In August 2019, nine-year-old Carter Bonsdorf was taken to Cowichan District Hospital complaining of severe stomach pain; he was also vomiting.
The care he received there was substandard. The follow-up later by oversight bodies was every bit as bad.
At the hospital the young boy was seen by an emergency physician who examined him and ordered an X-ray. Deciding he probably had flu, the doctor sent him home, with instructions to bring him back if things got worse.
Days later, Carter collapsed and became unresponsive. He was taken to Victoria General Hospital where surgery revealed his bowel had been punctured due to a congenital deformity. A third of his intestines were septic.
The boy then suffered a severe heart attack, and attempts to revive him were unsuccessful.
What followed, however, was in many respects as grievous.
Dissatisfied with the care Carter received in Cowichan, his parents talked with representatives of Island Health, which oversees hospitals on the Island.
At this meeting they were informed they could not be told the results of an internal review, due to Section 51 of the Evidence Act, which prohibits disclosure of the information collected.
Yet nothing in the act prevented health authority officials giving the parents a general understanding of where matters stood. They simply shooed the parents away.
Still dissatisfied, the parents then complained to the B.C. College of Physicians and Surgeons, the professional oversight body for physicians.
The College determined that the emergency doctor should have ordered blood work, and should have seen enough on the X-ray to call in an expert radiologist. He was found in need of further training, and agreed.
But was this really sufficient? As a result of the emergency physician’s failings, Carter’s life-threatening condition went undiscovered until it was too late.
Doesn’t that at least warrant a censure? The College felt not.
The parents then appealed to the Health Professions Review Board of B.C., the body which oversees decisions by professional health-care colleges (there are 15 in all).
The board published a review of the College’s findings, in the kind of tortuous language that would defeat a trained lawyer.
In essence though, it found the College’s decision “incoherent” in places, and noted that additional remedial steps, such as censuring the physician, had not been adequately considered given the facts presented.
Yet the board took the narrowest view of its powers. Perhaps that’s because it deems itself obliged to treat the College with “respect.” What was needed here was respect for the young boy and his family.
In any case, the board merely referred the matter back to the College to deal with as it saw fit. That left the College all the room it needed.
When we asked College staff when they anticipated responding to the board’s recommendations, they refused to say.
We were told peremptorily that the College only responds when directing a “public reprimand or citation for discipline.”
That leaves only one inference. The College has no intention of taking the matter further, the board’s critical findings notwithstanding.
Several conclusions can be drawn. At every stage in the oversight proceedings, no consideration was shown for the parents or the broader public interest.
On the contrary, the entire process appears to have been organized with the purpose of sparing the various actors embarrassment, or evading accountability.
Rather than protecting the public, the responsible authorities charged with oversight appeared more interested in following the path of least resistance, and taking care not to upset any apple carts.
Yet a young boy with his life ahead of him is dead. That should not be covered over with bafflegab and obscure legalisms.
A shakeup is required.
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