N.S. family blames hospital staff for 'hastened' death
Health authority denies claims but it's made changes in response
The last morning Tracy Gilbert saw her father alive, she walked into his room at the palliative care unit in Truro, N.S., and noticed he was struggling.
He was pulling at the sheets and moving his arms, she says, and it was obvious something was wrong.
At first, Gilbert thought her father was itchy. But two hours later, she realized it was much more severe — the bedside oxygen machine her family had become used to hearing had gone silent.
"There is no way that anybody can look at us and tell us that they didn't know he needed oxygen to live," said Gilbert.
Donnie Taylor's family alleges he went 13 hours without oxygen after he was returned to his hospital room following a family gathering down the hall.
The 69-year-old man died the next day — Aug. 23, 2017.
Taylor had a long battle with chronic obstructive pulmonary disease (COPD) believed to be caused by asbestos exposure on the job. In his final months, he was diagnosed with lung cancer.
But Taylor's family claims the lack of oxygen "hastened" his death.
Hospital staff doesn't agree. However, changes were made on the palliative care unit following Taylor's death.
"Instead of celebrating a birthday we were at a funeral home for his 70th birthday," said Kelly Knox, Taylor's daughter.
Sandra Taylor says she was discouraged from bringing her husband home from the hospital, and now lives with regret.
Health records obtained by CBC News confirm Taylor was prescribed five litres per minute of oxygen, but was only getting 10 per cent of that on the morning of his death. When the family notified a nurse about their discovery, the nurse immediately turned Taylor's oxygen level back up to five litres.
Pushing for answers
Seventeen months later, the Taylor family continues to push for answers. They recently filed a complaint with the College of Registered Nurses of Nova Scotia, hoping it will lead to disciplinary measures.
The Nova Scotia Health Authority (NSHA) conducted its own quality review following Taylor's death that resulted in several policy changes at Colchester East Hants Health Centre. The Department of Health also completed two investigations after the family filed a complaint.
The family has had several meetings with hospital officials, including at least one with senior management. The health authority has apologized to the family in writing and in person for their loss.
"It tells me that somebody said, 'Uh oh, something wrong here. We need to check this out,'" said Taylor's widow, Sandra.
"And, in the hospital's mind, they knew they were in trouble."
As a result of the quality review, staff at Truro's palliative care unit was ordered to "review documentation practices related to checking oxygen administration levels throughout each shift" and "provide intentional education regarding the role of oxygen on the Palliative Care Unit."
Staff were also trained on "development of communication skills."
The health authority will not comment on the case. Because it was a "serious reportable event" that led to a quality review, the health authority said all details are confidential.
Dr. Dave Henderson, senior medical director of integrated palliative care at the health authority, said a lot of work is happening behind the scenes to improve palliative care in Truro and across the province.
He said more than 1,200 health professionals have received additional training through a program called Learning Essential Approaches to Palliative Care (LEAP) in the last few years.
"Often still in nursing schools and medical schools, we don't get as much training as we would like in palliative care," said Henderson. "So we're working on that both provincially and nationally but also for those people that are out working already."
In the last year, the health authority's northern zone, which covers Colchester, Pictou County and Cumberland, received funding for three part-time palliative care social work positions. A full-time social worker has also been hired to focus on bereavement, grief and wellness counselling for the region.
One of those social workers has been working closely with the Taylor family.
Sandra Taylor said her husband knew he was dying and he had spent months preparing with palliative care staff for a comfortable death.
"He thought, you know, eventually, 'I would just sleep longer, and one time I just won't wake up.' And it should have been that way. That was the whole plan," she said.
Instead, his loved ones believe he spent his last day in pain.
Taylor's hospital charts indicate he was not in distress the night before his death. Rather, that he had apnea and appeared "congested." Sandra Taylor was called by staff around 6 a.m.
A review conducted by the Department of Health determined the family's claims of neglect were unfounded. Although on the question of how the drastically reduced oxygen levels ultimately affected Taylor's death, the report is inconclusive.
In her report, compliance officer Adele Griffith said: "It was reported by palliative care staff that it cannot be definitively determined that the affected patient did not suffer any discomfort because of the incorrect oxygen flow being administered; however, there is also no evidence to the contrary from staff."
It was also not confirmed in Griffin's findings that Taylor required continuous oxygen 24 hours a day.
The family strongly believes Donnie Taylor did require continuous oxygen.
They allege it was never turned back on following an early birthday party for Taylor the day before he died. Taylor was wheeled down the hall to a party room on portable oxygen, where his wife and daughters say he wasn't verbal but was aware of his surroundings.
Once the party was over, the family left around 8 p.m. Sandra Taylor said when she was walking out the door, nurses were moving him back to his room.
"When he didn't get the oxygen turned on [on] the wall, when that happened that may have been a chaotic error, maybe, you know, it's possible things like that can happen," she said.
But Taylor said she got angry when no one owned up to the alleged mistake.
"He didn't have oxygen and somebody didn't give it to him. And in this case they were special palliative care nurses and doctors."
Sandra Taylor is demanding answers from the four people who cared for her husband.
Knox believes the "culture of acceptability" within the palliative care unit needs to change.
"It's because you're dealing with somebody who isn't going to remember anyway. You know, they're pretty much really not going to know, right? And that is not acceptable," she said.
"Why would you say that about a man who spent his whole life caring about people and their rights. To have that happen to you and to your family … it's just wrong."