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Comment: No apology, no discipline after boy's death

Nine-year-old Carter Bonsdorf was taken Cowichan District Hospital in medical distress. A doctor sent him home. A week later, Carter was dead.
Tanisha Bonsdorf holds a portrait of her son Carter Bonsdorf who died on Aug. 24, 2019 at age nine. DARREN STONE, TIMES COLONIST

“Every family deserves a ­doctor” say the signs on so many of our neighbourhood boulevards.

Carter Bonsdorf, a nine-year-old boy in medical distress, deserved one, too. But not the one who saw him at Cowichan District Hospital that August midnight four years ago and sent him home.

Carter’s death a week later at Victoria General Hospital might have been avoided. His family hopes his story helps to make other parents aware of what can happen when doctors make mistakes.

We might place part of the blame on the fractured medical care our governors provide and we citizens pay for. For what is available to those in neighbourhoods with signs on boulevards cannot be so easily available in rural places.

Hospitals in sparsely populated regions expect fewer patients needing urgent care than those in cities do.

Carter’s family are under the impression that the doctor who saw him was a family physician who was designated on call to provide emergency care. Island Health says the Cowichan District Hospital emergency department is staffed in shifts on site by physicians certified to provide emergency medicine and has been since 2015 — four years before Carter’s short visit.

What really matters is that Carter’s doctor failed to provide emergency care.

In many medical schools prospective doctors are sworn to the Hippocratic oath, part of which has been interpreted as “first, do no harm.”

That doesn’t have to mean “do nothing” — but that’s basically what this doctor did. The doctor looked at the x-ray he ordered, told Carter’s mother and father, Tanisha and Alan, to take their boy home and give him Tylenol for pain “if required.”

In meeting with the two hospital officials after Carter’s death, the parents learned nothing: B.C. law requires that information given in a quality care review be kept secret to protect witnesses from legal action and encourage them to be forthcoming and candid.

Transparency of the process is not prescribed. It is a process in isolation.

An inquiry committee of the B.C. College of Physicians and Surgeons found the doctor’s charting “illegible,” the history of the case “inadequate,” the lack of blood-work, and the failure to follow up what the x-ray showed. It ordered the doctor to take courses which are voluntary and the doctor agreed to.

One of the courses was the San’yas Indigenous Cultural Safety Training Program, though the College inquiry found no “evidence” of Indigenous racism by the physician.

Carter’s family appealed the College’s findings to the Health Professions Review Board. It found that the inquiry committee “failed to address and discounted (the doctor’s) racism and discrimination” and had “no justification” for its prescribed remedy. It told the College to try again.

Perhaps the medical complaint process itself isn’t capable of dealing with allegations of racism and discrimination and should stick to things medical. Perhaps too much is expected of a process in which doctors are empowered to deal with complaints against one of their own.

Without physical expression, how does one produce “evidence” of such a thing unless it’s admitted by the person in question? There’s no doubt Carter’s family suspected racism based on what the doctor did and didn’t do.

The B.C. government’s ­Indigenous-led 2020-21 report In Plain Sight found Indigenous racism widespread in the health care system “especially in urgent care.”

The doctor who saw Carter reportedly said he didn’t even recognize that the boy was Indigenous. Yet the doctor works by the largest First Nations band in the province — about 5,000 souls, half of whom live on reserve lands.

Not being recognized is a feeling shared by First Nations across Canada: The rest of us don’t recognize them, their spiritual beliefs and customs. And we don’t recognize their traditional lands even though it’s customary now to acknowledge our trespasses.

Carter’s family has given up the fight. It has given up waiting for the College to issue a new report. It has no interest in trying other avenues.

No one in Island Health has apologized. No disciplinary action has been taken.

But Carter’s story has been told. That, not revenge, not even justice, is what his family wanted.

A too-short life has been acknowledged.

It’s now an echo for loved ones left: Laughter, boy shouts, water splashing, oars knocking on boats.

The call of a loon on a lake, alone.

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