REGINA – His daughters said Earl Luhr was a healthy, vibrant, 79-year-old man before he began to have trouble swallowing.
Eventually, Luhr had a couple of choking episodes, so he was admitted to Regina’s Pasqua Hospital in December 2013.
It’s there, Linda Bandorf and Lori Urszulan believe, a series of mistakes led to their father’s death.
“We want to ensure someone can go into a hospital comfortable that equipment is working and functional,” Urszulan told reporters at the Saskatchewan legislature Monday.
After a brief discharge, Luhr returned to the Pasqua to have a liquid feeding system inserted. He was transferred to a transitional ward on Jan. 2, 2014, Urszulan said.
“You could see it in his eyes. He was asking for help.”
According to a Regina Qu’Appelle Health Region fact sheet, it is standard policy to place a patient in a temporary area until an inpatient bed is available in the ward where they’re supposed to be cared for.
Urszulan said she was later told the transitional ward is used for patients awaiting placement in long-term care, many of whom suffer from dementia.
Luhr ‘s liquid food was not properly transferred to the unit, the family said, so he rapidly lost weight. On Jan. 6, 2014, they said Luhr was improperly fed, which caused liquid to go into his lungs.
“You could see it in his eyes. He was asking for help.”
Medical records show nurses attempted to suction the liquid out, but the device “quit working.”
A “code blue” was called, but the family said a crash cart – essentially a portable cart equipped with emergency life support items – was unable to enter the ward due to door locks meant to prevent dementia patients from leaving.
“They did not have an override key or code to get onto the floor to come for assistance,” Urszulan said. “Everything just took too long and my father died.”
“I want to know how my father can choke to death in a hospital with nurses around him,” Bandorf said.
‘Dangerous consequences’
The Opposition NDP raised the issue in Monday’s question period, linking Luhr’s death to overcrowding in Saskatchewan hospitals. NDP leader Cam Broten said Luhr’s case proves the issue can be fatal.
“When someone is having incredibly bad choking episodes and there’s no diagnosis yet, help needs to be nearby,” Broten said. “It cant’ be 30 minutes away, it needs to be seconds away.”
Two months prior to Luhr’s death, the Regina Qu’Appelle Health Region issued an alert that some elective surgeries had to be cancelled due to capacity issues.
RQHR said on Oct. 11, 2013, Regina General Hospital was at 111 per cent capacity while Pasqua Hospital hit 114 per cent.
Improved critical incident reporting
Urszulan and Bandorf want to see a list of improvements, including better reporting of critical incidents, nurses in all hospital wards to be properly trained in tube feeding and code blue teams to have an override key to access locked doors.
A government spokesperson said RQHR has made internal changes to the way orders are written for tube feeding and the way they’re administered. Health Minister Dustin Duncan also cited improvements to the timeliness of patient discharges and knowing when inpatient beds have been made available.
“When you check into a hotel, you know you’re checking out at 11 o’clock in the morning,” Duncan said. “In the hospital, we kind of left it up to chance a lot of the time.”
The health region issued an apology to the family in December 2014. “We feel that we have failed Earl and his family in a time we were most needed. For that we are truly sorry,” the letter reads.
It also notes that many aspects of Luhr’s care were “less than satisfactory.”
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