Investigation critical of emergency care following death at Lions Gate Hospital

“Come back if your condition worsens.”

This is the advice countless patients receive before being discharged from the hospital emergency ward. It’s the direction that Natasha Forry followed on three separate occasions before she died at North Vancouver’s Lions Gate Hospital on Oct. 12, 2020.

“If Natasha had gotten proper care, perhaps she would be here today,” Ann Forry, Natasha’s mother, told Global News. “I don’t know. We’ll never know.”

Since her daughter’s death, Forry has been searching for both answers and accountability. She has filed formal complaints with both Vancouver Coastal Health and the College of Physicians and Surgeons of B.C.

“The problem is this didn’t have to happen,” she said.

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Global News has obtained a copy of the final disposition report by the college’s complaints and investigations inquiry committee. The 20-page document contains a detailed timeline of events based on the accounts of medical staff who were responsible for Natasha’s care. It also contains the committee’s discussions and criticisms.

According to the report, the 29-year-old first visited the Lions Gate emergency department on Oct. 2, 2020, due to pain in her pelvic area. Two doctors determined it was an abscess that needed to be drained. The procedure was uneventful. Natasha was provided with some pain medication and told to come back if she developed a fever or suffered from increasing pain.

On Oct. 9, Natasha returned to Lions Gate complaining of the onset of pain in her abdominal area and leg. Bloodwork and a CT scan showed some minor abnormalities but nothing considered serious. The doctor said her condition often can be resolved at home with pain medication. Once again, the advice was to return to emergency if there were signs of fever, nausea, vomiting and worsening pain.

She was back the next day with persisting pain and feelings of nausea. She was first assessed while lying on a stretcher and it was noted that she seemed uncomfortable from the pain. An inspection of the area showed no signs of swelling, redness or infection. She was given pain and anti-nausea medication and IV fluids, and bloodwork was ordered. The report states that she felt better and asked if should could go home to rest. She was discharged.

Eleven hours later, Natasha was taken back in an ambulance. When she arrived, it was documented that she had acute shortness of breath and complained of persisting leg pain. On examination, the attending physician noted she was in respiratory distress and required supplemental oxygen. There was also discoloration, tenderness and swelling in her right thigh. The treatment was steroid medication, two antibiotics and IV fluids. A CT scan showed significant deterioration in the appearance of the lungs compared to the images collected two days prior.

Natasha would later be rushed into surgery due to a potential “life/limb-threatening emergency.” She became pulseless during the procedure, but was resuscitated. She would lose her pulse once again back in the intensive care unit where she was pronounced dead.

“It was terrible because I was reliving it as Natasha and I was reliving it as myself. I was re-traumatized and I know how horrible it was,” said Forry about reading the report.

The college’s inquiry committee cleared the actions of all the medical staff except the one emergency physician Natasha saw on Oct. 10.

“Given that this was her third visit to the emergency the Committee believed a thorough reassessment should have been documented after the administered treatment and prior to considering the discharge home,” states the report in the committee’s discussion section.

“Had the vital signs not improved, or had deteriorated following treatment further investigation and or admission to hospital would have been expected.”

The college also stated “a significant drop in the serum albumin was underappreciated” determining it was “thus critical of the care provided.”

Aside from the one physician being called in for a follow-up interview, it is unclear whether any further steps will be taken and whether that information will be made public.

The College of Physicians and Surgeons of B.C. explained that further actions could include:

1. Informal resolution through correspondence, interviews, and/or educational activities
2. Formal consequences, short of discipline, including reprimands and practice restrictions
3. Referral to the registrar with direction to issue a citation and begin disciplinary proceedings

A physician can avoid heading to disciplinary hearings by accepting the college’s citation and suggested action. College investigation findings are only released if it results in a physician being disciplined.

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Vancouver Coastal Health declined Global News’ requests for an on-camera interview with a health authority representative or the doctor whose actions were criticized in the report.

“This incident was tragic and does not reflect the high-level of personalized care Vancouver Coastal Health strives to provide all our patients,” the health authority wrote in a statement.

It also pointed to three recommendations that include developing new criteria for managing patients who repeatedly return to the emergency without a clear diagnosis, an interdisciplinary learning review, and a clear process for follow-up for families after a serious event.

Forry told Global News that those recommendations were declared shortly after Natasha’s death, and said she has yet to receive any follow-up about implementation.

Vancouver Coastal Health was asked about the status of the measures, given more than a year has passed, as well as if any further action would be taken in regards to the doctor and its overall policies in light of the committee’s findings. The response was there was nothing to add.

“I have no way of really grieving because this just keeps coming back and there’s no real accountability or justice,” said Forry of the response.

“Nothing’s changed. I think it is all smoke and mirrors.”