On Aug. 17, 2019, nine-year-old Carter Bonsdorf was playing in the water at the family cabin on Cowichan Lake with his younger brother Declan, who was swimming for the first time.
Their mother, Tanisha Bonsdorf, captured the happy moment with a photo of her two boys. But her memories of that carefree afternoon are now suffused with sorrow.
Thirty minutes after the photo was taken, Carter began to complain of stomach pain. Within a week, he was dead.
Tanisha and Carter’s grandfather, Logan McMenamie, the former Anglican bishop of Vancouver Island, are coming forward now, sharing Carter’s story in the hope of preventing other families from experiencing the grief they have endured.
It’s a story, they charge, of racism, medical incompetence, failed communication and failure to follow up on a radiologist’s X-ray report noting a possible bowel obstruction.
It’s the story of a boy who should still be alive.
Despite an internal review of Carter’s death by Island Health and a complaint to the College of Physicians and Surgeons of B.C., the family still does not know why Carter’s condition wasn’t caught and treated.
“The parents have the impression, and rightly so, that they weren’t listened to. And I think with better communication and more careful follow up, Carter didn’t have to die,” said retired Victoria lawyer Robert Gill, who has represented the family through the review processes.
‘I feel like I wasn’t listened to’
Telling Carter’s story is exhausting and traumatizing, said Tanisha, who was born in the territory of the Cowichan Tribes, taken in as a foster child by McMenamie and his wife, Marcia, when she was almost eight, then adopted by the couple at age 10, along with her sister.
“We’ve come to terms that we will live with grief forever, but we try to keep Carter alive,” she said, wiping away the tears that fall continuously.
“He lives on in that way,” said McMenamie. “He lives on in telling our story.”
Carter was “totally fine” that day swimming with his brother, said Tanisha. But around 4 p.m., he started complaining of stomach pain.
“We decided to go in and start planning for dinner so he could rest. Over the next couple of hours, he kept kicking his feet in pain. The pain kept coming on and off. He was thrashing about in pain. Within an hour, he started vomiting. He was unable to keep anything down. We tried Pepto. We were giving him fluids. We gave him Tylenol, but he didn’t keep that down either.”
Tanisha lay on the bed with Carter to try and get him to sleep. “But that wasn’t happening,” she said.
They decided to go to Cowichan District Hospital and arrived around midnight. They saw the doctor, a general practitioner with a speciality certification in emergency medicine, around 1:30 a.m.
Carter was the kind of kid who got very quiet around people he didn’t know, said Tanisha. He wasn’t showing his pain because there were strangers around, she said. “But we told them the reason we were bringing him there was because of the amount of pain he was in.”
Tanisha takes a deep breath and tries to control the shaking in her voice. “I feel like I wasn’t listened to about the level of pain he was in.”
The doctor ordered an X-ray but after he looked at it, “we were basically shooed out,” she said. He told them Carter had the flu and to take him home to rest and to give him fluids and Tylenol.
“The doctor did say if the pain worsens or moves to the side, then bring Carter back in for another check,” Tanisha recalled.
But the pain didn’t get worse. It remained the same.
“It reached its peak and stayed that way, so we didn’t go for follow up. So we went back to the cabin, packed up in the morning and went home.”
On Monday, at home in Metchosin, Carter was unwell, lethargic. All of a sudden, he screamed in pain and shouted “Dad,” then collapsed and became unresponsive.
His father, Alan, phoned 911. Attempts to resuscitate Carter weren’t successful until he arrived at Victoria General Hospital. He had been in cardiac arrest for almost an hour.
Carter was rushed in for exploratory surgery. The surgeon discovered he had a congenital deformity in his intestine, a soft spot where the bowel had punctured it.
A third of his intestines were necrotic. They were basically poisoning him, said Tanisha. The family later learned he had had a heart attack after developing sepsis from the bowel obstruction.
The care Carter received at Victoria General Hospital was amazing, McMenamie said. Although the doctors were hopeful the boy would recover, an MRI showed he had extensive brain damage.
“They said ‘We can keep him alive, but at what cost?’ ” said McMenamie.
Carter wouldn’t be able to breathe on his own. He wouldn’t be able to think. He would spend the rest of his life in a hospital bed.
“We had to make a hard choice. We instinctively knew that was not a life for him. He was a very active child,” said Tanisha. “It was exactly a week from the pain starting to the day of his death.”
‘We can’t tell you anything’
After Carter died, the Victoria General Hospital administrator filed a request for a review of the boy’s death. Six weeks later, Tanisha and Alan attended a meeting with representatives from the two hospitals. Both sets of grandparents and their family physician were there as well.
“They had an internal review but said they were unable to share because of legislation,” said Tanisha. “It was a huge shock when we went to that meeting and they said: ‘We can’t tell you anything.’ So why are we here then? That was the whole point of the meeting, in my point of view, was to go over what they found,” Tanisha said.
In May 2020, the family made a formal complaint to the B.C. College of Physicians and Surgeons. They believe Carter received poorer care because he was Indigenous and that he should have been kept in the hospital overnight.
The college’s inquiry committee found shortcomings in the clinical care Carter received. It criticized the doctor for not ordering bloodwork. It found the X-ray should have raised the doctor’s concerns because it was “abnormal enough to warrant further observation or consultation.”
The records show that when the X-ray was examined by a radiologist the day after Carter’s visit to the emergency department, two possible conditions were flagged — an early small bowel obstruction or an ileus, a condition in which the bowel does not work correctly, but there is no structural problem causing it. Both conditions warranted immediate follow-up. But nothing further was done.
Carter’s medical history recorded on the chart and physical examination were “inadequate,” the college found. The doctor’s charting, which they described as “illegible,” was in contravention of the college standard for medical record-keeping.
The college found no evidence of racism. However, it determined further education was necessary “to protect the public” and asked the doctor to voluntarily take four courses — medical record-keeping, advanced pediatric life support, clinical communications and the San’yas Indigenous Cultural Safety Training Program.
The family was not happy with the report or the college’s disciplinary actions and appealed the college’s findings to the Health Professions Review Board of B.C. The review board found the college’s disposition was not transparent or justified.
“It lacks internal coherence and rationale for not criticizing the doctor in respect of Indigenous Race, yet ordering a remedial course to address this issue,” the review board said.
The report was sent back to the college for reconsideration, “with directions to justify its decision or issue a further disposition.”
That report is still pending.
“The doctor said, and I’m trying to be calm, ‘I didn’t know Carter was Indigenous,’ ” said McMenamie. “This is Cowichan, the largest band in B.C. You have a responsibility as a doctor working in that community to know [whether] people you are dealing with are Indigenous or not and to be culturally sensitive.”
Disregarding racism is racism itself, said McMenamie, who ministered in the Cowichan Valley and retired as bishop in May 2020.
“Indigenous people are invisible. So many people say ‘Oh I didn’t see.’ They’re invisible in our culture because of the racism and they identify that in the government report In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care.”
While Tanisha told the doctor that Carter could keep nothing down — that he threw up twice in the hospital, including the anti-nausea medication they gave him —that doesn’t appear in the medical notes, said Gill, the family’s lawyer.
“Nobody wrote it down. The trouble with the college, they put a lot of weight on the medical notes. Reading between the lines, they must have believed Carter was tolerating fluids.”
Island Health said it is unable to discuss the specific details of its review or the care provided to Carter due to patient privacy.
But it did say that the health authority met with the family in 2019 to explain the “details of Carter’s care experience while abiding by the parameters of Section 51” of the Evidence Act, which prohibits disclosure of information and documentation collected as part of a hospital’s quality of care review.
“Island Health acknowledges we should have engaged and included the family more closely in this review process and we apologize for that oversight,” the health authority said in an emailed statement to the Times Colonist.
“Since 2019, many changes have been made to care in emergency departments within Island Health, including emergency medicine chart documentation, diagnostic imaging procedures and ongoing education and appropriate use of Pediatric Early Warning Systems.”
According to Gill, there is fairly good policy justification for Section 51 of the Evidence Act. The hospital system has an interest in improving the quality of health care by examining poor outcomes, he said.
“If players in the system have to be concerned about future litigation, their participation might be guarded, incomplete or even misleading. By creating a legal barrier to the sharing of information given in a quality review, participants will be more likely to be forthcoming and candid, thus improving the value of the review exercise,” said Gill.
Unfortunately, that means the family will never have closure on why there was no follow-up on Carter’s life-threatening but treatable condition.
Carter’s story was never about lawsuits, said Gill, but about trying to prevent something similar in future.
“The family were trying to improve the system. They let the statute of limitations run out without launching a lawsuit. They did that with their eyes open.”
No more appeals
The family has an opportunity for another appeal to the Health Professions Review Board. But that’s not going to happen.
“We are going in circles at this point,” said Tanisha, who has decided not to pursue any further action. “We’ve done all we can. It feels like it’s time now to share his story.”
Tanisha wants parents to know they should listen to their guts and not worry about overreacting when their children are ill. When her infant daughter, Malia, became ill two years ago, she took the baby first to Cowichan District Hospital, then turned around and drove to Victoria General for a second opinion.
McMenamie, who assists at the Anglican Parish of Central Saanich, said his grandson’s death has affected his ministry in many ways.
“Every time we tell the story, the scab is ripped off,” said McMenamie. “We all carry the scars of grief.”
Declan, now eight, has been very affected by the death of his brother. He carries a photo album with pictures of Carter with him at all times. He talks about Carter, who would have turned 13 on Aug. 9, all the time, encouraged by both Tanisha and McMenamie.
McMenamie and his wife have found comfort in a book called The Phone Booth at the Edge of the World by Laura Imai Messina. It’s a story about a phone booth where those who have lost loved ones can go and speak to them and experience healing.
“To be able to speak to someone who has died is a huge part of healing the losses we experience in our lives,” said McMenamie. “A conversation in a phone booth, even one that is not connected, restores our spirit. Being able to speak to our loved one, our friend for that moment, releases all that grief has trapped inside. It allows us to connect with a hope beyond death.”
These phone booths are popping up all over the world, he said.
“It’s a powerful book. We were talking to the people at Royal Oak [Burial Park]. They’re thinking of putting one in.”
The family is continuing on their journey, telling Carter’s story, helping Declan and helping themselves heal.
“Carter is gone, but he’s still with us,” said McMenamie. “We see him at the lake. We see him in playgrounds. We see him climbing on the log boom. We tell Declan: ‘Say hello to him.’ ‘Hello Carter.’ ”
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