Investigators for the College of Physicians and Surgeons of Saskatchewan found a Regina doctor altered the medical records of a woman who died hours after being in her care — and they said those revisions indicate the doctor was more concerned about being criticized for her standard of care than creating an accurate record.
Despite that, the college didn't find fault with how Svitlana Cheshenchuk cared for 71-year-old Sandra Hendricks. The Regina woman died of a heart attack on October 17, 2014, just hours after an appointment with Cheshenchuk.
Hendricks' daughter is distraught at what she calls a lack of answers and accountability after the college's review of this matter.
"I want to know what happened to my mom," said Shelly Riffel. "She went to the doctor, came home and died."
Hendricks was already in dire straits while at Cheshenchuk's office, as indicated by an urgent electrocardiogram the doctor obtained, which indicated Hendricks may have been having a heart attack.
But instead of getting immediate care, she picked up her prescription from the pharmacist and went home, where she died a few hours later.
The autopsy found she had coronary artery disease, which "placed Ms. Hendricks at risk of sudden death."
Why would a woman in such a medical state leave the doctor's office? And why would the doctor let her go?
Those questions are difficult to answer with certainty, especially since Cheshenchuk has significantly revised the woman's medical records. Following an investigation by the college, the committee's July 2017 preliminary inquiry report concluded the record "was altered so many times it no longer is an accurate reflection of the examination of Sandra Hendricks."
That makes Riffel suspicious.
"I feel like she was trying to cover up that she didn't tell my mom to go to the hospital," Riffel told CBC's iTeam.
However, in the college's investigative report, it notes the doctor offered a range of explanations justifying why the changes were made.
Doctor says Hendricks refused to go to emergency
In Cheshenchuk's written response to the investigation, she said she warned Hendricks "that most likely she has heart attack and that she needs to be investigated further immediately."
Despite that warning, Cheshenchuk said Hendricks declined to go to emergency and went home. She said Hendricks was insisting she was merely suffering from bronchitis.
"I wished I could admit the patient to the hospital against her will but I was not in the position to do that," Cheshenchuk wrote.
But Riffel doubts her mother received such a warning for two reasons. First, she said her mother wouldn't ignore advice like that.
"I can't imagine if my mom was told she's having a heart attack, that she would just not believe and just say, 'Oh, I'm going home.'"
Second, she said Cheshenchuk's medical records can't be trusted.
According to the college's investigative report, Cheshenchuk learned of Hendricks' death on Oct. 20, 2014, which is three days after Hendricks' appointment.
On Oct. 20, Cheshenchuk altered the medical notes to indicate she told Hendricks to go to emergency, but she was reluctant. Yet the committee found that Cheshenchuk's "notes made on the day of the appointment (Oct. 17) do not make any reference to the advice that Dr. Cheshenchuk states she provided."
Cheshenchuk told the college she didn't finish writing her notes on the day of the appointment because she ran out of time.
Multiple alterations over 8-month period
According to the preliminary inquiry committee, over the next eight months the doctor made a series of additional changes that "indicate that she provided appropriate care to the patient and that the patient refused her advice."
Riffel said when she learned this, "I thought, well, why is she altering notes? And then I thought maybe — and no one can prove this — maybe my mom was never told that she was having a heart attack."
The nature of the alteration of records is indicative of someone who was concerned about being criticized for their standard of care. - Preliminary Inquiry Committee Report, College of Physicians and Surgeons
Cheshenchuk added notes indicating Hendricks didn't want to go to the hospital, didn't want to listen to advice, refused an ambulance, didn't want to provide contact details for family and "was obviously irritated by my advice."
In May 2015, seven months after Hendricks died, Cheshenchuk added blood pressure numbers to her record. When questioned about this by the college, Cheshenchuk said she had taken the blood pressure at the time of examination and recalled that it was normal, so she "just put in random numbers to reflect that."
The college found that Cheshenchuk failed to note that these were modifications or late entries to the record.
It said Cheshenchuk offered several explanations for the alterations. She said "these changes were a result of stress due to the patient's death" and she "wanted the records to accurately reflect the examination."
The college pointed out, though, that she couldn't "adequately explain how she recalled certain details months after the examination." The doctor blamed some of the changes on her "poor knowledge" of the medical records computer program.
The committee's report said "the nature of the alteration of records is indicative of someone who was concerned about being criticized for their standard of care, not the desire to accurately reflect the details of the examination."
Last month, it found Cheshenchuk guilty "of unbecoming, improper, unprofessional, or discreditable conduct" because she altered Hendricks' records and failed to disclose that fact to the college. She was reprimanded, suspended for a month and required to take ethics and record keeping courses.
'Is altering notes the worst thing that happened?'
Riffel said that is just a "tap on the fingers." She's stunned that inadequate record keeping is the only thing the college found wrong.
"I'm not sure if she should have done something different for my mom and is altering notes the worst thing that happened in this case?"
It feels like my mom's getting blamed for her own death even though she was going to the doctor to get help. - Shelly Riffel
While Riffel doubts Cheshenchuk did warn her mother, she said even if she did, is that really sufficient care?
"I don't understand why someone is being told to go to the hospital who the doctor thinks she's having a heart attack and she just lets her go. And that's OK."
It appears the college did investigate questions around the quality of care.
A January 2016 letter from the college to Cheshenchuk said one of the concerns it was investigating was that "your treatment of Ms. Hendricks may have failed to meet the standards of the medical profession."
But the college didn't lay charges related to Hendricks' quality of care. In an email to CBC, it said it can't charge a physician with unprofessional conduct "unless there is a reasonable probability of that charge being proved at a hearing."
In a letter to Riffel last month, an official explained "Dr. Cheshenchuk would have testified as set out in the report of the preliminary inquiry committee and there would have been no direct evidence available to challenge her evidence about what she told your mother."
In her letter to the college, Cheshenchuk said she feels sorry for the family's loss.
"In retrospect I really wish there were guidelines and procedures in place for involuntary hospital admission of patients in life-threatening situations. However, Mrs. Hendricks as an adult and mentally capable person, was the only one to decide whether to go or not to go to the hospital. I had no way to force her."
Riffel said that seems insensitive and wrong.
"It feels like my mom's getting blamed for her own death even though she was going to the doctor to get help."