, or at all. Further submit that nothing was entered because nothing was done.

A typical single dose of Stemetil for a small woman with a low body weight is 5 mg. According to the hospital record Arlene Berry was given 10 mg x 4, double the normal dose for her size and body weight.

The anti-emetic effect of Stemetil undergoes metabolism in the gastric mucosa and on first pass through the liver where it enters the enterohepatic circulation and is excreted chiefly in the feces.


This could be significant as regards potentiation of ototoxicity and I will search it out further. try 1 )ototoxity in constipation; 2) bowel obstruction; 3) billious vomit and see if there's a connection.


Toxic doses of Stemetil can lead to changes in the blood-brain barrier (BBB), allowing infectious agents to gain entry to the brain where they invade the central nervous system and produce lethal CNS (brain and spinal cord) infection.

Stemetil is highly bound to proteins in blood (91-99%) and has a duration of activity from 4 to 6 hours. Caveat: Blood borne infection or meningocci in the blood "lyse" easily. Allowing a pathogenic bacterium to cross the placenta can and will invariably also cause meningitis. Bacterial Meningitis is an inflammation of the meninges secondary to bacteremia. It occurs when a foreign pathogen invades the subarachnoid space and populates the CSF, Compare: Bacterial Meningitis with Drug-induced Aseptic Meningitis (DIAM) citations

Septicemia occurs when organisms spread to the bloodstream from a focus of infection elsewhere. Sepsis occurs as a result of a toxic condition resulting from septicemia. Sepsis involves the spread of germs throughout the body's blood and tissues and denotes presence of microorganism actively growing in blood.

Stemetil enhances permeability of the blood-brain barrier and crosses the blood-brain barrier, breaching BBB integrity, thus allowing penetration of normally excluded agents (rapid increase in permeability of the blood vessels is followed by a precipitous drop in blood pressure which causes patient to become unresponsive). As it goes past the blood-brain barrier it carries with it any blood borne infections, which then triggers an inflamatory reaction - septicemia, sepsis and septic shock may follow.
.
Further, rapid deterioration with progression to spontaneous meningitis is an invariable accompaniment of an untreated serious infection, in this case pyogenic bacterial infection. Spontaneous meningitis denoted meningitis not related to head injury or neurosurgery. Rapid progress of the infection may actually be displaying a pronounced "blood-brain barrier breach", characterized clinically by an abrupt and "rapid evolution", the result of a certain contraindicated medication, namely the Stemetil.


CAVEAT: Almost any organism (bacterial or viral) that gets into the brain may cause meningitis.

Stemetil may increase sedation in an already sedated patient, and is therefore contraindicated. According to the record, the patient stated that she was "very tired". Further, the medical record at A-22 of documents a "sedated" Cognative Perceptual Pattern. Symptoms of overdosage include CNS depression which may vary from simple lethargy to coma. Stemetil poisoning is marked by oversedation, respiratory depression and hypotension, with evidence of same on the face of the record throught.


Neuroleptic Malignant Syndrome(NMS) is characterized by alterations in consciousness (obtundation), autonomic instability (tachycardia - HR in the 160's), and hypertension or hypotession (low blood pressure).
NMS can present without fever in an afebrile patient.

CAVEAT: Oversedation results in obtundation.

The record at
A-1 documents "I was called in that night because the patient had become obtunded". The record at N-4 documents the patient's transfer to the ICU in "resiratory distress" at 0320 hours. A-16 documents BP of 163/117 at 0330 hours that by 0352 hours had dropped to 85/52 (lasting about 7 minutes before being restored), as evidenced by the record at N-2. Adequate cerebral perfusion must be restored within 3 - 5 minutes for complete neurological recovery. That was NOT done and it seems clear from the record that some permanant brain damage was done at that point.

This is evident by the patient's discovery by duty nurses at 0020 hours of the patient's "head against the left side bed rail with her feet under the right side rail", seen at N-6 of the record, a focal deficit suggestive of a dystonic reaction, but may also be a sign of impending herniation. Dystonia occurs in response to a variety of different types of 'toxic substances", especially in those with "acute infections" or severe dehydration. According to that record the patient was simply "repositioned" by the nurses, with "assesssment unchanged" in the face of life threatening indicators.

From that record, it seems clear that the patient had suffered a near fatal reaction to the drug Stemetil, at that time, and that far from getting better she was becoming progressively worse. Further, the negligent selection and administration of the drug Stemetil followed by the failure on the part of the healthcare providers to follow any protocol whatsoever (to include withdrawal of the offending drug) in the absence of the patient's family physician showed wanton and reckless disregard for the safety of this patient, which substantially contributed to her demise. Dr. Spiller, the ED physician did nothing to lessen or prevent the outcome.


A-19 documents an arterial pO2 of 129.0 H, suggestive of hypercapnea. Hypercapnea is a hallmark of "cerebral dilation".

Bacterial meningitis is a serious infection of the fluid in the spinal cord and the fluid that surrounds the brain. Meningitis type infection causes swelling of the brain tissue due to increased ICP resulting in massive oedema and hampers blood flow with decreased attenuation throughout the cereberal hemispheres causing stroke symptoms that include paralysis, which if left untreated can result in herniation, or massive hemorrhage into brain substance. A complete loss of cerebral perfusion may follow.

There is nothing in the coroners report to suggest massive hemorrhage. The final CT done at the time of death reveals that the brain is not significantly distorted.

Further, once in the CSF, bacteria multiply rapidly due to absence of local defences where they further degrade blood-brain barrier and exacerbate tissue damage. Infected material can also block blood vessels to the brain resulting in an "inferior ischemia" (impaired organ perfusion), marked by coma. Further, in patients with multiple brain abscesses, distension of the posterior fossa can result in herniation with mid-line shift. In severe cases, the basal cysterns may become completely obliterated. Meningitis can kill within 24 hours if left untreated.


A-1 documents "she was afebrile" (without fever). A-26 documents a body temperature slightly under 38 degrees C at 0230 hours that is consistent with low grade fever. A-29 documents a body temperature of 37.5 during the 22nd hour of May 23rd. Temperatures between 37.5 degrees C and 38.2 degrees C mark a low grade fever. Only 50% of patients with a brain abscess present with a fever and, when present, fever is often low-grade. Further, an afebrile state and is a prominant finding with single or multiple brain abscesses. Multiple abscesses usually arise from meningitis .

Compare Amebic Meningoencephalitis type multiple (abscesses) space-occupying brain lesions.

N-4 documents "incontinent blood tinged urine" at 0305 hours. Incontinence suggests loss of bladder control and is a very serious side effect of phenothiazine type drugs, eg. Stemetil (prochlorperazine), and possibly first sign of a drug reaction. Incontinence denotes decreased urine output that is the hallmark of "impaired water excretion".

A decision was made to intubate the patient and you will note from the record that during the intubation procedure the patient's HR soared to 174 bpm at 0325 hours, evidenced at A-24 of the record, that is consistent with a "wound or injury caused suddenly" = ACUTE TRAUMA. CAVEAT: In traumatized tissue, bacterium produces many toxins.


The record at N-3 documents the time of the patient's intubation at 0325 hours. The same record documents a "large amount of dilute urine" at 0325 hours that is consistent with panic factor. A-24 documents the mechanical charting of the patient's vital signs beginning at 0315 hours and you will note from that record the complete absence of documented blood pressure between 0320 hours and 0330 hours, over the entire course of the intubation procedure. The very same information is omitted at A-26 , between 0300 hours and the time of the patient's discharge.

Shock is marked by an increase in heart rate. SHOCK is accute circulatory failure leading to inadequate tissue perfusion and end organ injury. With shock at least one element of the cardiovascular system has malfunctioned = evidence of hemodynamic insuffiency and altered perfusion.

SHOCK can be induced by any external stimulus including chemicals, sound, and emotional events. This shock causes TRAUMA, the disruption of communication between cells. When cells lose communication with the cellular matrix, they can react unpredictably. There may be signs of hemorrhage and shock, including rapid heart rate and falling blood pressure.



Further, traumatic injury to the CNS initiates an autodestructive cascade of biochemical and pathophysiological changes that ultimately results in profound and widespread reduction in tissue perfusion and irreversable tissue damage. The concept of a systemic inflamatory response syndrome expresses the notion that the body responds in certain ways to a variety of insults. The hallmark of reperfusion injury is an "inflamatory reaction".

Further, the ET was malpositioned for one full hour before the error was discovered by one of the duty nurses. When an endotrachial tube is misplaced in the esophagus and misplacement is detected late, the compromise of the patient's safety can be significant. Misplacement of the ET in the esophagus is the most lethal toxicological complication associated with pulmonary toxicity due to a compromised airway leading to hypoperfusion. CAVEAT: Brain abscess is also a potential complication of esophageal dilation.


N-2 documents ET (Endotracheal Tube) pulled back at 0425 hours. The same record documents another "large amount of dilute urine" at 0425 hours.


Incontinence (loss of bladder or bowel control, vertigo), indicate possibility of general medical condition, or DRUG substance.
Compare UTI


PANIC ATTACK TEST

During a panic attack, a racing or pounding heartbeat is a hallmark of
"terror"(fright) – a sense that something unimaginably horrible is about to happen and one is powerless to prevent it



A-16 documents BP of 163/117 at 0320 hours (panic attacks actually raise blood pressure). Notably the patient's blood pressure is omitted for 0325 hours, however the patient's HR soared to 174 bpm at 0325 hours evidenced at A-24 of the record

Diabetes insipidus can be caused by several conditions, including meningitis - inflammation of the meninges, the membranes that cover the brain and spinal cord. In this case, the findings are inconsistent with diabetes insipidus.

In acute meningitis hyponatremia is not exclusively brought about by inappropriate water retention. The amount of fluid in the body is tightly controlled by a series of cardiovascular reflexes and the kidney. The kidney, which is an extra-ordinarily metabolically active organ, regulates its own blood flow (over a wide range of blood pressures), and excretes a dilute urine when the person is overhydrated, and a "concentrated urine" when the patient is dehydrated.

Further, during a full-blown PANIC attack adrenaline kicks in due intense fear. One of the main functions of adrenaline is to expulse any excess urine from the urinary bladder. With PANIC or intense fear people frequently lose control of their bowels and bladders. A loss of bowel or bladder control is frequently the result of trauma, and iatrogenic injury is no exception. There are only two entries with respect to a "large amount of dilute urine" on the face of the record, the first being at 0325 hours, the exact same time when the ET was inserted, and again at 0425 hours, being the exact same time when the ET was pulled back, fairly reliable signs of PANIC FACTOR.

The essential feature of a Panic Attack is a discrete period of intense fear or discomfort that is accompanied by somatic or cognitive symptoms.
The attack has a sudden onset and builds to a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom

Panic Attacks are manifested by specific periods of apprehension or fear. and are the result of trauma, disaster or catastrophe.


CAVEAT: Neutrophilia is seen in any acute insult to the body and is a hallmark of inflamation. The record at A-19 documents a Neutrophil count of 92.0 H (High) with an Absolute Neut's of 20.0 H



INFLAMMATION is a common response to trauma as individual cells attempt to resolve the trauma through high metabolic activity. Other reactions include edema and shut-down. Unless intercellular communication is restored, inflammation can become chronic.


Toxic injury or injury from inflammation may cause acute or chronic renal failure.


TRACE LG AMT DILUTE URINE TO PANIC - HAPPENED 2 TIMES


A-18 of the medical record, what I take to be the Cardiac Index, documents a "Sinus Tachycardia", marked by a Heart Rate in the 160's which results from increased automaticity of the SA node due to synpathetic stimulation of the heart. Pathologic tachycardia accompanies anoxia (lack of oxygen to tissues) which can be responsible for a drop in blood pressure, such as caused by injury, panic (trauma), congestive heart failure, hemorrhage or shock., and is also the normal response to deep pain. The patient had no prior history of heart problems.

Caveat: Rapid progression and circulatory failure with profound hypotension and tachycardia are clinical features of the staphylococcal toxic shock syndrome. In the early stages most of the findings may be "unremarkable". S. aureus bacteremia in which locallized symptoms and physical findings are few can progress rapidly through the stages of sepsis syndrome, sepsis, severe sepsis, septic shock and refractory septic shock (also referred to as septicemia). Compare Septicemia.

Sepsis denotes infection in the bloodstream by a bacterium or virus. Symptoms udually include irregular blood-sugar level, and an increase in breathing problems.

Sepsis is a toxic condition resulting from septicemia.. Septicemia occurs when organisms spread to the bloodstream from a focus of infection elsewhere. Septicemia denotes presence of microorganism actively growing in blood, usually having a nosocomial, or hospital aquired etiology. Neck stiffness is an unreliable sign. Further, NO neck stiffness or photophobia occurs in septicaemia.

Hypotension (low blood pressure) is a hallmark of severe sepsis. Septic shock is a form of circulatory shock, preceded by signs of severe infection, often of the genitourinary or gastrointestinal system The hallmark of septic shock is "decreased perfusion". Septic patients will often go into DIC. Coagulopathy in severe sepsis is commonly associated with multiple organ dysfunction, being the clinical hallmark of sepsis. Sepsis is the host response to infection and involves a series of clinical, hematological, inflamatory and metabolic responses that can ultimately lead to organ failure.
Severe sepsis is typically associated with activation of the coagulation system, leading to deposition of thrombin in the microvasculature and hence interaction of coagulation and inflamation. Coagulation system and platelets are fully activated in uncomplicated sepsis. According to the record platelets and coagulopathy are fully activated.

Severe sepsis denotes sepsis associated with organ dysfunction and hypotension despite adequate oxygen replacement - can also suggest septic shock .

A-19 documents a normal Hemoglobin with a Count of 120, (normal 120-160). Hemoglobin carries oxygen supply to vital organs. Facts suggest inadequate oxygenation despite the fact that oxygen levels were returned to normal by compensatory mechanisms, marked by a clinically evident inability to adequately ventilate or oxygenate the patient.

A-26 documents a blood pressure of 162/80 (hypertension) at 0220 hours that by 0235 hours had dropped to 78/70 (hypotension), with evidence of "orthostatic hypotension" seen throught the record. CAVEAT: Septic shock is a potentially lethal drop in blood pressure due to presence of bacteria in blood.

Orthostatic hypotension has many possible causes, such as untreated diabetes, and cardiac insufficiency, or severe loss of fluid from vomiting. The most common cause is "medication" related. Severe bleeding can also result in orthoststic hypotension.


CAVEAT: Any disease, drug, or spinal cord injury that damages the nerves which control blood vessel diameter can cause orthostatic hypotension. In persons with orthostatic hypotension, gravitational opposition to venous return causes a decrease in blood pressure and threatens cerebral ischemia, resulting in an "inferior ishchmia".

Multiple medications, restricted diet or poor nutrition causes gastrical intestinal lessions to gastrointestinal bleeding, which provides an excellent breeding ground for bacteria.

According to the patient's Rx list, she was given Amoxicillin, a penicillin-like drug having fairly broad spectrum against many bacteria. Notably , Staph infections in the bladder are sensitive to Amoxicillin.

The hallmark of staph infection is the abscess which consists of a fibrin wall surrounded by inflamed tissues enclosing a central core of pus containing organisms and leukocytes (usually resulting from trauma or insult, ie. medical procedures) containing bacteria of the staphylococcal variety. CAVEAT: S. aureus bacteremia (in which locallized symptoms and physical findings are few) can progress rapidly through the stages of sepsis syndrome, sepsis, severe sepsis, septic shock and refractory septic shock (also referred to as septicemia). See: The Sepsis Syndrome: Differential Diagnosis of the Flu-like Illness. Compare Septicemia.

Sepsis results from a generalized procoagulant (excess coagulation) response to the infection leading to deposition of thrombin in the microvasculature via interaction of coagulation and inflamation that is a hallmark of Disseminated Intracascular Coagulation. DIC is now considered part of a pathphysiological process involving excess coagulation such as seen in Sepsis, SIRS or multidysfunction syndrome.


Multiple brain abscesses that develop in the septic patient are often related to bacterial endocarditis, pneumonia, and diverticulitis:

Fibrinogen is a blood plasma protein in which high levels contribute to abnormal arterial clotting and thus acts to promote platelet aggregation resulting in thrombosis. Platelet activation and thrombosis is a hallmark feature of acute ischemic syndromes in which heart-kidney interactions are reported in the PubMed. Serum fibrinogen in a safe range is A-19 Fibrinogen 4.67 H Confirmed.



Coagulopathy in severe sepsis is commonly associated multiple organ dysfunction. Sepsis as the host response to infection involves a series of clinical, henatological, inflamatory and metabolic responses that can ultimately lead to organ failure. DIC is part of a pathophysiological process involving "excess coagulation" such as seen in sepsis.

CAVEAT: Coagulopathy is a blood disorder, ie. blood dyscrasias = blood disorder. Stemetil is contraindicated in patients with blood dyscrasias.

Multiple blood clots in the CSF (cerebro-spinal fluid) are the initial cause of post-hemorrhagic ventricular dialation and lysis of blood clots. Thus excess fibrin clots capture the platelets and produce thrombosis with impaired organ perfusion.

D-dimer suggests "thrombosis", and is the confirmatory test in Disseminated Intravascular Coagulation (DIC). Increased amounts of fibrinogen and D-dimer substances in the blood is a hallmark of DIC. Coagulation system and platelets are fully activated in sepsis. A-19 D-dimer 1000 H (high) Confirmed

aPTT denotes the activated partial prothrombin time and is elevated in 90% of those with coagulopathy. The Normal therapeutic Range is omitted from the record. Heparin therapy (23-35 is normal >60 seconds = Panic)
A-19 Heparin 60 - 100 seconds

WBC (White Blood Cells) are elevated with dehydration, hyperviscosity secondary to dehydration, and infection. An increase in the number of WBC's is called "leukocytosis". Leukocytosis is a common feature of inflamatory reactions, particularly those caused by bacteria. A leukocyte response suggests leukocyte recruitment which may point to the likely offending organism as being a Gram-negative pathogen. Leukocytosis is also a prominant finding in intestinal obstruction and strangulated hernia. WBC is elevated with abscess formation. A-19 WBC 22.4 High We now have a confirmed WBC leukocytosis.

A severe leukocytosis can also suggest a "leukemoid reaction". The term leukomoid is used to describe inflamation and left shift in situations of pyogenic (pus producing bacteria) inflamation so severe that CBC resembles leukemia. Compare Granulomatous reaction.

Further, leukocytes are responsible for detoxification of toxic proteins, such as caused from allergic reaction, and cellular injury. With inflamation, as long as leukocytes are contained within the blood vessels they are restrained from attacking infection at its source, but if the blood cells become freely permeable to cells and fluid, it would be fatal. Indeed something very much like that happens during anaphylactic or toxic shock - a rapid increase in permeability of the blood vessels, followed by a precipitous drop in blood pressure and then, often death.

CAVEAT: Stemetil (prochlorperazine) is highly bound to blood plasma protein making it freely permeable to cells and fluid .

Neutrophils (also known as granulocytes). An increased neutrophil count is called neutrophilia. Neutrophilia is the most common cause of leukocytosis. In the CBC, leukocytosis (especially neutrophilia) indicates "systemic infection". Neutrophils 92.0 H A-19 Absolute NeutÕs 20.0 H We now have a confirmed Neutrophilia. Compare Granuloma.

Neutrophil accumulation in tissue is a hallmark of inflamation, (often due to clinical insult, ie. iatrogenic/procedure related). Neutrophilia was first noticed in patients with gram negative sepsis and endotoxemia. Endotoxins and other bacterial products appear to cause direct cellular injury while elicitinf cytokins that attract neutrophils which enhance hypersensitization, brain edema, and hypercoagulability with vascular inflamation from endotoxin, a hallmark of the inflamatory effect in endotoxic shock. It is well described in the scientific literature that the presence of endotoxin is common in rapidly dividing bacteria at sites of localized infection and abscesses in the gut.

Acute bacterial infection is a common feature of Neutrophylia, especially with pyogenic (pus producing) bacteria - suggests generalized or systemic infection that is a hallmark of septicemia. Also, commonly involved are Gram-negative enteric bacteria, and endogenous flora. Most of these infections occur as "soft tissue infections" e.g. boils, abscesses, cysts. Most common pathogen is the S. aureus bacteria that can lead to toxic shock syndrome. Gram-negative flora is also associated with Meningitis. Although meningitis and septicaemia are seperate diseases, the most common cause of bacterial meningitis (the miningococcus) often causes septicaemia at the same time.

Staphylococci aureus bacterium, may also lead to staphylococcal septicaemia (blood poisoning). Staphylococcus aureus septicemia is often mediated by peptidoglycan-induced "platelet aggregation" and activation of "coagulation cascade", usually having a pulmonary etiology. Conversely, S. aureus abscesses usually are associated with "purulent CSF" containing polymorpho-nuclear neutropholic leukocytes, which may infer an oncology related infection due radiation injury to the CNS.

A-19 Neutrophilia typically occurs in response to inflamation and acute infections (bacterial or viral), blood toxicity and hemorrhage. Leakeage of oxydative metabolites from the neutrophils into the tissue can potentiate the inflamatory process. In fact all of the relevant literature suggests that neutrophilia typically occurs because of "inflamation and infection". Compare: Neutrophilia in Bacterial meningitis - also called acute pyogenic meningitis. Pyogenic denotes pus producing infection or suppuration marked by exudates of purulent matter composed largely of neutrophils and dead tissue. CAVEAT: Purulent exudates, clotted blood, radiation necrosis and fibrinous deposits are usually the result of "iatrogenic" (doctor caused) injury due to clinical insult, or inadequately treated infection.

Platelets are cells that form the primary mechanism in blood clots. An increased numbers of platelets in the peripheral blood is called thrombocytosis, and is increased with coagulopathy (coagulation activities) such as cohesion of platelets to each other forming clumps (blood clots). Platelets are also elevated with drug reactions, toxic substances, metabolic disturbances, and dehydration. A high platelet count is referred to as "thrombocytosis". A-19 Platelet Count 544 High. We now have a confirmed thrombocytosis.

Further, platelet aggregation is the clumping together of platelets or cells in the presence of fibrinogen at the site of injury (resulting in diminished blood flow and delivery of oxygen) which contributes to the coagulation cascade with activation, ie, iatrogenic injury, or trauma of any kind whether clinical or not. High platelets also known as thrombocytes may either dispose to blood clotting or hemorrhage, or both. An increase in platelets may also indicate a benign reaction to an infection, surgery, blood vessel injury, or certain medications, but is mainly responsible for sludging of the blood. Platelets are thus the cells that form the primary mechanism in blood clots.

In TSS (Toxic Shock Syndrome), "thrombocytosis" (rather than thrombocytopenia) is common. High platelet count (marked thrombocytosis) is common in second week of toxic shock-like syndrome.


A reduced lymphocyte count is called "lymphocytopenia". Lymphocytopenia suggests presence of ascites due to fluid build-up in the abdomen. Ascites is an excess of fluid in the membrane lining of the abdomen (the peritoneal cavity. The main pathogenic factor is sodium retension in which abdominal pain is the most striking finding. If bacterial infection is present this can suggest spontaneous peritonitis. Most cases of bacterial peritonitis occur as a result of ascites due to liver, kidney or heart failure.

Iatrogenic lymphocytopenia is the hallmark of an exhausted immune system and is caused by cytotoxic chemotherapy, and "radiation" therapy, marked by a reduction in the absolute number of T cells. Lymphocytes are the most sensitive to whole body radiation resulting in accellerated destruction of T cells (a sign of radiation injury) and their count is the first to fall in radiation sickness. Other syndromes associated with lymphocyte depletion include Staphylococcus aureus shock in immunodeficient patients. Signs of TSS when T cells are abscent. S. aureus shock in immunodeficient patients is also reported in the literature. S. aureus infection can result in septic and toxic shock with depletion of immune cells and massive cytokine production. A-19 Lymphocytes 2.0 L Absolute Lymphs 0.4 L


We now have a confirmed Lymphocytopenia due to depletion of T cells that is the hallmark of the Toxic Shock Syndrome. Compare Radiation Necrosis.


In TSS (Toxic Shock Syndrome), profound but transient "lymphocytopenia" associated with marked "leukocytosis" was the most striking laboratory finding and one not previously emphasized in the literature. S. aureus was isolated from sites of soft-tissue infection, the vagina or the endocervix in all except one case. Lymphocytopenia associated with TSS is reported in the PubMed. A decreased number of lymphocytes may also indicate sepsis. "Sepsis" is the term we use for an overwhelming "bacterial" infection.

Septic shock is a form of distributive shock most commonly caused by infection with Gram-negative bacteria. The hallmark of septic shock is marked peripheral anteriolar vasodilation, which results in low systemic vascular resistance, high cardiac output, severe hypotension, and inadequate tissue perfusion.

HCT (Hematocrit) is the measurement of the percentage of red blood cells (RBC) in whole blood with a reduction suggestive of anemia. Most common reasons include loss of blood (traumatic injury, surgery, bleeding colon, nutrition deficiency, kidney failure). An abnormal HCT can suggest sicle cell anemia in which the blood sicles and prevents outflow because of sludging. Other reasons for a low HCT include dehydration, iatrogenic fluid overload or vasoconstriction following acute blood loss. Anemia is present when HCT is A-19 documents a HCT 0.361 L (low).


CAVEAT: It can take 24 to 72 hours post trauma to reflect the true volume loss.


Exertional fatigue is the hallmark of mild anemia



CAVEAT: Signs of shock marked by hypotension and a falling HCT level are all associated with TRAUMA. The most common cause of a falling hematocrit is loss of blood.
Damaged RBC's can cause thrombosis (clotting) with secondary ischemic damage to adjacent and surrounding tissues causing infarction (cellular death).

RDW (Red BloodCell Distribution Width) - its principal function is to transport oxygen to the blood and becomes elevated with oxygen deprication and is also increased with anemic hemoglobinopathy, ie.in sickle cell anemia.
A-19 RDW 18.4 H

Monocytes are a type of phagocyte which mature into macrophages, important germ eating cells. Search key term for "phagocytes". Patients with a low monocyte count have a higher risk of getting sick from an infection, particularly those caused by bacteria. In this case the Monocyte count is within the "normal" range, to rule out phagocytosis. A-19 Absolute Mono's 0.60 (Normal) Confirmed

Caveat: In cancer, leukemia, neoplasms (malignant effusions), monocytes become elevated. In this case the monocyte count is well within the "normal" range, to rule out metastatic tumors.

On CT there was decreased attenuation throughout the cerebral hemispheres with evidence of massive edema, obliteration of ambient cysterns and a 1 cm mid-line shift suggestive of "no cerebral perfusion", which is evidence of impaired organ perfusion. CT Scan - Sudbury Regional Hospital - Coroner

A-18 of the medical record documents an "inferior ischemia", a sign of reduced oxygen supply to vital organs due to reduced or poor blood flow, which is also evidence of "impaired organ perfusion" (infected material can block blood vessels to the brain resulting in an inferior ischemia. Ischemic comes from the Greek words "ischein" meaning "to hold back" from "haima" meaning "blood" and the word "ikos" meaning "pertaining to". The hallmark of reperfusion injury after brain ischemia is an "inflamatory reaction" which can result in shock and circulatory collapse, marked by a rapid drop in the blood pressure.






A-20 documents a serum potassium of 3.4 L (low) Potassium plays a critical role in regulating heart beat and other critical functions. A low potassium level is called hypokalemia which results in an electrolyte imbalance which can lead to cardiac arrest. It may result from excessive potassium loss by the renal or gastrointestinal route as caused by renal or gastrointestinal disorders. No potassium replacement was ordered or administered because NO lab tests were performed soon enough to verify or treat accordingly.***

A-7 documents that the patient was seen to be "pale, dry and cool", fairly reliable signs of adrenal insufficiency, or compromised perfusion. Compare Shock Syndromes in which vasoconstriction, pallor, cold peripheries all point to circulatory failure.


The two versions of the patient's vital signs is proof of spoliation of the record. To downplay by omission is the most common form of spoliation. The most common feature in omission is leaving out pertinent information to obfuscate the truth.



Severe stomach pain is the result of alterations in GI function which can rapidly lead to gastric rupture, or perforated rupture.***



Reduction in blood flow (relative ischemia) impairs oxygen delivery and causes cerebral hypoxia



"Had she been started on decadron she might have enjoyed respite from her headache and might have lived a few weeks longer, but with multiple metastatic tumors, she would have been inoperable and, at best, palliativewhole brain radiotherapy would have extended her life a very few months".

Abscesses are treated by antibiotic therapy and drainage, not with brain damaging neuroleptic drugs. Prednisone is used to reduce damage to otherwise healthy organs. Treatment of abscess involves removal of the causative agent (usually a bacterial infection) by antibiotic therapy In the case of multiple infections spread via the blood from a distant source a variety of different bacteria are usually involved. Thus a corresponding wide spectrum of antibiotics is given for these abscesses. In most other instances surgical aspiration is used. Aspiration has two advantages, it gives a sample of the abscess for bacterial analysis, a determination which is essential in treating the abscesses, and also serves to alleviate "mass effect". The cerebral edema and increased intracranial pressure associated with brain abscess are also specifically treated in a neuro-ICU. In addition to treating the infection proper, measures are taken to reverse the complications of meningitis. In this case that was not done.

Generally, the prognosis associated with brain abscesses is dependent on the rapidity and efficacy of treatment, the age and medical condition of the patient, and the size and location of the abscesses. In recent decades brain imaging techniques such as MR scanning used to detect the early presence of brain abscesses have reduced mortality rates from about 40% to about 15%. In this case that was not done.


In my opinion, the physicians who looked after Arlene Berry met a reasonable standard of care".

In my opinion, the physicians who looked after Arlene Berry should be charged with criminal negligence causing death.***



It is true that diagnosis of adenocarcinoma of the left lung was made prior to the lung resection and prior to radiation therapy. There is NO evidence on record to suggest metastic Cancer.

Difficulty ambulating, a sign of poor ballance and uncoordinated movements is a common feature in toxic ataxia/toxic sedation which results in dizziness and drowsiness, but there were definite upper motor neuron signs in the legs causing this patient to "pull to the right when walking", as evidenced by family and friends. The commonly observed deficit was one of weakness on one side of the body, such as seen in hemiparesis, vascular limb ischemia, unilateral limb ataxia, or limbic encephalitis, the result of CNS infection. Further, hemiparesis or unilateral limb ataxia is almost always an indicator of focal posterior fossa abnormality, such as infarct, demyelination, or abscess.

It seems clear that the coroner's expert (whose identity is omitted) assumptively considered a few cursory physical findings, but failed to take into account from the patient's medical history, ie. from the patient's belated bloodwork, particularly the Neutrophilia, including a documented CAUTION with respect to a "resistant bacteria", suggestive of an antibiotis resistant bacterial infection. Typically, the origin of the infection is indicative of its bacterial identity, at this point at least we know what to look for. Further, a progressive or increasingly severe headache concurrent with "nausea, vomiting, and drowsiness" can suggest clinical features of meningitis, cerebritis, or brain abscess that is consistent with a bacterial infection.

CAVEAT: Brain abscesses are life threatening due to systemic and local toxicity in early stages of cerebritis, and increased intracranial pressure during/after capsule formation.

You will note that N-9 of the record documents an "INFECTION CONTROL PRECAUTIONS" for a "resistant bacteria", evidenced by a check mark in the box . The particulars with respect to any bloodwork on the days before the patient's death (if done at all) are omitted. Apart from that caution , NO precautions are reported because NO precautions were taken. Supportive Care & Symptom Control Regimens are absent. Further, N-10 documents the patient's level of care as "routine", which showed little or NO concern for the safety of this patient. From these records it is clear that Arlene Berry was simply turned away at the door in the face of life threatening indicators - goes to evidence of gross negligence, and substandard care.

Submit, from the record there was every indication that Arlene Berry was about to suffer a catastrophic decline, at least from foreseable "dehydration" due to decreased oral/water intake and malnutritian from excessive vomiting over the previous week or more, which should have prompted immediate medical attention, but did not. Submit also that dehydration, which interupts blood flow and causes blood clots, cutting off the supply of oxygen to various parts of the body resulting in a toxic condition, the result of poor oxygen exchange as evidenced by a slurred speach, marked by a sedated and haggard appearance, and drowsiness together with constitutional symptoms documented on the record to include headache and vomiting with severe stomach pain, as evidenced by the "abdominal pain ongoing for 2 weeks" documented at A-5, and at A-8 of the medical record can constitute a "life-threatening medical emergency" on the face of the record.

According to the record, on May 23rd of 2000 "she returned" to the emergency department "with the very same complaints", as evidenced by the record at A-6. Submit that rapid evolution of illness or patient return within 24-48 hours suggests the severety of illness as to "mandate treatment in an intensive care unit". How could they realize she was sick knowing that and elect not to admit her to hospital at that time?

Submit that N-2 of the nurses notes clearly document "attempts to pull away to painful stimuliy" at 0400 hours, to rule out complete cessation of motor response at 0245 hours . From that record it is clear that Dr. Jordan lied. I was present at that time and had asked Arlene two times (in the presence of her foster brother) if she could hear me to wiggle her toes and she did, not once, but twice. In my opinion, Arlene appeared to be more paralyzed than anything, which may suggest one of two things, either chemical restraint, or meningitis.

Further, with meningitis, muscular power in the limbs is usually well preserved, muscular hypotonia occurs quite regularly, which may explain the "plantars responses". This may also explain why Arlene was able to wiggle her toes when I asked her to (not once, but twice), obviously she could still hear me at that time. It must have been a nightmare for her.

With respect to the occular, eyes mid sized and fixed gaze is a common feature of adverse reaction to phenothiazine type drugs., and you will note from the record that she was given Stemetil. Further, in "acute bacterial meningitis" the pupils may become dilated and fixed, with papilledema (late) as the disease progresses. With meningitis, any of the ocular muscles may become paralyzed - most frequently one or both, hence mid-sized with fixed gaze.

The lession in the region of the occipital lobe that measures less than 1 cm seen on the first CT that was done in Timmins is consistent in appearance with an old hemorrhage, or early stage cerebritis during/after capsule formation in the early stage of abscess development (capsules can rupture resulting in the formation of multiple abscesses), or perhaps even an abscess secondary to an occipital dermoid cyst. Rupture of a dermoid and leakage of a cyst contents into a ventricle or subarachnoid space may produce an epidymitis or meningitis respectively.

CAVEAT: Brain abscess in a previous hemorrhage or infarction area as a complication of systemic infection, or untreated bacteremic spread is reported in the literature.. A systemic bacterial infection can effect all organ systems, and the brain is no exception.

The record clearly documents NO METASTASIS and a NEGATIVE mediastinoscopy.

As you are aware, the occipital lobes interpret vision. Brain tumors are more solid/dense and therefore are usually associated with multi-focal deficits; tumors of the occipital lobe usually produce homonymous hemianopia or partial visual field deficits. A tumor in the occipital lobe can cause loss of vision on the side of an occipital neoplasm which, in addition to loss of vision in half of each visual field may also cause hallucinations, and seizures. Arlene Berry had no such deficits.

Had this lesion been a recent tumor, there would have been onset visual misperception in half of one or both visual fields, with visual impairment and subsequent loss of vision with evolution. With a soft tissue infection the expanding lesion would have been assymptomatic. Even multiple brain abscesses may not cause focal deficit to suggest their presence.

Further, the blood chemistry at A-19 of the hospital record documents a Neutrophil count of 92.0 H, with an Absolute NeutÕs of 20.6 H. An increase in the neutrophil count suggests neutrophil emegration (the normal range is 1.3 - 6.7). Emigration of neutrophils, together with tissue destruction is the hallmark of abscess formation. These lesions are commonly produced by a group of microorganisms known as the pyogenic (pus-producing) bacteria). The staphylococci are a group of bacteria possessing pyogenic properties. particularly Staphyloccocal. meningitis, or variants thereof.

Staph meningitis is an infection caused by the bacterium Staphylococcus aureus, also known as S. epidermidis, which causes an inflammation of the membranes surrounding the brain and spinal cord, which can rapidly result in paralysis. Some of the symptoms of meningitis are similar to brain tumors. Patients with Staph. meningitis may have high levels of neutrophil in the CSF, marked by Neutrophilia. Acute bacterial infection is a common cause of neutrophilia, especially with pyogenic bacteria. CAVEAT: Leukocytosis (especially neutrophilia) is a hallmark of systemic infection. Systemic infection is marked by widespread tissue destruction. The record clearly documents an elevated WBC count, marked by neutrophilia, that is, to confirm leukocytosis, and further submit that the record speaks for itself.

With meningitis, intracranial infection can result in cerebral abscesses which can lead to brain herniation and shift of midline structures. ICP itself can be responsible for further damage to the CNS by decreasing blood flow to the brain causing the brain to herniate (push through) the opening in the back of the skull where the spinal cord is attached. Once bacteria have established a foothold on the membranes surrounding the brain, they trigger inflammation severe enough to cut off the blood
supply resulting in decreased cerebral perfusion and cause swelling in the brain.
The decreased attenuation throughout the cereberal hemispheres may result in stroke symptoms that include paralysis, which if left untreated can result in herniation or massive hemorrhage into brain substance.

With meningitis, CT of the brain often shows obliteration of the cisternae surrounding the midbrain and of the subarachnoid space over the cerebral hemispheres and is reported in the literature. With meningitis intracranial infection can result in cerebral abscesses which can lead to brain herniation and shift of midline structures. ICP itself can be responsible for further damage to the CNS by decreasing blood flow to the brain causing the brain to herniate (push through) the opening in the back of the skull where the spinal cord is attached .

Further, when Dr. Jordan finally showed up in the small hours of May 24th of 2000, precious moments that followed were not taken up with measures to save this patient's life, but rather ways to accellerate her demise, that is, he proposed a DNR. A decision was made to intubate the patient and you will note from the record that during the intubation procedure the patient's HR soared to 174 bpm that is consistent with trauma, or injury caused suddenly. Further, the ET was malpositioned for one full hour before the error was discovered by one of the duty nurses and further submit that any negligence of the patients airway can result in a decreased or no cerebral perfusion and that is exactly what happened here, which goes to evidence of negligence and substandard care. Any negligence of the patient's airway or throat secretions can trigger an inflamatory response.

From the record it seems clear that Dr. Jordan did not support the use of agressive intervention to keep alive someone he had already injured, for to give treatment to remedy a wrong would result in the fact that mistakes were made and there is nothing on record to suggest that the patient was adequately oxygenated prior to intubation. From the record it seems clear that Dr. Jordon had done too little too late by reason of his failure to attend, and from the record it is clear that nothing was done by any of the other healthcare providers in his absence.

Clinical presentation of brain abscess is usually similar to other intracranial space occupying lesions but the symptoms of an abscess(s) tend to be more rapidly progressive than those associated with neoplasm. Microorganisms can be spread by the blood during a systemic infection. In this case bacteria are carried to the site of abscess from a distant source. Under these circumstances there is not a solitary abscess but rather multiple abscesses in the brain. Brain abscesses. can produce "purulent meningitis" associated with signs of neurologic damage or brainstem malfunction.There is nothing on record to suggest metastatic CA of the brain, indeed there is nothing to suggest other than "purulent meningitis", with evidence of sepsis, including neuroleptic drug involvement.

The evolution of abscess is characterized by four stages: early cerebritis, late cerebritis, early capsule formation, and late capsule formation. Most patients receive this diagnosis when the abscess is in the stage of late cerebritis or mature formation.
The period that is required for the formation of a mature abscess varies, ranging from 2 weeks to several months. Arlene Berry developed flu-like symptoms 2 weeks following radiation therapy. 10 days later she is dead. Spontaneous meningitis can kill in 24 hours if left untreated. The infection may mimic space occupying lesions of the CNS. Some of the symptoms are similar to brain tumors. Even when the imaging characteristics are very suggestive of tumor, a biopsy is the only way a precise diagnosis can be made. It seems clear that the opiniated expert failed miserably in postulating his opinion.

Staph meningitis is an infection caused by the bacterium Staphylococcus aureus, also known as S. epidermidis, which causes an inflammation of the membranes surrounding the brain and spinal cord. In the very early stages of meningitis, it can appear like the flu. The record at OP-54 clearly documents "2 weeks had the flu".

Further, with multiple abscesses the meninges typically show a purulent exudate that obscures the sulci making radiographic appearance of microabscesses less visible,. hence they are not well opacified. In severe meningitis, the basal cisterns may become completely obliterated and that is what happened here.

Morbidity due to a brain abscess generally results from brain herniation due to mass effect, in this case the result of iatrogenic neglect.

Further, rapid deterioration is an invariable accompaniment of an untreated condition, in this case pyogenic bacterial infection.. However, rapid progress of the disease may actually be displaying a pronounced "blood-brain barrier breach", chracterized clinically by an abrupt and "rapid evolution", the result of a certain medications, ie. the Stemetil.

Although it is clear that the patient was transferred to Sudbury with ventillatory support, and although Dr. Jordan was aware of the need for emergency care and life support, after ordering it, he cancelled it, without family consent, and waited for this patient's death. From the record it seems clear that this is a medical homicide.






Missed meningitis is second only to missed myocardial infarction in total damages per year. Many lawsuits are filed even though treatment was promptly instituted because of the frequency of neurologic sequelae.

Failure to promptly institute treatment or failure to educate regarding follow-up care in previously discharged patient.

Accurate and timely diagnosis of the type of meningitis (ie, viral, fungal, bacterial) must be made in cooperation with an infectious disease specialist so that the appropriate treatment can be rendered as soon as possible. Failure to do so is Gross medical negligence.


Altered Medical Records




Get the FACTS