Health minister Adrian Dix said he’s taking the rare step of ordering an independent review into a patient’s death because of the family’s continuing concerns after the initial investigation conducted by two health agencies.
The Vancouver individual, whose identity is being withheld, died in November 2018 and the only detail Dix would disclose is that paramedics had difficulty “accessing” the patient.
Dix conceded it is rare for health ministers to intervene in such cases and this is the first time he has done so since he became health minister two years ago. But he felt it was important for family members who told him that they wanted “fresh” eyes on the circumstances leading to the death.
“I just felt we needed to do more,” he said, referring to the patient safety review that B.C. Emergency Health Services and Provincial Health Services Authority carried out right after the death.
The new review will delve into the medical care in the weeks before the death and the emergency response “in the hours surrounding the death.”
The previous investigation was conducted with so-called Section 51 protection, which means there is no public disclosure. Section 51 safety reviews are conducted to see if anything can be learned from a death and suggest steps to prevent reoccurences.
Dix said the new study will have more transparency and will give family members more access to information and findings; the report will also be made although some information may be redacted “for the sake of privacy.”
Dix said he could have referred the case to the Patient Care Quality Review Board but in this case, there was a “technical glitch” that would have meant passing a new regulation. So, he said he decided to refer the case to Dr. Jim Christensen, an emergency physician at St. Paul’s Hospital in Vancouver and head of the academic department of medicine at the University of British Columbia. He will be assisted by Dr. Michael Feldman, the paramedic services medical director and provincial dispatch medical director at Toronto’s Sunnybrook Centre for Prehospital Medicine.
In a purposely vague media release, the ministry of health said the review panel will have the “co-operation” of four agencies — Providence Health Care, VCH, BCEHS and PHSA.
“British Columbians can and do rely on our emergency responders when they are at their most vulnerable,” Dix said in the announcement. “Whenever we are faced with a case that may warrant a review, we look to independent experts who can look for learnings and suggest improvements that will benefit patients, first responders and the system as a whole.”
The government will receive the report by July.
Officials with PHSA would not comment on the internal review process that has already taken place. On its website, PHSA states: “When a patient safety event occurs, the goal is immediate management, disclosure and analysis of the event through a structured process, focused on system improvement, that aims to identify what happened, how and why it happened, whether there are any ways to reduce the risk of recurrence and make care safer. PHSA conducts patient safety event reviews in accordance with Section 51 of the B.C. Evidence Act.”
The review is meant to enable “full, open and candid discussions amongst health care professionals” with the goal of improving care for future patients. Further education or policy changes may be recommended.
“Patient safety event reviews do not preclude health-care professionals from cooperating in other reviews by outside investigative bodies, such as the police or regulators, nor do they shield health care professionals or PHSA from potential civil suits.”