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REPORT TO THE MINISTER OF JUSTICE AND ATTORNEY GENERAL

IN THE MATTER OF

THE PUBLIC FATALITY INQUIRY

OF

DR. MICHAEL ANTHONY JENSEN

Judge S. L. Van de Veen

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TABLE OF CONTENTS

REPORT TO THE MINISTER OF JUSTICE .....................................................................................................1

INTRODUCTION ...............................................................................................................................................2

IDENTITY, DATE, TIME AND PLACE OF DEATH............................................................................................3

EVIDENCE RELATING TO THE CIRCUMSTANCES UNDER WHICH DEATH OCCURRED.........................3

(A) Medical Examiner’s Report ........................................................................................................3

(B) Evidence of Dr. Williams ............................................................................................................3

Events Prior to Surgery ..............................................................................................................3

The Surgery ...............................................................................................................................4

(C) Evidence of Dr. Jensen’s Mother – Dorothy Dawe ....................................................................5

(D) Evidence of Mr. Jensen – Dr. Jensen’s Father ..........................................................................6

(E) Evidence Regarding Nursing Care – Pre-Operative to ICU .......................................................6

1. Pre-Operative........................................................................................................................6

Nancy Salthammer...............................................................................................................6

2. Day Surgery Unit – Pre-Op ...................................................................................................8

Carleen Christensen.............................................................................................................8

3. Operating Room....................................................................................................................8

Amy Sartori ..........................................................................................................................8

4. Recovery Room ....................................................................................................................9

Susan Wright – Recovery Room Nurse ...............................................................................9

Cheryl Renkas – Recovery Room Nurse ...........................................................................10

5. Day Surgery Unit – Post-Op................................................................................................11

Carrie Lynn Tuck................................................................................................................11

Carol Anne Martinson – Day Surgery Unit Nurse...............................................................12

Susan Seitz – LPN Day Surgery Unit.................................................................................14

6. Outreach Team – Code 66..................................................................................................14

Nancy Van Berkel – ICU Nurse – Code 66 Team..............................................................14

7. Intensive Care Unit (ICU) ....................................................................................................15

Heather Cathro - ICU Nurse...............................................................................................15

Jody Fitzpatrick – Nurse – Code Blue Team......................................................................15

Staci McPherson – Respiratory Therapist..........................................................................16

Deborah Willis – Respiratory Therapist..............................................................................17

Michelle Pemberton – Respiratory Therapist .....................................................................19

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(F) Administration Protocols and Policies ...........................................................................................20

Janice Stewart – Director, Heart Health (Cardiac Services) ..............................................20

Debbie Goulard – Director, Emergency Services, Calgary Health Region (CHR) .............20

CAUSE AND MANNER OF DEATH................................................................................................................22

Dr. Sam Andrews – Assistant Chief Medical Examiner, Province of Alberta.......................................22

Dr. Robert Williams – Ophthalmologist ................................................................................................23

Dr. Yair Rubin – General Anaesthesiologist, Rockyview Hospital .......................................................24

Dr. Peter Samuels – General Anaesthesiologist, Rockyview General Hospital...................................27

Dr. Joey Kevin Grochmal – Resident, Rockyview Hospital..................................................................29

Dr. Paul James Emile Boiteau – Head, Department of Critical Care Medicine, U of C .......................31

Dr. Gregory Schnell – Cardiologist ......................................................................................................34

Dr. Peter Singer – Deputy Chief Toxicologist, Alberta – 1988 – May 2010 .........................................35

Dr. Richard Merchant – Clinical Associate Professor, Department of Anaesthesia, UBC ...................36

Dr. Juan Jose Ronco – Clinical Professor (Critical Care and Respiratory), UBC ................................38

ALBERTA HEALTH SERVICES CHANGES IMPLEMENTED AFTER THE DEATH OF DR. JENSEN..........41

RECOMMENDATIONS FOR THE PREVENTION OF SIMILAR DEATHS .....................................................41

1. The need for enhanced monitoring of complex patients throughout their hospitalization

including pre-operative care and post-operative care, even in cases of minor surgery ...........41

2. Consistency with respect to monitoring guidelines for nurses in the day surgery unit .............43

3. Review of communication protocols and practices at Rockyview General Hospital regarding

transfer of care of patients .......................................................................................................44

4. Paging and follow-up procedures with on-call physicians........................................................45

6. The use of ECMO (Extracorporeal Membrane Oxygenation) equipment ................................45

7. Request for legal authorization from parents immediately after notification of death...............46

CONCLUSION.................................................................................................................................................46

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CANADA Province of Alberta

Report to the Minister of Justice and Attorney General Public Fatality Inquiry

Fatality Inquiries Act

WHEREAS a Public Inquiry was held at the Provincial Court of Alberta

in the City of Calgary, Alberta , in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village)

on the 18th – 27th day of November , 2009 , and by adjournment year

on the 29th day of January , 2010 , and by adjournment year

on the 29th – 30th days of April 2010 , and by adjournment year

on the 1st day of September 2010 , and by adjournment year

on the 15th day of October 2010 , and by adjournment year

on the 23 – 25th days of November 2010 , and by adjournment year

on the 28th day January 2011 year

before Judge S. L. Van de Veen , a Provincial Court Judge,

into the death of Michael Anthony Jensen 29 years (Name in Full) (Age)

of #39, 5400 Dalhousie Dr. N.W., Calgary, Alberta and the following findings were made: (Residence)

Date and Time of Death: January 12, 2007 at 0200

Place: Rockyview General Hospital, Calgary, Alberta Medical Cause of Death:

(“cause of death” means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).

Undetermined Natural Causes

Manner of Death: (“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable – The Fatality Inquiries Act, Section 1(h)). Natural

Report – Page 2 of 46

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INTRODUCTION – [1] One of the purposes of the Fatality Inquiries Act is to reassure the community and the family and friends of the deceased that the death of their loved one has not gone unnoticed and is important. It is also to provide the Minister, the family, and the community with information and details concerning the circumstances and the cause and manner of the death. This Report to the Minister is intended to accomplish that purpose and also, with the benefit of hindsight, to make any recommendations arising from the evidence at the Inquiry which may prevent similar deaths in future. [2] Section 53(3) of the Fatality Inquiries Act specifically prohibits the Inquiry from making any findings which include conclusions of law or assignment of legal responsibility or blame. The purpose of the Inquiry is to determine, as far as possible, the matters set out in s.53 of the Fatality Inquiries Act which includes the circumstances, the cause, and the manner of the death of Dr. Jensen. [3] The conduct of this Inquiry has limitations set out in the Fatality Inquiries Act. One of these is that the combination of s.45(1) of the Act and s.9 of the Alberta Evidence Act limits the power of the Court to compel documentary evidence. Section 9 of the Alberta Evidence Act prohibits the Fatality Inquiry from compelling evidence in the nature of Quality Assurance Records which are prepared to study, assess, and evaluate the provision of health services with a view to their continual improvement. Such documentation would include the review the Rockyview General Hospital or the Alberta Health Services itself would have done surrounding the death of Dr. Jensen. This document could greatly have assisted the Inquiry to focus upon relevant evidence and issues. In its absence, given the complexity of the medical evidence required at this Inquiry, it was difficult at times to identify and address relevant evidentiary issues in this case. However, the expert evidence was of assistance in this regard. [4] It is clear there are good reasons why the Quality Assurance Records are not compellable, and these have to do with ensuring an open and candid process of the Quality Assurance Review. If staff participating in such reviews are in jeopardy of having their participation become public at the Fatality Inquiry itself, they may be reluctant to fully participate in the process. The Quality Control Review itself could thereby become of limited value in its purpose to ensure continual improvement of care. [5] However, Fatality Inquiries by their nature do not have the benefit of the examinations for discovery process available in other civil proceedings and hence, some evidentiary issues do not become clear until after witnesses have testified or even until the Inquiry evidence itself is complete and the submissions have been made. At such times, in the following Report, I have stated that the evidence is either unclear on the matter, or the question raised by the evidence was not pursued. [6] This particular Fatality Inquiry is unique in a number of ways. Firstly, the mother of the deceased, Ms. Dawe, is a lawyer and has therefore the knowledge and skills to participate extensively in the conduct of the Inquiry. As an example of the time and energy she has spent, she filed a 94 page submission with the Inquiry at the conclusion of the evidence and this document includes some eleven suggested recommendations to prevent similar deaths. In addition, she actively participated in the determination of the witnesses to be called and the cross-examination of those witnesses. A variety of counsel meetings were held throughout the course of the Inquiry and she was actively involved in those as well. She is to be commended for her efforts with respect to the conduct of the Inquiry. [7] Usually families of the deceased lack legal representation at Fatality Inquiries and therefore their participation is very limited. Unfamiliar with legal proceedings, they often feel intimidated by the process and as a result their participation is usually restricted to merely being present and having status as a participant. Rarely do they direct questions to witnesses or feel confident enough to evaluate the evidence or suggest recommendations to avoid similar deaths. This is unfortunate as it is often the family who have the most personal interest in the circumstances of the death of their loved one.


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[8] Another uncommon feature of this Inquiry is that two expert witnesses from other jurisdictions were called at the direction of the Court. Both an expert anaesthesiologist and critical care specialist testified as experts, having had the benefit of reviewing the entire medical evidence in this case in advance. The expert witnesses were Dr. Merchant, a specialist in anaesthesiology and Clinical Associate Professor at the Department of Anaesthesia at the University of British Columbia and Dr. Ronco, a critical care and respiratory specialist and Clinical Professor of Medicine (Critical Care and Respiratory) at the University of British Columbia. Their evaluation of the circumstances of the death of Dr. Jensen and possible causes of his death, with the benefit of the advance review of the entirety of medical evidence, have been very helpful. This is especially true since the autopsy in this case was inconclusive with respect to the determination of a cause of death, and the testimony of each practitioner who treated Dr. Jensen focused upon their individual specific area of care. [9] I have set forth a significant degree of detailed evidence from each of the witnesses who testified at the Inquiry in order to provide the basis for the Recommendations I have chosen to make in this case and to provide the Minister and the practitioners involved in this case with as much information as possible concerning the death of Dr. Jensen. IDENTITY, DATE, TIME AND PLACE OF DEATH – [10] Doctor Michael Anthony Jensen died on January 12, 2007 at 0200 at the Rockyview General Hospital in the City of Calgary, in the Province of Alberta. EVIDENCE RELATING TO THE CIRCUMSTANCES UNDER WHICH DEATH OCCURRED – (A) Medical Examiner’s Report [11] From the Certificate of Medical Examiner, Dr. Jensen was at the Rockyview General Hospital for an elective vitrectomy (eye surgery that removes some of the clear jelly from inside the eye) on January 11, 2007. After the surgery and while he was in recovery, his blood pressure dropped (hypotensive) and his blood became poorly oxygenated (cyanotic). He was transported to the Intensive Care Unit (“ICU”) where a transesophageal echocardiogram revealed no movement of the right side of his heart. His condition deteriorated and he died in the early morning of January 12, 2007. He had a past history of cerebral palsy. (B) Evidence of Dr. Williams –

Events Prior to Surgery

[12] Dr. Williams was the physician who referred Dr. Jensen for the vitrectomy. Dr. Jensen was referred to Dr. Williams from the Gimbel Eye Centre in August of 2006, after Dr. Jensen had been diagnosed with uveitis, an inflammation of the iris and the blood vessels that coat the inside of the eye. Dr. Williams noted a loss of vision in Dr. Jensen’s eye as well as inflammation along with acute retinal necrosis, which involves a viral infection of the retina. He confirmed that it is possible this infection was of the same type of viral infection that can cause cerebral palsy. [13] Dr. Jensen was admitted to hospital for two to three days in August of 2006 for a course of antibiotics and steroids that were intended to reduce the inflammation and the infection. At that time Dr. Williams believed that the progress of the disease had been slowed by this treatment and Dr. Jensen was directed to continue taking medications orally after his discharge from the hospital. It was known by August of 2006 that at some point in time Dr. Jensen would likely develop retinal detachment. On September 1, 2006, Dr. Williams provided laser treatment to wall off the diseased part of the retina from the portion that was healthy


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in an effort to prevent further deterioration and further detachment of the retina. Dr. Williams was uncertain what sort of anaesthetic was used during this procedure, but believed that it would have probably been a “block” rather than a topical or peribulbar1 anaesthetic. Dr. Williams felt that the laser treatment worked for awhile and Dr. Jensen had regular follow-ups in Dr. Williams’ office afterwards. However by December 2006, Dr. Jensen’s vision was deteriorating and Dr. Williams had concerns about the health of the optic nerve. [14] On January 3, 2007, Dr. Jensen attended the emergency department after a sudden change in vision. His retina had become detached and he returned to Dr. Williams’ office on January 5, 2007. The discharge instructions from the visit to the emergency department noted tachycardia, but Dr. Williams did not feel that this had anything to do with Dr. Jensen’s eye problems and confirmed that he had no other information about the status of Dr. Jensen’s heart. [15] During the January 5, 2007, office visit, the decision to attempt surgery was taken. Ms. Dorothy Dawe, Dr. Jensen’s mother, was also present at that meeting. Dr. Williams knew that because of the damage to the optic nerve that had already occurred, the prognosis for Dr. Jensen’s vision was poor, even if the retina could be reattached. In addition, the damage to Dr. Jensen’s retina, in combination with the pre-existing scar tissue suggested that surgical repair would be difficult. Dr. Williams recommended that surgery not be attempted although this would have meant that Dr. Jensen would lose vision in that eye. [16] Dr. Jensen was insistent that he wanted to try the surgery, understandably in order to save his vision in the eye. Dr. Williams accordingly put in a booking request for the Rockyview General Hospital on a relatively urgent basis, meaning that Dr. Jensen did not need to be operated on that day, but that the surgery needed to be scheduled quickly. [17] Dr. Williams testified that there are usually several options to repair retinal detachment, but in Dr. Jensen’s case, because of existing scar tissue and anticipated difficulties, a vitrectomy was required. He confirmed there are two anaesthetic options for this surgery, local and general. Most patients, indeed 95% of patients, have local anaesthetic because it is safer, and involves less discomfort. In Dr. Jensen’s case, local anaesthetic was not a reasonable option, because the surgery would be longer than one-and-a-half hours, and difficult. In addition, Dr. Williams believed it would be very difficult for Dr. Jensen to be able to lie still on the operating table for more than two hours, due to his cerebral palsy condition. [18] Dr. Williams was aware that Dr. Jensen had experienced breathing and heart rate issues on recovery from a previous general anaesthetic and that these issues were most likely from cerebral palsy interaction. He booked Dr. Jensen for day surgery estimating the time needed for the actual surgery to be one hour and twenty minutes. When completing the booking request, Dr. Williams did not indicate a pre-admissions clinic with an anaesthesiologist would be required in Dr. Jensen’s case. He felt the cerebral palsy itself did not warrant a referral to the pre-admission clinic because he did not have any specific recollection of discussing previous problems with anaesthetic directly with Dr. Jensen. He left the final determination of what sort of anaesthetic should be used in the surgery to the anaesthesiologist. Dr. Williams shared his concerns regarding Dr. Jensen’s ability to stay still for the length of the surgery when he conversed with the anaesthesiologist prior to the surgery. He believed that the booking request forms would be reviewed by an anaesthesiologist before being received by the day-surgery unit and it was his evidence that patients were often referred to pre-admission clinics through this review process. However, there was a short-time frame between the booking of the surgery on January 5, and the date of surgery being January 11, and it might be that a pre-admissions clinic review process did not occur because of this short time frame.

The Surgery [19] On a scale of 1 to 10, Dr. Williams described Dr. Jensen’s surgery as an 8 or 9 in terms of difficulty. After removing as much scar tissue as possible, Dr. Jensen’s eye was filled with perflurocarbon liquid and laser treatment was also done on the eye. Dr. Jensen had more bleeding than is usual in this type of surgery

1 Peribulbar denotes the area around the eye.


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but this was dealt with successfully. The surgery lasted one hour and thirty-five minutes (from 1350 to 1525)2, and therefore took fifteen minutes longer than the one hour and twenty minutes initially expected. There were no concerns about Dr. Jensen’s vital signs or general status during the surgery. [20] The perflurocarbon liquid was later removed and replaced with air and then with silicone oil to which F6H8 (a substitute for the vitreous humour that had been removed) had been added to make it heavier and therefore allow it to better hold the newly re-attached retina in place. F6H8 had become available in Canada in late 2005 or early 2006, but had been used in Europe for six to seven years. Dr. Williams testified that he had used it in previous surgeries without any difficulty and he described the substance as “terrific stuff” in terms of allowing greater success for these types of surgeries. Whether any medication or substances used in the surgery played any role in Dr. Jensen’s death was examined by the Inquiry and will be discussed later in this Report. [21] The surgical report indicated that Dr. Williams administered a regional block to Dr. Jensen during the surgical procedure. Since this is his usual practice, and since it was listed in the surgical form completed by the nurses throughout the course of the operation, it is his belief that this is what he did in this case. A regional block is a local anaesthetic administered into the side of the eye and behind the eye to provide pain relief following surgery. He consulted the anaesthesiologist about administering this regional block and does not believe the regional block would add to the impact of the anaesthetic. [22] Of note is the evidence of Dr. Rubin, the anaesthesiologist, who testified that he told Dr. Williams to administer the retinal block at the beginning of the surgery in order to avoid any opioids being administered to Dr. Jensen during the surgery itself. However, Dr. Williams does not recall doing this at the beginning of the surgery, nor being requested to do so. The question of whether the administration of the retinal block during the surgery, rather than at the outset of the surgery as recommended by Dr. Rubin, contributed to Dr. Jensen’s deterioration was not explored by the Inquiry. [23] Dr. Williams saw Dr. Jensen briefly following the surgery to advise him that he felt Dr. Jensen should remain in hospital overnight, primarily because of pain that was anticipated due to the difficulty of the surgery. This decision was taken at about 1700 or 1800 and at that time Dr. Jensen was sitting up in bed and “quite alert”, in the words of Dr. Williams. Dr. Williams had no concerns about Dr. Jensen’s condition at that time and he did not find out until the next morning that Dr. Jensen had died. He was surprised that he was not contacted when Dr. Jensen’s situation became acute, but since Dr. Jensen was the only one of his patients to have died, he wasn’t certain whether it would be usual for him to be contacted. (C) Evidence of Dr. Jensen’s Mother – Dorothy Dawe [24] Ms. Dawe recounted Dr. Jensen’s birth and medical history and noted that he had spastic quadriplegic cerebral palsy. His physical difficulties included trouble swallowing, and gross and fine motor impairments in his arms, hands and legs, particularly on his right side. He was able to walk but had an uneven gait and developed scoliosis. He did not suffer from any cognitive impairment and had successfully completed a Bachelor of Arts with Distinction in 2001 and a Master of Arts in 2003. At the time of Dr. Jensen’s death, he was a doctoral student in political science at the University of Calgary. He was posthumously awarded his doctoral degree in June 2007. [25] Ms. Dawe confirmed Dr. Williams’ evidence that the eye surgery was originally scheduled as day surgery, and that the procedure took longer than expected. She was present when Dr. Williams attended on Dr. Jensen at around 1700 and advised that he wanted Dr. Jensen to remain in hospital overnight due to concerns that there might be significant discomfort in the eye.

2 Dr. Jensen’s father testified that the surgery took 2 and a-half-hours. The discrepancy between his evidence and the time frame of one hour and thirty-five minutes testified to by Dr. Williams, may be explained by the fact that Dr. Jensen spent an additional hour in the recovery room.


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[26] Shortly after 1715, Dr. Jensen began to cough and began drooling more than usual. He reported anxiety. The coughing worsened around 1800 or 1830 by which time Dr. Jensen was sweating profusely. At that time a nurse came to check on Dr. Jensen and gave him medication. It was at that point eye and chest pain was also reported by Dr. Jensen, who subsequently settled after being given medication. Also, around that point he ate some soup and crackers which Ms. Dawe fed to him. She reported that he had trouble swallowing and coughed while he ate but noted that this did not seem abnormal at the time as Dr. Jensen always had problems with eating. [27] Ms. Dawe stated that she left the television room shortly after Dr. Jensen ate. It was between 1915 and 1930 when she left and when she returned about 20 minutes later, Dr. Jensen was in respiratory distress and seemed to be panicked. Shortly thereafter the Code 66 was called and Dr. Jensen was taken to the ICU. She said that even then, she did not realize how serious the situation had become or that it was Dr. Grochmal’s intention to intubate Dr. Jensen at that point. Because of past experience, Ms. Dawe basically expected Dr. Jensen to require assistance, and when he was taken to ICU, she believed his situation would be successfully dealt with.

(D) Evidence of Mr. Jensen – Dr. Jensen’s Father

[27] Mr. Jensen testified that both he and Ms. Dawe expressed concern to the admitting nurse during the pre-operative work-up, specifically with respect to Dr. Jensen’s prior difficulties with anaesthesia. [28] As mentioned, it was his evidence that the surgery took two-and-one-half hours3, even though he and Ms. Dawe had been told it would only take one-and-a-half or one-and-three quarter hours. He testified the surgeon told him the surgery was the most difficult removal of scar tissue that he had ever conducted. [29] Mr. Jensen testified that when Dr. Jensen came out of the recovery room he was wearing nasal prongs, indicating an intention that Dr. Jensen should be kept on oxygen, but he was not given any oxygen during his stay in the day surgery unit. [30] Mr. Jensen testified that when his son was admitted to the ICU, a nurse expressed concern that his blood was very dark in colour but nothing changed in his treatment even after this was noted. Mr. Jensen also testified that he felt an inordinate amount of time elapsed before the oscillator was used on his son as a means of saving his life. [31] Mr. Jensen testified the was very upset by the fact that he and Ms. Dawe were asked by Dr. Boiteau to sign a form to allow an academic autopsy to be carried out on Dr. Jensen’s body. He felt that there should be a certain period of time that medical staff is required to wait before asking a newly bereaved family to sign any significant document.

(E) Evidence Regarding Nursing Care – Pre-Operative to ICU

1. Pre-Operative

Nancy Salthammer

[32] Ms. Nancy Salthammer was the nurse who conducted Dr. Jensen’s pre-operative telephone interview on January 10, 2007. She has 30 years of nursing experience and in 2007 had been at the Rockyview

3 See Note 2.


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General Hospital for 8 years. She had no personal contact with Dr. Jensen, other than seeing him on the day surgery unit following his surgery. [33] She confirmed that a telephone interview is conducted only with those patients who will not be attending a pre-admission clinic and that the decision regarding which route a particular patient will take is made by the surgeon on the day surgery unit booking request form. This would have been Dr. Williams and he did not request a pre-admission clinic. This form is also reviewed by an anaesthetist before it is received in the day surgery unit and the anaesthetist can also initiate the pre-admission clinic procedure. [34] She testified that there had been a change in practice at some point but she is not certain whether this occurred before or after Dr. Jensen’s surgery. The change appears to relate to the selection of patients for telephone interviews as opposed to those designated for pre-admission clinics. She now no longer speaks to any “24-hour” patients and frequently talks with patients up to two weeks in advance of their surgery. [35] Ms. Salthammer testified that she had come to understand from the outset that Dr. Jensen was scheduled to remain in hospital overnight following his surgery. However, she later stated that that may have been a mistaken understanding and that usually these 24-hour patients are designated to be seen in the pre-admission clinic. Ms. Salthammer noted several possible reasons why a 24-hour patient would not be seen in the pre-admission clinic and indicated that she felt one of those situations must have occurred to have led her to be speaking with Dr. Jensen the day prior to his surgery. One such possibility was that there had not been time between Dr. Jensen’s surgery booking and the surgery itself for a pre-admission clinic appointment to have been arranged. She testified that this occurred on occasions where patients were added to the list on very short notice. Dr. Jensen’s surgery was booked on January 5 and the surgery was slated for January 11, 2007. [36] Ms. Salthammer testified that during her telephone interview with Dr. Jensen, she filled out the day surgery unit form in which she noted his allergies, health history and noted “cerebral palsy seizure disorder” in the comments area. She noted informally, by a post-it note on the form, that Dr. Jensen was very independent and bright intellectually, but that she had some difficulty understanding his speech. She also confirmed that she would have reviewed the standard pre-surgery instructions with Dr. Jensen. [37] She testified that she did not complete the “reactions to previous anaesthetics” area of the day surgery form and did not indicate Dr. Jensen had prior breathing problems. In Exhibit 1, Tab 3, page 1 of the Patient Care Flowsheet Day Surgery/24-Hour form, in the “Reactions to Previous Anaesthetics”, the yes box for reaction to general anaesthetic is checked and beside the “If Yes, describe” area is a written notation of “breathing problems”; also the “Family history of anaesthetic problems” is checked as a yes. Ms. Salthammer testified that this comment regarding breathing problems was not in her handwriting. She indicated that the only reason she would not have completed this portion of the form was if a patient was unable to provide that information, in which case the form would be left blank for the admitting nurse to complete with the patient on the day of surgery. She confirmed that although she didn’t specifically recall her conversation with Dr. Jensen, she would have asked him about this and would only have left the form blank if he had been unable to provide this information. The entire form is usually reviewed by the admitting nurse on the morning of surgery. [38] Ms. Salthammer did not have any personal contact with Dr. Jensen on the day of surgery, but around 5:30 or 6:00 p.m. when she was in her office, she heard what she described as “unusual coughing” and what she also described as “a not good sounding cough”. She went to the nurses’ station to ask who was coughing and was told by the nurses there that it was Dr. Jensen and that his mother had said that he coughs like that sometimes. Ms. Salthammer noted twice during her testimony that she said to the nurses on the Unit that she did not think his cough “sounded right”. She had no personal knowledge of any of the subsequent events.


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2. Day Surgery Unit – Pre-Op

Carleen Christensen

[39] Ms. Carleen Christensen was the licensed practical nurse (LPN) who admitted Dr. Jensen to the day surgery unit. Ms. Christensen has 30 years experience as a LPN and had worked in the day surgery unit for 6 years at the time of her testimony. Ms. Christensen believed Dr. Jensen to be a 24 hour patient but this was based solely on the fact that he had been admitted to bed 44 which she described as a designated 24 hour bed. She gave him a bracelet indicating he had a penicillin allergy and completed the form regarding previous anaesthetic on the Patient Care Flowsheet - Day Surgery/24-Hour form. She did not recall any specific conversation with Dr. Jensen or his family, but recalls that most of the questions required a yes or no answer and that these were provided by both Dr. Jensen and his mother. [40] Ms. Christensen indicated on the form that there was a family history of anaesthetic problems but she was unable to recall any conversation on that topic and it may have been Dr. Jensen’s own history of difficulty. She also testified that on some occasions she telephones the operating room to let the anaesthetist know that there is a history of problems with anaesthetic, but she did not do so in Dr. Jensen’s case. She did not take this step because the anaesthetist had already previewed the chart and was going to meet with Dr. Jensen pre-surgery. She had no concerns about Dr. Jensen’s speech difficulty because his mother would be going to the holding area with him and would be there to talk with the anaesthesiologist directly. [41] She testified that as part of the admission process she would have checked Dr. Jensen’s vital signs, confirmed his height and weight and asked when he last took any regular medications. She noted that his pulse was a little fast and she checked it manually to see if it was regular, which it was. His blood pressure was good and in her opinion he was fit for surgery. There was nothing in his history or condition on the morning of the surgery that gave her any concern regarding allowing him to be transferred to the operating area. [42] She confirmed that the day surgery area was busy the day of Dr. Jensen’s surgery. Dr. Jensen was supposed to have eye drops 90 minutes prior to his surgery which was scheduled for 1155 but he was not yet at the day surgery unit. Ms. Christensen testified that she began admitting Dr. Jensen at 1100 and was in contact with him for approximately 40 minutes. She had no indication of why Dr. Jensen was late arriving for admitting. She stated that she completed her shift shortly before 1500 and was not involved in Dr. Jensen’s care after he returned from surgery. 3. Operating Room Amy Sartori [43] Ms. Sartori was the circulating operating room nurse on the day of Dr. Jensen’s surgery. At the time of Dr. Jensen’s death, she had 6 years nursing experience with 5 of them being in the operating room at the Rockyview General Hospital. As the circulating nurse, her job is to meet with patients in the holding area and admit them to the operating room. She also assists with anaesthesia and positioning the patient, gets supplies for the anaesthetist and surgeon and does the charting. [44] It is standard procedure for Ms. Sartori to review a patient’s chart, either in paper form or on the computer, prior to meeting the patient for the first time. She will ask the patient questions to confirm consent to the surgery and to ensure that it is the right patient for the correct surgery. She confirms the chart is complete, that all paperwork is filled out, and that all pre-operative orders have been carried out. She also confirms that pre-operative medications have been administered.


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[45] Ms. Sartori testified that it is her practice to confirm whether patients have had prior surgery and if there had been any problems, particularly regarding anaesthetic. If the patient has not had prior surgery, Ms. Sartori will ask if any family members have had surgery and if they experienced any problems with anaesthetic. [46] She described in general terms the various types of precautions that are taken to avoid blood clot formation and that sometimes compression stockings are used if ordered by the surgeon or anaesthesiologist. [47] Ms. Sartori testified that she could not recall if she had looked at Dr. Jensen’s chart, either the paper chart or the computer chart, before meeting him in the operating room reception area. She did recall meeting him in the holding area but had no recollection of any specific conversation with him. She testified that had she know or been advised of a prior problem with anaesthetic, her course of action would have been to ask if the patient had told the anaesthesiologist and to also talk directly with the anaesthesiologist. [48] Ms. Sartori reviewed the medications that had been given to Dr. Jensen during surgery and she characterized all of them as being common for vitrectomy surgery. She testified that she had never seen different medications used for cerebral palsy patients. [49] Ms. Sartori had very little specific recollection of Dr. Jensen’s case nor was she able to answer questions regarding details of any conversations she had had with other health care workers. 4. Recovery Room

Susan Wright – Recovery Room Nurse

[50] Ms. Susan Wright was one of the recovery room nurses who treated Dr. Jensen after his surgery. Ms. Wright has a BSc in Nursing, and has worked in ICUs, burn units, critical care, as a cardiovascular nurse clinician, in chronic pain units and lithotripsy. At the time of her testimony she had been a recovery room nurse at the Rockyview for 14 years. Ms. Wright testified that she had a conversation with Dr. Jensen which lasted for approximately 15 minutes. She specifically wanted to engage him in conversation as she was aware, based on the chart, that he had had prior breathing problems after an anaesthetic and that he had cerebral palsy. He had no respiratory problems during this conversation and while he was somewhat sleepy on arrival in the recovery room, after about 10 minutes he appeared to be fully alert. [51] Ms. Wright testified that the recovery room standard for oxygen saturation was 92%. When the patient has orders for oxygen as required, as Dr. Jensen did, Ms. Wright has the discretion to determine whether oxygen is required based on her observations of the patient’s breathing. She was unaware of the day surgery unit procedures regarding oxygen, but in her opinion it is preferable to trial patients off oxygen prior to removing it entirely. [52] She confirmed that she had cared for cerebral palsy patients in the recovery room before. She testified that whether any special precautions are required are patient dependent and that in general the head of the bed is raised to assist with breathing and airway management. Cerebral palsy patients are positioned on their sides if they have any problems with regurgitation. Of interest, with regard to the positioning of cerebral palsy patients from a nursing perspective, is the evidence given by Dr. Boiteau who testified that at 2200 he directed a central line to be inserted and according to both his and Dr. Grochmal’s evidence, Dr. Jensen was laid flat for this purpose. Dr. Jensen’s vital signs immediately deteriorated at this point and his first cardiac arrest occurred as they were inserting the central line. At 2357 Dr. Jensen was still laid flat when an x-ray was taken.


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[53] Ms. Wright confirmed that she assumed cerebral palsy was the reason Dr. Jensen had a general anaesthetic for this surgery which is normally done under a local anaesthetic. Dr. Jensen was in the recovery room for approximately one hour which she thought was appropriate given the length of his operation and how stable he had been in the recovery room. She later confirmed that outside of her conversation with Dr. Jensen which she clearly recalled, she had no specific memory of the details of Dr. Jensen’s case or conversations about his case with other health providers. She transferred Dr. Jensen’s care to another nurse, Ms. Cheryl Renkas, just before 1600. This was part of the normal nursing shift change. During the time that she was Dr. Jensen’s nurse, Ms. Wright had no concerns about his condition or about how he was coming out of anaesthetic. She did not give Dr. Jensen any medication and Dr. Jensen was her only patient during this time frame. [54] Her interpretation of the chart is such that Ms. Renkas discharged Dr. Jensen from the recovery room on oxygen. She testified that when patients are discharged from the recovery room on oxygen, the oxygen line is attached to the oxygen tanks that are under all stretchers. This was apparently not done, according to the evidence of Mr. Jensen, Dr. Jensen’s father, who testified that the nasal prongs utilized for the administration of oxygen, although present when Dr. Jensen was transferred out of the recovery room, were not connected to oxygen. Of note, too, is that there is some evidence that not all gurneys had oxygen tanks attached to them. Cheryl Renkas – Recovery Room Nurse

[55] Ms. Cheryl Renkas was the second recovery room nurse involved in Dr. Jensen’s care. At the time of Dr. Jensen’s death, Ms. Renkas was an experienced nurse with over 20 years of experience, 14 of them as an ICU nurse in various hospitals and 6 years as a recovery room nurse. In 2007 she had been a recovery room nurse at Rockyview General Hospital for 2 years. [56] Ms. Renkas assumed care of Dr. Jensen between 1540 and 1555. She testified that a report from a previous nurse is a standard procedure in every case, although she had no specific recollection with respect to Dr. Jensen’s case. She did not recall any specifics about Dr. Jensen’s case, but in reviewing the chart, she confirmed that his colouring was good, he was able to deep breathe and cough, and was able to move himself in bed. His oxygen saturation at both 1555 and 1610 appears to have been 97% on 3 litres of oxygen. The reading obtained by the day surgery unit at 1615 was 91% on room air. The lower reading on room air was not, from Ms. Renkas’ point of view, a concern, and the difference was explained by the difference in room air versus being on oxygen by the use of medical equipment. [57] Ms. Renkas administered Zofran (an anti-nausea medication) to Dr. Jensen at 1600, although his vital signs met the discharge criteria at that point. She kept him in the recovery room for another 15 minutes after the medication was administered. During her assessments at 1555 and 1610, Dr. Jensen was stable with his blood pressure and heart rate basically unchanged during his recovery room stay and his respiratory rate was at 97% on 3 litres of oxygen. She also testified that when he left the recovery room he was still wearing nasal prongs. This agrees with the evidence of Dr. Jensen’s father, who noted that his son was wearing unconnected nasal prongs when he came out of the recovery room. At the time of his surgery in 2007, it was the usual practice for patients who were being transported on gurneys without oxygen sources to be disconnected from oxygen in the recovery room before the 30 second trip to the day surgery unit, then to be reconnected to oxygen in the day surgery ward. Ms. Renkas was unable to recall if the gurney on which Dr. Jensen was transported was one on which oxygen was available, but stated it would have been her usual practice to connect the oxygen if it had been such a gurney. [58] She stated she would have told the porter what rate of oxygen Dr. Jensen had been on in the recovery room with the expectation that he would be put back on oxygen in the day surgery ward. She confirmed that passing this message via the porter was the usual procedure. She stated that the day


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surgery unit would have known he was on oxygen from the presence of the nasal prongs and because it was noted in her chart. No formal report was made in this case as a phone call would only have been made from the recovery room to the day surgery unit if there had been something out of the ordinary. [59] Both Ms. Wright and Ms. Renkas testified they would expect Dr. Jensen to have oxygen reconnected in the day surgery unit, but this was not done. As mentioned earlier, whether this failure contributed to the outcome in this case is not clear from the evidence at the Inquiry, but a question arises in this regard considering the drop in oxygen saturation levels which occurred later in the day surgery unit. 5. Day Surgery Unit – Post-Op Carrie Lynn Tuck

[60] Ms. Carrie Lynn Tuck is a LPN (licensed practical nurse) and in 2007 had 2 years of experience in various units at the Rockyview. At the time of Dr. Jensen’s death she had been working in the day surgery unit for 4 months. On the day of Dr. Jensen’s surgery, Ms. Tuck was working the evening shift (1430 to 2245) and was Dr. Jensen’s primary care nurse in the day surgery unit. [61] Ms. Tuck testified that the role of a LPN in the day surgery unit is to admit the patients, prepare them for the operating room and to look after them upon their return from the operating room or the recovery room. She stated that it is her standard practice when receiving a patient from the recovery room to review the recovery room records, the pre-anaesthetic history, the anaesthetic records, other notations from the day surgery unit and any orders entered in to their computer system by the doctor. [62] Ms. Tuck testified that she had no part in Dr. Jensen’s pre-surgery care in the day surgery unit as she did not come on shift until 1430. She could not recall seeing Dr. Jensen prior to the time she did her first assessment on him at 1615, after he returned from surgery. Therefore, she was unable to make any comment regarding what arrangements were in place regarding oxygen when Dr. Jensen arrived from the recovery room. She testified that at her first assessment she had concerns regarding his excessive salivation so she reviewed his prior chart and became aware that he had experienced breathing problems following a previous anaesthetic. [63] Ms. Tuck’s opinion was that vital sign monitoring on an hourly basis was appropriate for Dr. Jensen. The frequent vital sign monitoring, consisting of every 15 minutes for three times, then every 30 minutes for two times and then on a hourly basis, was, in Ms. Tuck’s understanding, applicable for patients who had had open incision surgery under a general anaesthetic but not applicable to eye surgery patients. The following evidence indicates that she monitored Dr. Jensen on an hourly basis, rather than implementing the more frequent vital sign monitoring. [64] She testified that at the first assessment at 1615, other than Dr. Jensen’s excessive salivation, she had no concerns regarding his condition. Her assessment at 1715 showed that his oxygen saturation level was at 96% on room air. Her assessment at 1815 also did not give her any concern as his colour was good and his oxygen saturation level on room air was 92%. In contrast with Ms. Martinson’s testimony, Ms. Tuck noted that any oxygen saturation above 90% is an acceptable level in the day surgery unit. Ms. Martinson thought any oxygen saturation level above 88% was acceptable. [65] Ms. Tuck testified that her next recollection of Dr. Jensen is when she heard him coughing in the T.V. room. There is no indication she did any testing concerning Dr. Jensen’s swallowing capacity before introducing the orange juice. She described the cough as sounding like “when you accidentally get something down the wrong tube.” She said she went to check on him but didn’t specifically note the time. She said that when she got to Dr. Jensen he was bright red and coughing. She asked him if he was getting air in and said that he nodded a yes. When she asked him if he felt that he was choking, he shook his head to indicate no. When asked if he wanted to return to his room, he again indicated no by shaking his head.


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She said she then went and got Dr. Jensen some orange juice and told him that he was to call out if he needed any help as there was no call button in the T.V. room. She testified that she was not particularly concerned about Dr. Jensen’s coughing as his colour was good and Ms. Dawe, his mother, was present. Dr. Jensen was tolerating the orange juice she had given him and neither he nor his mother seemed to be unduly concerned about the coughing. [66] Ms. Tuck testified that she recalled Ms. Salthammer bringing Dr. Jensen’s coughing to her attention but is not clear if this occurred before or after her assessment of Dr. Jensen’s coughing spell as noted above. She advised Ms. Salthammer of the results of the coughing spell. It should be noted that neither the coughing spell or the checking done by Ms. Tuck when she heard the coughing, was documented on the chart. [67] Ms. Tuck testified that the next interaction with Dr. Jensen was when she heard a call for help from him. When she arrived in the T.V. room he was alone, was a pale blue colour and was leaning in the chair. Ms. Tuck said that she asked the unit clerk to call a Code 66 as she rolled Dr. Jensen’s chair back to his bed. She testified that she didn’t know how much time passed since she had given Dr. Jensen the orange juice during her assessment of his coughing spell. She said that at this point she was by herself. She believed it was around 1915 or so that this occurred. [68] She testified that when she got Dr. Jensen back to his room, she put in the nasal prongs and turned up the oxygen “all the way”. She recalled Ms. Martinson being there at this point and that they began a set of vital signs and attempted to get Dr. Jensen back into his bed which, by the shaking of his head, he indicated that he did not want to be put in the bed but to remain in his chair. [69] Ms. Tuck testified that she believes the vital signs recorded at 2000 showing that Dr. Jensen had 84% oxygen saturation on 100% oxygen were the ones that she and Ms. Martinson recorded. [70] It was Ms. Tuck’s belief that the ICU Outreach team had arrived within a minute or so and that according to her notes, they worked on Dr. Jensen for approximately half an hour in the day surgery unit although she testified that it felt like much less time than that. [71] Ms. Tuck testified that she was not aware that Ms. Seitz had given Dr. Jensen Atasol 30. She said that it was her expectation that any pain medication administered would be recorded on the pain flow assessment sheet but that Dr. Jensen’s file did not contain such a sheet.4

Carol Anne Martinson – Day Surgery Unit Nurse

[72] Ms. Martinson has 33 years of nursing experience, in neurosurgery and surgical units. For the 10 years prior to 2007 she had been at Rockyview on a surgical floor and since 2003 has split her time working as a relief nurse on the day surgery unit and part-time on a surgical unit. She testified that she admitted Dr. Jensen to the day surgery ward from the recovery room at 1615. She took his vital signs and noted these would have been taken on room air unless there was reason to put the patient on oxygen. The policy in the day surgery ward is to give oxygen if the patient’s oxygenation saturation level is below 88%. She was aware that the recovery room policy required that oxygenation saturation levels be maintained at 90%, but did not know why the two policies were different. [73] Ms. Martinson’s practice is to compare the vital signs taken at the time the patient is admitted to the unit to those prior to surgery. In Dr. Jensen’s case he arrived at the hospital with a 93% oxygen saturation level and a pulse rate of 104. On arrival in the day surgery unit from the recovery room, his oxygen

4 This contrasts with Ms. Seitz’s testimony that she would have advised Ms. Tuck if she had administered any medication to patients.


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saturation level was 91% on room air and his pulse rate was 105. She testified this indicated that the post-recovery room levels were not a concern and Dr. Jensen was not placed back onto oxygen. The evidence suggests a different view was held by the recovery room nurses who expected Dr. Jensen to be put back on oxygen, but the day surgery unit’s view was his room air reading was enough to justify not doing so. [74] Ms. Martinson stated that she was not aware of any procedure through which patients were trialed off oxygen, i.e. to see whether the oxygen levels were maintained. Of note, however, is that at 1610 in the recovery room Dr. Jensen’s oxygenation levels were at 97% on 3 litres of oxygen, and when Dr. Jensen was initially admitted to the day surgery unit, his oxygenation tested at 1615 was 91% on room air. At 1715, an hour later, it had risen to 96% on room air, and then it fell to 92% at 1815 when he was tested again. Therefore, his oxygenation levels fluctuated while in the day surgery unit from 1615 to 1815, but remained at 90% or better on room air. [75] She had not read any notation about Dr. Jensen having a previous reaction to anaesthetic, but if she had her normal practice would have been to ask him about the problems he had encountered. She did not have any conversation with the porter about oxygen and she confirmed that her usual practice is to ask the porter whether a patient was on oxygen. She could not recall whether Dr. Jensen was on oxygen when he arrived. She did not recall Mr. Jensen, Dr. Jensen’s father, being present in the day surgery unit, nor did she recall Mr. Jensen making any mention about oxygen for his son, or having a conversation with Mr. Jensen regarding whether Dr. Jensen should be on oxygen or not. [76] Based on the chart, she confirmed that it appears that his vital signs had been taken hourly after his arrival in day surgery, at 1615, 1715 and 1815. The general policy for the day surgery unit is to check the vital signs of patients who have been under a general anaesthetic every 15 minutes (three times), then every 30 minutes (two times) and then every hour for three hours. She was unable to confirm whether this was done in Dr. Jensen’s case. It is not usual to follow this protocol for eye patients who are usually monitored every hour for three hours and then every four hours. Eye patients, even those who have had a general anaesthetic, are checked for frequently only if a doctor’s notes indicate this is needed. [77] On returning from her supper break, Ms. Martinson heard Dr. Jensen coughing in the patient lounge. She was unsure of the exact time and her testimony reflected this – “probably six – seven – 7:15, 7 – shortly after 7.” She mentioned the coughing to Dr. Jensen’s primary nurse, Ms. Carrie Lynn Tuck and they went together to assess Dr. Jensen. They asked Dr. Jensen if he was choking and he replied that he wasn’t and told them that he coughs a lot. Ms. Dawe was not present in the TV lounge at that point. [78] Ms. Martinson and Ms. Tuck returned Dr. Jensen to his room at that point and took his vital signs. When they noted his oxygen was low, they put the nasal prongs back in place and administered oxygen. Ms. Martinson did not recall what the oxygen saturation level was at that point but said that she thought it was below 80-something or in the low 80’s. She recalled asking someone to get an oxygen mask, as the level was not coming up even with the use of oxygen through the nasal prongs. At 2010 Dr. Jensen’s oxygen saturation was 84% on 100% oxygen. [79] Because of Dr. Jensen’s oxygen saturation level, Ms. Martinson and Ms. Tuck asked the Unit clerk to call a respiratory technician and shortly after that they decided to call a Code 66 to have ICU come and do an assessment. The Code 66 was called as the nurses were concerned that Dr. Jensen would get worse because his level of alertness was decreasing and his colour was poor. Ms. Martinson did not recall any shortness of breath and there was no report of coughing other than in the lounge. [80] Ms. Martinson recalled both respiratory and ICU Outreach arriving very quickly and once the ICU team arrived they decided to take Dr. Jensen to ICU and intubate him5.

5 This conflicts with Ms. Tuck’s testimony that according to her notes the ICU Outreach Team worked on Dr. Jensen in his room for approximately a half an hour before taking him to ICU.


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Susan Seitz – LPN Day Surgery Unit [81] Ms. Susan Seitz is a LPN (licensed practical nurse) who in 2007 had 19 years of experience. She was scheduled to work at the day surgery unit from 1100 until 1915 on the day of Dr. Jensen’s surgery. Her role was to cover for the primary nurse during breaks and she received instructions from the primary nurse regarding patient care during the one-half to three-quarter of an hour period of the primary nurse’s break. [82] Ms. Seitz had a specific recollection of taking over Dr. Jensen’s primary nursing care on the evening after his surgery. The primary nurse went for a dinner break between 1815 and 1830 and returned around 1900. Ms. Seitz did not specifically recall getting a verbal report from the primary nurse, Ms. Carrie Tuck, when she took over or giving a report to Ms. Tuck upon Ms. Tuck’s return. However, she testified that that would have been the usual practice. She confirmed that if a patient had been coughing or having difficulty breathing there would definitely have been a verbal report given by her to the primary nurse. [83] Ms. Seitz confirmed, based on the patient record, it was she who gave Dr. Jensen two tablets of Atasol at 1829. She had no recollection of giving the medication or of having a conversation with Dr. Jensen or any of his family members at this time. [84] She did recall Dr. Jensen coughing while he was under her care, although she was unsure of the exact time at which that occurred. She went into the TV room and asked if he was okay and his mother said “Yeah, he’s fine.” It did not appear to her that Dr. Jensen was having difficulty breathing at that time and he appeared to her to be alert and to have good colour. She did not recall if he was given dinner, but remembered him having fluids as he was watching television. She said good-bye to him in passing as she left for the evening. Ms. Seitz confirmed that the patient record was from her point of view, complete. 6. Outreach Team – Code 66 Nancy Van Berkel – ICU Nurse – Code 66 Team [85] Ms. Van Berkel has a diploma in nursing with post-graduate studies (first graduate degree) in ICU nursing and 30 years of experience in ICU nursing. At the time of Dr. Jensen’s death she had been part of the Rockyview ICU Outreach Team since 2006 and was the ICU nurse who responded with the Outreach Team to the Code 66 call concerning Dr. Jensen. She testified that the ‘Code 66’ or ‘ICU Outreach Team’ was created to improve response times when a patient is at risk. It has three members, namely a registered nurse, a respiratory therapist, and a doctor. [86] She testified that typically the doctor responding to the Code 66 would be an intensivist and if it was a resident instead, the resident’s responsibility would be to contact the intensivist. [87] She had no memory of the incident, but testified from handwritten notes. Her notes indicated that Dr. Jensen was awake, sitting up and had taken food and drink prior to the change in his condition. His oxygenation level on room air was 78% and between 82 – 86% with assistance. Her notes indicated that his blood pressure was low, that he had cyanotic lips and fingertips and that he complained of pain in his left eye (the operative site) and right side of his head. She noted the increased work to breathe was a concern and that his discolouration increased. She also noted that it was difficult to maintain adequate oxygen saturation as a result of which Dr. Jensen was transferred to the ICU for intubation. Ms. Van Berkel also testified that the need to intubate a patient would take priority over an immediate chest x-ray.


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7. Intensive Care Unit (ICU) Heather Cathro - ICU Nurse [88] In 2007, Ms. Cathro had 3 years of nursing experience with 2 years in the Rockyview ICU. She was also working on her Master’s in Nursing at the same time. Ms. Cathro became involved with Dr. Jensen’s care upon his arrival at the ICU. She reported that his breathing was laboured and that he was very very sick by the time he arrived in the ICU in severe respiratory distress. She confirmed that Dr. Jensen was ventilated and that initially he was being adequately oxygenated through the breathing tube. She did not know what led to the drop in the oxygenation level that occurred at 2230, but at a certain point it was determined that the ventilator was not effective and the respiratory therapists began to manually ‘bag’ Dr. Jensen. Bagging means manually supplying Dr. Jensen with oxygenated breaths. She noted that it was unusual for a patient to be manually oxygenated for any serious length of time as Dr. Jensen was, and that the amount of effort it appeared to take to manually bag Dr. Jensen also appeared to her to be atypical. After manual bagging had also proved to be insufficient, the use of nitric oxide machine and the oscillator were considered and attempted. [89] Ms. Cathro confirmed that at some point an arterial line was inserted to allow continuous blood pressure monitoring and to provide quick access for blood work testing. She recalled a comment being made that the blood appeared venous (that is from a vein and not an artery), and she believed this remark was made by a respiratory therapist, Tracy LeBlanc. However, because a good blood pressure reading was obtained from the line, Ms. Cathro was satisfied that this line was properly placed within the artery. She testified that the blood pressure reading would not have been the same if this line had been incorrectly placed in a vein. In her opinion, the unusually dark colour of the blood from the arterial line was an indication that Dr. Jensen was not oxygenating well at that time. [90] Ms. Cathro testified that the timeframe between the arrival of the oscillator at 0027 and its use in Dr. Jensen’s care at 0118 was a reasonable timeframe. She confirmed that this equipment was introduced very late into the resuscitation effort and is used only when other methods of ventilation have failed. Jody Fitzpatrick – Nurse – Code Blue Team [91] Ms. Fitzpatrick graduated in 2003 with a B.A. in Nursing and had experience in rural emergency rooms, long-term care and general medical units. Since 2005 she has been at the Rockyview ICU. She was on the Code Blue team and helped Ms. Cathro set up the room. She remembers Dr. Jensen being quite blue when the Code 66 team brought him in and that they would have hooked Dr. Jensen up to a cardiac monitor, a blood pressure cuff and an oxygen saturation monitor, all of which are attached to a wall. [92] She testified that there are two nurses on the Code Blue team, one doing charting, preparing medications and watching the monitor, and the other being the “do” nurse. Ms. Fitzpatrick was the charting nurse and Ms. Van Berkel was the other Code Blue nurse that night, the “do” nurse. During resuscitation charting is done by hand as there is a time lag factor on the computer. [93] Ms. Fitzpatrick testified that she would have relied upon word of mouth information about any medication Dr. Jensen had received prior because it would have taken a half an hour to read through the whole chart and the ICU is more focused on the patient. All the different departments have different record sheets and it would be important to know about a patient’s medication and pain level. The system in the ICU does not update in real time (there is a lag) and whomever happens to be near the computer will sign in and chart something so it becomes part of the record. Accordingly, recording times and actual times of implementation of the recorded item can be different. Sometimes someone else can chart under another person’s name if the system is left logged on.


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[94] Vital signs were taken by the computer in the wall, but she testified that nurses can change the time if something is going on or if the monitor slips. Over 90% of the vital signs are downloaded. There is no way to check if the monitor is working; nurses just assume that it is. [95] Ms. Fitzpatrick remembers that while the first code was going on they were taking blood from the previously inserted arterial line for the labs. The arterial line was shown as being inserted at 2202 but that could be a few minutes off, but probably not as much as half-an-hour. She recalls that the blood they drew was dark and that it was dark pretty much every time they drew blood from the arterial line. The chart indicated that the central line was placed at 2330 and that would likely be real time. [96] According to the chart, the nitric oxide was ordered at 2315 and was initiated at 2345 and this is a typical time frame to set up the nitric oxide machine because it was not on the unit and needed to be brought in and set up. There was consideration of proning Dr. Jensen but that did not occur. Ms. Fitzpatrick does not remember having an active role in Dr. Jensen’s care but may have helped Ms. Berkel. Staci McPherson – Respiratory Therapist [97] Ms. McPherson received her diploma in Respiratory Therapy in 1996 and has worked at the Rockyview General Hospital since then. Ms. McPherson was the “float” respiratory therapist on the night of Dr. Jensen’s’ death. This position means that she covered the Code 66 beeper and backed up the ICU, the nursery and at night covered various floors. [98] She became involved in Dr. Jensen’s care when the Code 66 was called by the day surgery unit. When she arrived, Dr. Jensen was in a chair on oxygen by nasal prongs. As she arrived he was being put on a breath mask, but his oxygen levels remained low so she took an arterial blood gas sample. She realized as she was analyzing the blood gas results that Dr. Jensen would need to go to the ICU. [99] Ms. McPherson could not recall whether she called ahead to the ICU from the day surgery unit or whether she notified them, as she was en route to the ICU with Dr. Jensen, that the team was planning to intubate Dr. Jensen and warn the ICU to prep for the intubation. She confirmed that by the time Dr. Jensen arrived at the ICU they were ready to begin placing the intubation tube for ventilation. [100] After delivering Dr. Jensen to the ICU, Ms. McPherson left to continue seeing her other patients. She left Dr. Jensen in the care of Ms. Willis and Ms. Pemberton. She stated she would have given a report at that time regarding his case which would have included a brief history and the results of the arterial blood gas test. [101] She returned later that evening to the ICU but could not recall if she had been paged or called back by an overhead announcement. She believed that she assisted in the manual bagging of Dr. Jensen that occurred and was asked by Dr. Boiteau to get the nitric oxide machine and then the oscillator equipment. She confirmed that Dr. Jensen was more difficult to bag than some patients. [102] To get the nitric oxide machine she had to go down stairs and get the key from respiratory therapy and then unlock the two doors to the pool and storage room and return upstairs with the nitric oxide machine. She stated that this procedure would have taken five to ten minutes. She noted that since January of 2007 the nitric oxide machine is now stored in a spot right outside the respiratory therapy department. [103] Once the machine was in the ICU there was a mandatory checkout procedure that had to be completed. All of the lines on the nitric oxide machine must be flushed within 15 minutes prior to use, in order to remove toxic gas build up. This process takes approximately 15 to 20 minutes. Ms. McPherson testified that now, in addition to the equipment being moved to a more accessible location, the therapists do the checkout procedure within the respiratory department and then take the machine to the ICU.


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[104] Ms. McPherson confirmed that she had not used the nitric oxide machine in some time and that she found the print on the instructions to be very small and difficult to read so that it took a long time to read the instructions out. She and Ms. Willis worked together to complete the checkout procedure and called in another respiratory therapist who Ms. McPherson thought might have more recent experience with the nitric oxide machine. This therapist, who she recalled as Abby, believed that there was a connector missing on the machine. Ms. McPherson could not recall what steps were taken with respect to this connector but noted that there were extras in the blood gas lab just across the hallway and that solutions could also be improvised. [105] Subsequent to Dr. Jensen’s death, Ms. McPherson made a recommendation about making the instructions easier to read and that was adopted. She testified that the entire process now takes from 20 to 30 minutes whereas in Dr. Jensen’s case, 45 minutes passed between the time Dr. Boiteau requested the nitric oxide machine and when it was used. [106] Ms. McPherson also retrieved the oscillator and helped set it up. She described it as equipment that would be introduced for patients with rising carbon dioxide levels, such as Dr. Jensen had, or in cases of lung injury. Based on Dr. Jensen’s chart the oscillator was in Dr. Jensen’s room for approximately 50 minutes before it was used. Ms. McPherson noted that during some of that time Dr. Jensen was being manually bagged and that this was being co-coordinated with chest compressions which made introduction of the oscillator inappropriate. [107] Ms. McPherson testified that she had occasionally treated patients with cerebral palsy prior to Dr. Jensen. She was unable to say whether cerebral palsy patients have a greater incidence of respiratory issues and in her experience had not noted cerebral palsy patients having more respiratory issues than the general population after general anaesthesia. [108] Ms. McPherson confirmed that she does not consider either the nitric oxide machine or the oscillator to be items that should be available immediately. She confirmed that while nitric oxide improves oxygenation temporarily, the statistical evidence shows that there is no improvement in patient outcomes when it is used. The nitric oxide machine can provide additional time to identify a patient’s underlying health problem but does not assist in correcting the issue. [109] With respect to possible causes of death Ms. McPherson was hesitant to make a definitive statement. She suggested that if Dr. Jensen’s death had been caused by a pulmonary embolism she would have expected to see poor oxygenation but not necessarily the rising carbon dioxide levels that Dr. Jensen had due to his poor ventilation. In contrast she considered aspiration consistent with the low oxygenation and high carbon dioxide readings. Further, based on his airway she did not appear to feel that he had suffered anaphylactic shock, but she was not comfortable answering questions on that point without further research.

Deborah Willis – Respiratory Therapist

[110] Ms. Deborah Willis was a respiratory therapist at the Rockyview General Hospital and was involved in Dr. Jensen’s care when he was received in the ICU. Ms. Willis retired in November 2007 after being a respiratory therapist for 31 years, the last 11 being in the ICU at the Rockyview. [111] When Dr. Jensen was received in the ICU, respiratory therapy was asked to set up for intubation and ventilation. Ms. Willis had no specific recollection of Dr. Jensen’s care immediately after he was admitted to the ICU, but believed she was involved in ventilating him. [112] She reviewed the chart which reported that the Code 66 was given at approximately 2000 and that he was on a ventilator by 2048. According to her, this time frame is reasonable. Although Ms. Willis had no specific recollection of Dr. Jensen’s case, there was also a notation indicating that once the intubation was


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completed the tube was suctioned and a small quantity of secretions was removed. No questions were asked concerning the secretions which were removed from Dr. Jensen’s tube after completion of intubation. The evidence is therefore not clear whether these secretions were removed from his lungs, which may have shed some light on aspiration being the cause of death. [113] She was asked about the discrepancies between readings of Dr. Jensen’s oxygen level by the finger prong device and by the arterial blood gas reading and the interpretation of those readings. She testified that as a respiratory therapist she relied on the arterial blood gas measurement. She confirmed that it was not unusual for the arterial blood gas measurement to be significantly different than the finger prong measurement. [114] Her next clear memory of Dr. Jensen’s care was after Dr. Boiteau arrived at which point she recalled a Code Blue being called and herself and two other therapists assisting in manual resuscitation. [115] She testified that she was asked by Dr. Boiteau to set up the nitric oxide and according to her the process of retrieving the nitric oxide machine from the floor below, completing the required checks (the “checkout procedure”) and putting it in line with the ventilator takes between 26 and 37 minutes. She also notes that one or two of the steps in the lengthy checkout procedure were confusing to her and the other therapist which led to an additional five minutes being taken for the process. This confusion was about the instructions regarding how the hook-up to the nitric oxide needed to be done. There was also a connector missing from the nitric oxide machine and Ms. Willis testified that it took three to four additional minutes to find another connector piece. She recalled being frustrated by the checkout procedure, but confirmed that it is mandated by the manufacturer of the machine. She also testified that Dr. Jensen’s case was the first time she had set up either the nitric oxide machine or the oscillator in a Code situation. [116] Ms. Willis testified that respiratory therapists are now more accustomed to using these machines due to the experience they gained during the H1N1 outbreak. She testified about a meeting that took place at the hospital in 2009 between herself, other nurses, Dr. Jensen’s parents and counsel. At the inquiry, Mr. Jensen questioned her regarding his recollection that at the meeting on the evening of Dr. Jensen’s death, she had stated that it had taken 45 minutes just to get the oscillator out. She denied any recollection of that conversation. [117] It appears there was a concern regarding the placement of the intubation tube. Ms. Willis testified that if an intubation tube is incorrectly placed you would never want to leave it very long before moving it, so a chest x-ray is always done after intubation to check placement. In her opinion, the chest tube would have been moved when the x-ray revealing the imperfect placement was received, but not charted until later. She testified that Dr. Jensen’s intubation tube was initially placed at a 26cm depth, then advanced to 28cm after viewing the chest x-ray which had been taken at 2010. However, this move was not charted until 2200, almost 2 hours after chest x-ray. She was certain that the time between the placement and adjustment of the intubation tube would not have been that long a period. [118] Regarding procedural changes after Dr. Jensen’s death, Ms. Willis and other respiratory therapists who worked on Dr. Jensen approached their department manager the morning after his death and asked about the possibility of shortening the checkout procedure. She was later advised that this concern had been addressed but no evidence was given concerning the nature of the changes to the checkout instructions. Ms. Willis clarified that the therapists’ concerns had to do with the checkout procedures and the instructions for those procedures, rather than the time it took to get the machines from where they were stored. She expressed concern that no one outside of ICU would have been able to complete the checkout procedure.


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Michelle Pemberton – Respiratory Therapist

[119] Ms. Pemberton graduated from the NAIT Respiratory Therapy Program in 2006 and had been at the Rockyview General Hospital since her graduation. Ms. Pemberton was working as a casual relief respiratory therapist at the time of Dr. Jensen’s surgery. [120] Her testimony was that a respiratory therapist is responsible for administering inhaled medications. They do not require any specialized training to work in the ICU, but this did form part of Ms. Pemberton’s general orientation when she was hired. [121] On the night of Dr. Jensen’s death she was assigned to the ICU with Ms. Willis. There was also a respiratory therapist student, Ms. Tracy Leblanc, present with Ms. Pemberton that night. Ms. Pemberton first became involved in Dr. Jensen’s care when he was brought into the ICU by the Code 66 team. She testified that it would be usual for the ICU respiratory therapist to receive a report from the Code 66 respiratory therapist, although she could not recall any specific report in this regard. [122] Ms. Pemberton had only a vague recollection of setting up the room for Dr. Jensen. Her next recollection after setting up the room was that of intubating Dr. Jensen and placing him on the ventilator. She did not recall anything out of the ordinary about this process. She confirmed that there is always a respiratory therapist present when an intubation is done. She did not recall whether she or Ms. Willis made the determinations regarding the ventilator settings. [123] Ms. Pemberton’s next memory of Dr. Jensen’s case is of receiving the arterial blood gas after the arterial line was placed. The arterial saturation level was 67% and Ms. Pemberton’s chart (which may contain Ms. Leblanc’s notes) stated that this was perceived to be venous. According to Ms. Pemberton, the blood coming from line was much darker in colour than what would normally be expected with an arterial sample, although the patient monitor readings indicated that the line was correctly placed in an artery. This was brought to Dr. Boiteau’s attention, but other than that Ms. Pemberton took no steps with respect to the placement of the arterial line. [124] On the ventilator, Dr. Jensen’s oxygen level rose. It was measured at 85% at 2037 and 97% at 2107. Despite this, Ms. Pemberton was of the opinion that the blood gas results at 2107 looked worse than those obtained at 2012. While Dr. Jensen’s oxygenation had improved, his pH and carbon dioxide levels were worse. [125] Ms. Pemberton had not been involved in the use of a nitric oxide machine on a patient prior to Dr. Jensen. She was not involved in either the retrieval or setting up of the nitric oxide machine that night. She felt that it should take two to five minutes to retrieve the machine from the basement and a further 20 minutes to do the required checkout procedure. She also testified that it was not unusual for the procedure to take 30 to 45 minutes as it did in Dr. Jensen’s case. [126] Since Dr. Jensen’s case, Ms. Pemberton has only been involved in three or four cases in which nitric oxide has been used. [127] She was unable to recall whether the oscillator had been used in Dr. Jensen’s case. She confirmed that the chart indicated that he had been placed on an oscillator but stated that she was not involved in its initiation. She had not been involved in any cases prior to Dr. Jensen’s in which the oscillator had been used. It was usual, according to her, for the set up of the oscillator to take 20 to 30 minutes. [128] Ms. Pemberton was also asked about possible reasons why Dr. Jensen’s oxygen level as measured by the finger prong device was higher than the measurement from the arterial blood gas test. She noted that


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the finger prong device is also measuring pulse levels, but otherwise said only that there were many factors that could cause this discrepancy. She also noted that she was not accustomed to treating patients with cerebral palsy.

(F) Administration Protocols and Policies Janice Stewart – Director, Heart Health (Cardiac Services)

[129] Ms. Janice Stewart was the Director of the Heart Health (Cardiac Sciences) Program at the Rockyview General Hospital at the time of Dr. Jensen’s death. She was not directly involved with Dr. Jensen’s care or treatment, but some of the evidence she gave specifically related to policies and guidelines relating to monitoring patients’ vital signs. [130] She confirmed that at least two sets of stable vital signs are required before a patient is moved from the recovery room to the day surgery unit. From the evidence of Ms. Renkas, it appears that when Dr. Jensen’s vital signs were taken in the recovery room at 1555 and 1610, both were taken when he was assisted with oxygen. Dr. Jensen’s oxygen saturation in the recovery room was 93% on 3 litres of oxygen. The testing done at 1615 in the day surgery unit read as 91% on room air. [131] Ms. Stewart testified it is within the recovery room nurses discretion to determine whether or not a patient meets discharge requirements and that in January 2007, the policy was that patients maintain oxygen saturation levels equal to or greater than 90% for 15 minutes following the removal of oxygen. [132] Ms. Stewart testified that the determination regarding whether a patient will attend a pre-admission clinic is made either by the surgeon on the booking request (in this case Dr. Williams) or by the reviewing anaesthesiologist. There is no way to determine which anaesthesiologist reviewed any particular file after the fact. Ms. Steward also confirmed that it is general hospital practice to have a nurse make telephone contact with patients who are referred to the pre-admission clinic, and this nurse may make independent referrals to the pre-admission clinic. It seems there was too little time for this to occur in Dr. Jensen’s case and it may have been of some significance to his monitoring before, during and after the surgery. [133] Ms. Stewart was questioned regarding policy surrounding administration of oxygen in the day surgery unit, primarily because Dr. Jensen was transferred from the recovery room to the day surgery unit with nasal prongs unattached to any equipment. Ms. Stewart testified that the day surgery nursing staff would check the physician’s orders regarding the administration of oxygen, and would not rely on the presence of nasal prongs or otherwise. She also testified that a porter might be relied upon by the nurses to convey a message that oxygen needed to be re-initiated, but noted that specific instructions regarding oxygenation would not be conveyed through the porter but would have to be confirmed through a patient’s chart. She confirmed that it would be common practice for nurses to ask porters to relay this type of information.

Debbie Goulard – Director, Emergency Services, Calgary Health Region (CHR)

[134] Ms. Goulard has a degree in Nursing, a Master’s in Health Care Administration and was Manager for Transition Services for the CHR for 8 years. She was the Director of Emergency Services for the whole of the Calgary Zone at the time of Dr. Jensen’s surgery. She would have been responsible for five emergency and urgent care departments and she confirmed that the Rockyview General Hospital is classified as a tertiary care hospital. In contrast, the Foothills Hospital is classified as an urban teaching facility and the major trauma centre for the city of Calgary. Despite this distinction she stated that the acuity level of patients seen at each hospital is fairly equivalent. Different specialties are located within each hospital with ophthalmology being located at the Rockyview.


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[135] Ms. Goulard testified that in January 2007, the ICU Outreach Team or ‘Code 66’ team was in its first year of inception and that the Rockyview was the 1st site to have the team up and running and to have protocols in place. The protocols that were in place in 2007 covered where the team responded to a patient; the role of the physician in the team and what decision making powers the team had, such as deciding in conjunction with the team physician, that a patient had to go to the ICU. She noted that it was the physician who had the final decision. [136] At the time of Dr. Jensen’s death there were two nurses on duty in the ICU who had been in that capacity for two months, along with eight nurses who had been there for more than two to three years. The outreach nurse on duty that night had more than twenty years of experience in an ICU department. Ms. Goulard was questioned about the fact that the respiratory therapist in ICU that night was junior and that Dr. Boiteau requested that a more senior therapist attend, which in fact, did occur. Ms. Goulard confirmed that nurses have a minimum of two to three years experience before being considered for a position in the ICU. [137] With respect to location of equipment in the hospital, she confirmed that the oscillator and nitric oxide machines were stored in the respiratory therapy unit which is one floor down from the ICU department. She agreed that it would be better to have these machines stored so that they were more readily available to the ICU department but said that there is currently no storage space within the ICU that can accommodate them. [138] Her evidence confirms that respiratory therapists had to obtain a key to control the elevator, go down to the respiratory therapy unit, get a key for that room, and then another key for the rehabilitation area where the equipment was stored. She testified that changes have since been made to install a key pad rather than an actual key procedure which shortens the time within which these machines can be retrieved. [139] Ms. Goulard confirmed that the manufacturer’s checkout instructions for the nitric oxide machine were extensive and because it was rarely used, there was likely some delay in getting it up and running. She testified that the checkout procedure for the nitric oxide machine was streamlined between 2007 and 2010, and that checkout procedures have now been condensed to a one page document that is laminated and taped to each machine rather than being kept in a binder. [140] She confirmed that there is no ECMO6 (extra-corporeal support and membrane oxygen) machine at the Rockyview. This machine can only be operated by a cardiovascular intensive care specialist and as of November 2010 the only ECMO machine in Southern Alberta was at the Foothills. [141] She was asked about the length of time it took for communications between Dr. Grochmal and Dr. Boiteau to be established and she testified that as far as she was aware the expectation is that the intensivist be available and on-site within thirty minutes of being paged. This was not a written protocol, and Ms. Goulard said that the usual practice would be to call the intensivist at home or try their cellphone if there was no response to the page. This call to the clinician on call was usually made by the Unit clerk upon request by the doctor or the clinician. The usual time frame for this step would depend on the acuity of the situation for which the hospital is trying to contact the intensivist. [142] She testified that the Health Authority provides pagers and batteries to staff, including doctors, and the staff are expected to change the batteries as required. Some of the pagers had no indicator to show when the batteries are about to die. Some of the pagers did have a tone to indicate low battery but it wasn’t functional if the pager was on silent/vibrate mode. There is no formal monitoring of the pagers by the Health Authority, which has over 5,000 pagers in the system. New pagers have since been issued, but Ms. Goulard was unsure if this addressed the battery issue.

6 An ECMO machine is similar to a heart-lung machine. It works by continuously pumping blood from the patient through a membrane oxygenator that imitates the gas exchange process of the lungs, i.e. by removing carbon dioxide and adding oxygen. The oxygenated blood is then returned to the patient. The machine provides continuous cardiopulmonary support on a long-term basis as adjunctive management of severe respiratory and cardiac failure.


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CAUSE AND MANNER OF DEATH – [143] The cause of death in this case is undetermined. The autopsy is inconclusive, but considerable time throughout the course of this Inquiry was spent examining the evidence concerning possible causes of death. Dr. Ronco, agreeing with both Dr. Boiteau and Dr. Schnell testified that he concluded the cause of death was primarily a lung problem of unknown cause leading to very serious respiratory failure, which led in turn to an inordinate strain on Dr. Jensen’s heart. The most likely cause of death, therefore, was “acute hypoxemic respiratory failure”. The Inquiry focused upon what caused the lung problem which in turn led to the respiratory failure and the majority of the evidence given at the Inquiry points to aspiration, for which Dr. Jensen was at high risk as a result of his specific kind of cerebral palsy. The evidence given by each physician who testified, as to the possible cause of Dr. Jensen’s death, follows. Dr. Sam Andrews – Assistant Chief Medical Examiner, Province of Alberta [144] Dr. Andrews is the Assistant Chief Medical Examiner for the Province of Alberta and has occupied that position since July of 2006. He completed a five year anatomical pathology residency at the University of Alberta, followed by a one year forensic pathology Fellowship with the Medical Examiner’s office in Albuquerque, New Mexico. He was qualified to give expert evidence with respect to medical examinations and autopsies. [145] Dr. Andrews testified that this case was initially declined by the Medical Examiner’s office as it was a death related to surgery and was deemed by the Medical Examiner to be a possible or reasonable complication of surgery and therefore reportable under the Fatality Inquiries Act. He went on to testify that after a further review, it was determined that because of Dr. Jensen’s young age and that the cause of death was not as obvious as was originally thought, that Dr. Jensen’s death should be accepted as a case by the Medical Examiner’s office. [146] Dr. Andrews testified that the most significant finding in the autopsy was that there were no structural anatomical diseases that would have accounted for Dr. Jensen’s death which he could attribute death to. He testified that a limitation of an autopsy is that it cannot determine functional abnormalities such as a cardiac arrhythmia or abnormal heart rhythm but can see structural diseases or structural abnormalities in the tissues and organs. [147] In his view, given the clinical history of Dr. Jensen, the cause of death was very suggestive of a blood clot in the lungs, which is a common post-surgical complication that can lead to sudden death. In addition to Dr. Jensen’s difficulty breathing, the echocardiogram that was completed prior to Dr. Jensen’s death revealed no movement on the right side of his heart, which Dr. Andrews noted is common if there has been a pulmonary embolism. Dr. Andrews expected to find blood clots during the autopsy but did not. As a result, although he could not rule out pulmonary embolism as the cause of death, he was also unable to provide expert opinion to the effect that pulmonary embolism was the cause of death in this case. [148] Dr. Andrews suggested abnormal cardiac conduction disorder as a possible cause of death because the autopsy revealed that there was no structural disease present. This is often a genetic abnormality of the cardiac conduction system (the electrical impulses that cause the heart to beat regularly) and can lead to sudden death which does not show at autopsy. Dr. Andrews testified it is not possible to confirm or disprove this possibility through the autopsy, given the current state of medical technology. [149] Dr. Andrews further testified that the administration of anticoagulant medication during resuscitation efforts could have dislodged any clot in the lungs, but according to the records he was provided with, it did not appear any anticoagulant medication was given in this case.


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[150] An additional cause of death mentioned by Dr. Andrews was aspiration of gastric contents. Dr. Andrews did not believe this was a likely cause of death because generally gastric aspiration involves a drawn-out process in which pneumonia develops and death ensues several days later. It was his evidence that if there has been gastric aspiration, gastric contents would be visible in the upper trachea, the upper airways of the lungs, and microscopically in the air sacks of the lungs. No gastric contents were visible during his examination of Dr. Jensen’s lungs. [151] An additional cause of death discussed by Dr. Andrews was perflurocarbon/silicon embolism. Dr. Andrews stated that a “particular foameous of the blood” is visible on macroscopic examination if perflurocarbon/silicon embolism caused or contributed to the death. He was not certain whether resuscitation efforts would have affected the visibility of foaminess, but he did not observe foameous (bubbles in the coronary artery circulation) which would have been expected had this been the cause of Dr. Jensen’s death. Dr. Robert Williams – Ophthalmologist [152] Dr. Williams has a BSc in microbial biology, and a Doctorate in Medicine. He completed one year of pre-ophthalmology; three years residency in ophthalmology and a two year residency at Cornell University. He is currently an Associate Staff Member, Rockyview Department of Surgery (Ophthalmology) and Clinical Assistant Professor, Department of Surgery, at the University of Calgary. His area of expertise involves anything involving the retina, such as retinal detachments, macular degeneration, diabetes, et cetera. [153] With respect to the possible causes of death, Dr. Williams testified that the mortality rate for vitrectomy surgery is essentially zero, and in the event deaths do occur as a result of this surgery, it would be attributable to anaesthetic rather than the surgery itself. He was unable to comment on the possibility of an air embolism being a cause of death, because it was not seen in the autopsy. [154] With respect to pulmonary embolism, Dr. Williams testified he formed the impression that this was the cause of Dr. Jensen’s death. Dr. Williams’ reason for this view is based on a discussion with ICU doctors regarding the circumstances of the death. He confirmed that the bleeding that occurred during surgery could not have contributed to the formation of an embolism, because a pulmonary embolus has to come from a large vessel to be of a sufficient size to cause problems. The tiny vessels in the eye could not have produced a clot of sufficient size to cause a pulmonary embolism. [155] Clots from large blood vessels in the legs, which are typically the source of pulmonary emboli can be formed if body positioning during surgery is incorrect. Dr. Williams confirmed that body positioning was difficult in Dr. Jensen’s case due to his cerebral palsy, which made it impossible for Dr. Jensen’s arms and legs to move in certain ways because of the muscle contractions that were present. Dr. Jensen was therefore positioned with pillows to provide extra support. Dr. Williams was aware of these issues but stated this was mainly the province of the nursing team and anaesthesiologist. His main concern was that Dr. Jensen’s head be positioned properly so that he could complete the surgery. [156] Dr. Williams noted that he and his medical colleagues had discussed the possibility that Dr. Jensen’s death was the result of an allergic reaction to the anaesthetic. However, Dr. Williams was confident that Dr. Jensen’s death was not a reaction to the anaesthetic he was given during surgery. This is because Dr. Jensen seemingly had a good recovery and general alertness when Dr. Williams saw him later that afternoon after surgery. [157] With respect to reaction to any substances used during the surgery Dr. Williams was of the view that the silicone gel used during the surgery could not have entered Dr. Jensen’s blood stream and caused a reaction. Because of the tiny size of the blood vessels in the eye, the surface tension present in the bubbles of the silicone gel and any other liquids used during the course of the surgery is too great to permit them to


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travel down the small blood vessels. Dr. Williams confirmed that this type of leakage can occur months or even years after surgery, when the liquid injected into the eye has started to break down, but was confident that it was impossible that this could happen at the time of surgery. [158] He also felt that it was near impossible that the perfluorocarbon liquid (F6H8) had entered Dr. Jensen’s bloodstream. He was not aware of any instances where this compound had been linked to death or of any studies that had shown it had toxic or cardiotoxic effects. Dr. Williams confirmed that F6H8 is less frequently used now, but that is because there is now a single compound that performs the same function as the silicone oil and F6H8 combined. [159] With respect to the role of cerebral palsy in Dr. Jensen’s death, Dr. Williams testified that he had no specific training in dealing with patients with cerebral palsy. He confirmed that the cerebral palsy did not play any part in how he opted to treat Dr. Jensen’s eye condition and in his opinion there was nothing about the cerebral palsy that would have caused him to focus on Dr. Jensen’s previous problem with general anaesthetic. Dr. Williams was unable to provide any suggestion regarding recommendations. He could not think of anything he would have done differently. Dr. Yair Rubin – General Anaesthesiologist, Rockyview Hospital

[160] Dr. Rubin received his Doctorate of Medicine in 1996. He went on to complete a five year residency at the University of Calgary Department of Anaesthesia, and a one year residency in Ambulatory Anaesthesia at Duke University. He has been with the Rockyview Department of Anaesthesia since 2003. Dr. Rubin was the anaesthesiologist involved in Dr. Jensen’s surgery. He testified that he did not see Dr. Jensen’s chart until he met with him in the operating room waiting area on the day of surgery. [161] Dr. Rubin testified that he noted during the meeting that Dr. Jensen’s chart indicated previous problems with anaesthetic. During the pre-operative interview Dr. Rubin asked a number of questions about what had occurred in prior surgery and when the breathing problems had occurred in the past. Dr. Jensen’s mother, Ms. Dawe, was present during this conversation and it was determined that problems had not been during prior surgery, but had developed in the recovery room phase. Dr. Rubin also discussed the heart rate issue with Dr. Jensen and Ms. Dawe along with the use of general versus local anaesthetic and which anaesthetic would be appropriate. Dr. Rubin agreed with Dr. Williams that general anaesthetic ought to be used, notwithstanding that the eye surgery usually only required a local anaesthetic. The choice of the general anaesthetic was because the muscle spasm potential in Dr. Jensen’s case could result in significant eye damage if local anaesthetic alone was utilized. [162] Dr. Rubin varied his usual anaesthetic practice as a result of the pre-operative interview. Because of Dr. Jensen’s breathing problems after anaesthetic, Dr. Rubin did not use any opioids or any intermediate or long-acting muscle relaxants. He requested Dr. Jensen’s prior medical chart and believed that it arrived just prior to surgery, but was not certain whether he had seen the chart prior to the surgery going ahead. However, on reviewing the previous medical chart, Dr. Rubin felt that the previous heart issue was confined to complaints of chest pain, and in view of the normal electrocardiogram that had been obtained in Dr. Jensen’s case, he felt that this was unrelated to the anaesthetic used in the prior operation. [163] Before surgery began, Dr. Rubin used Esmolol (to prevent high pressure and high heart rate) for the pre-operative intubation and Midazolam (to reduce anxiety and reduce the chances of any sort of seizure activity). Dr. Jensen was also given Metoclopramide (an anti-nauseant) and Tetracaine (a local anaesthetic to desensitize the eye for the pre-operative cleaning). After the administration of the foregoing medications, Dr. Rubin began the anaesethesia with Propofol and also administered Succinylcholine, which is a short-acting muscle relaxant to assist with the intubation. Desflurane was administered by Dr. Rubin during surgery to keep Dr. Jensen asleep. Dr. Rubin had no concerns about using either Propofol or Desflurane in


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Dr. Jensen’s case. He recalls Dr. Jensen was also given a retinal block at the beginning of surgery and he testified that he had specifically asked Dr. Williams to do this at the beginning of surgery to avoid the use of opioid medications during the surgery. [164] Dr. Jensen responded to all of the medications administered as expected during the first portion of the surgery and there were no issues from an anaesthesiology point of view. Dr. Rubin testified that usually an adverse drug reaction to anaesthetic occurs fairly immediately and the longest delay reflected in the literature for this type of reaction is approximately twenty minutes. Other than the Desflurane, which Dr. Jensen received throughout the surgery, the pre-operative medications were administered at approximately 1300, so Dr. Rubin would have expected any reaction that was going to occur to have happened prior to 1355. [165] Although Dr. Rubin had originally intended to be present for Dr. Jensen’s entire surgery, he was called away because his wife had gone into pre-term labour, and he left at 1355. Dr. Samuels replaced Dr. Rubin as Dr. Jensen’s anaesthesiologist and there would have been a five to ten minute overlap as Dr. Rubin discussed the history of the case and the course and status of Dr. Jensen’s anaesethesia with Dr. Samuels. Dr. Rubin confirmed that Dr. Jensen had swallowing difficulties and that he had previous post-anaesthetic concerns, as a result of which Dr. Rubin was avoiding opioids and muscle relaxants. [166] Once surgery was underway and Dr. Jensen was stable under anaesthesia, Dr. Rubin completed the recovery room orders in which he ordered intravenous fluids, oxygen, morphine and anti-nauseant medication (Ondansetron) on an as-needed basis. The amount of morphine ordered was a lower than normal dose. [167] With respect to oxygen, Dr. Rubin’s understanding was that there was a guideline in place that stipulated that a satisfactory oxygen level was one in the 90th percentile so that a patient would be maintained on oxygen if their oxygen saturation dropped below that level. He was uncertain how long this level had to be maintained, but believed it was set out in the protocol. There was nothing in Dr. Jensen’s history that would have led Dr. Rubin to be concerned about Dr. Jensen’s post-surgical oxygen levels, especially as his oxygenation levels after the previous surgery had been good. [168] Of some note is the fact that Dr. Williams and Dr. Rubin conflict on the question of whether or not a retrobulbar block7 was performed in Dr. Jensen’s case. Dr. Williams had no specific recollection of performing this retinal block and he testified that the usual procedure is to perform this at the end of this surgery, while Dr. Rubin testified that he asked Dr. Williams to do this at the beginning of the surgery in order to avoid the use of opioid medications during the procedure. The question of whether the block would have made any difference to Dr. Jensen’s condition, particularly as it appears to be related to the type of anaesthetic used, is not answered by the evidence at this Inquiry. [169] Dr. Rubin was questioned regarding a notation on the chart noting that Dr. Jensen had cerebral palsy with seizures and had muscle spasms. Further on in his testimony, Dr. Rubin testified that he recommended a general anaesthetic rather than a local eye block because of Dr. Jensen’s history of muscle spasms in particular and also seizures, seemingly differentiating the two. When Dr. Rubin referred to seizure disorder in Dr. Jensen’s case, he may have been referring to the muscle spasticity that Dr. Jensen experienced as a result of his cerebral palsy. The only relevance of the question of whether Dr. Jensen, in fact, had a seizure disorder would be whether the Atasol 30 medication later administered was appropriate. [170] On the possible causes of death, Dr. Rubin’s first thought was pulmonary embolism as the cause of Dr. Jensen’s death. However, he ruled this out in view of the negative autopsy results. On the subject of pulmonary embolism, Dr. Rubin also believed that the type of eye surgery Dr. Jensen underwent was considered a low-risk surgery for blood clot formation. With respect to the subject of compression stockings being ordered mid-operation, he thought this could disrupt the surgery itself and put the patient at greater

7 A retrobulbar block is a pain management tool whereby a needle is inserted into and in behind the eye to administer a small amount of long-term anaesthetic to cover pain.


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risk, unless the surgery was going to be a great deal longer than expected. Dr. Rubin stated that the main concern regarding blood clot formation had to do with a long period of immobilization with respect to certain types of surgery that are considered high-risk for blood clot formation such as joint replacement or major abdominal surgery. In the event such surgeries take longer than two hours, blood clot formation is a concern. I note that Dr. Jensen was immobilized for approximately two and-a-half hours which included his surgery and time in the recovery room. [171] With respect to any medication or anaesthetics used in surgery being a cause of death, Dr. Rubin was of the view that if these contributed to the cause of death, breathing problems would have been expected to occur fairly shortly after arrival in the recovery room, which was not the case with Dr. Jensen. The onset of respiratory systems difficulties for Dr. Jensen took place five hours after the majority of the anaesthesia medications were given and in his view, none of those drugs could have been implicated in Dr. Jensen’s respiratory problems. Only small amounts of the medications would have been in his system at that time and Dr. Rubin was confident that these could not have any effect. [172] With respect to the Propofol and Ativan that Dr. Jensen was later given in the ICU, Dr. Rubin testified that these could likely not have caused respiratory distress, since Dr. Jensen was already intubated by that time. The Rocuronium given to Dr. Jensen in ICU was a muscle relaxant, a type of medication that Dr. Rubin avoided during the surgery. However, Dr. Rubin believed those medications were administered to assist Dr. Jensen to be extubated and to breathe on his own following surgery. The primary concern in ICU would have been to ventilate Dr. Jensen successfully and that eventual extubation would have been a remote concern. According to Dr. Rubin, giving muscle relaxants to allow ventilation is fairly routine. [173] With respect to the subject of allergic reaction, Dr. Rubin speculated that a severe allergic reaction may have been responsible for Dr. Jensen’s death, because Dr. Jensen’s clinical presentation in conjunction with the failure of the autopsy to show a pulmonary embolism suggest the possibility of a severe allergic reaction. [174] With respect to the role of cerebral palsy, Dr. Rubin had classified Dr. Jensen as a “2” on the American Society of Anaesthesia risk classification scale. On this scale, 1 indicates no health issues at all and a 5 indicates a patient so ill that they could not be expected to survive, either with or without surgery. Dr. Jensen was classed as a 2 because his cerebral palsy was a non-life threatening medical condition that resulted in impairment. Dr. Rubin also noted on the pre-anaesthetic review form that Dr. Jensen had swallowing difficulties. While this was not a direct concern from an anaesthesiology point of view, Dr. Rubin noted that this made the possibility of aspirating in the recovery room more likely. [175] Dr. Rubin had prior experience administering general anaesthesia on patients with cerebral palsy. It was his evidence that the severity of the cerebral palsy and the types of issues that a particular patient has are the factors that affect his decisions with respect to anaesthesia in any given case. With respect to Dr. Jensen, his only concern arising from the cerebral palsy was the possibility that he may have been more than normally sensitive to opioids, as a result of which these drugs were not used during the surgery. There was nothing in Dr. Jensen’s past history, including his history of cerebral palsy, which would have changed his recommendation that Dr. Jensen proceed with the surgery under a general anaesthesia. [176] Dr. Rubin confirmed that had he been the anaesthesiologist reviewing Dr. Jensen’s chart, he would have suggested a pre-admission clinic based on Dr. Jensen’s previous problems after anaesthesia. This would have ensured that Dr. Jensen’s old charts would have been available at the time of the surgery for the anaesthesiologist to review, rather than requiring Dr. Rubin to call for the charts just before the surgery. However, he confirmed that he would not have done anything different in Dr. Jensen’s case, as he found the old charts reassuring from an anaesthesia point of view since they suggested that Dr. Jensen’s prior difficulties were not directly due to the anaesthesia.


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Dr. Peter Samuels – General Anaesthesiologist, Rockyview General Hospital [177] Dr. Samuels has an MSc in Physiology, a Doctorate of Medicine, with a four year residency in anaesthesia and a Fellowship in Regional Anaesthesia and Acute Pain Management. He has been a general anaesthesiologist at the Rockyview since 1998 and since 1999, a Clinical Associate Professor at the University of Calgary Faculty of Medicine. [178] Dr. Samuels was of the view that even a pre-admission clinic would not have changed the plan for Dr. Jensen’s anaesthesia. He confirmed he was briefed by Dr. Rubin when he went into the operating room, and was also told that Dr. Jensen had cerebral palsy, a seizure disorder that was treated, and slurred speech, but was otherwise a high functioning individual. He was also told about Dr. Jensen’s swallowing difficulties. He was not sure if he was aware that Dr. Jensen had a previous problem with anaesthetic during prior surgery, or whether he learnt this after Dr. Jensen’s death. [179] Dr. Samuels did not know what type of cerebral palsy Dr. Jensen had. He understood that when he arrived, Dr. Jensen had already been given a general anaesthetic and an eye block. Dr. Jensen was breathing on his own at that point and Dr. Samuels testified that Dr. Rubin advised him to minimize the amount of sedation used during surgery so that Dr. Jensen would be as alert as possible for the extubation. He stated he did not recall reviewing Dr. Jensen’s chart before taking over Dr. Jensen’s care. [180] Dr. Samuels testified that he continued to administer Desflurene for the remainder of the surgery, after he took over from Dr. Rubin and that he also administered Fentanyl, a pain relief medication that also works to decrease coughing, and thereby protects the eye from pressure increases that occur when a person coughs. [181] He also administered two anti-nausea medications to prevent any vomiting, which he felt was especially important in Dr. Jensen’s case due to the concern that because of his cerebral palsy he might not be able to effectively clear any regurgitated materials from his mouth and thereby be at risk of aspiration. Sedation is a further risk for aspiration and it was to minimize this risk that Dr. Samuels did not want Dr. Jensen to be heavily sedated when he was extubated. Dr. Samuels did not report any problems associated with Dr. Jensen’s extubation. [182] Dr. Samuels testified he had no concerns about how Dr. Jensen’s surgery had gone from an anaesthesia point of view, and following surgery he removed Dr. Jensen’s endotracheal tube and accompanied him to the recovery room. Once there, he reapplied monitors to Dr. Jensen and waited for those to display Dr. Jensen’s vital signs. He had no concerns about Dr. Jensen as he turned him over to the recovery room nurses. [183] Post-operatively, Dr. Samuels testified that he ordered IV fluids at the rate of 100ml/hour and oxygen as required. These post operative instructions differed from those ordered by Dr. Rubin. Dr. Rubin had ordered IV fluids at a rate of 150ml/hour. Both Dr. Rubin and Dr. Samuels ordered oxygen as required. Dr. Samuels testified that the difference between 150ml/hour and 100ml/hour of fluids was not significant. [184] The post-operative order given by Dr. Samuels was that for pain relief, Fentanyl rather than morphine was to be provided, since Fentanyl was used during the surgery and he preferred to continue its use. [185] A notation in Dr. Jensen’s day surgery chart showed that at some point Dr. Jensen’s oxygen saturation was 91% on room air (with no additional oxygen), which suggested to Dr. Samuels that oxygen was no longer required.


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[186] Dr. Samuels testified that after an hour in the recovery room he would not expect any of the medications given during surgery to be having any effect on Dr. Jensen. He confirmed that breathing problems are not a common reaction to anaesthetic. Coughing, on the other hand, is common for all patients when the endotracheal tube is removed, but coughing would be an uncommon occurrence an hour or two after the tube had been removed. Dr. Samuels did not believe that the coughing that occurred at 1730 or 1800 could have been due to the use or removal of the endotracheal tube. [187] In the recovery room, Dr. Samuels told the nurses Dr. Jensen’s name, age, and that he had cerebral palsy. He described the surgery and anaesthetic used and told them about the medications Dr. Jensen had been given. He did not recall if he specifically advised the nurses to watch for breathing problems or sign of blood clot formation, as he considered these to be usual duties of recovery room nurses for all patients. In some cases anaesthesiologists will request recovery room nurses to contact them prior to discharging a patient from the recovery room but this typically happens where a concern has arisen during the course of surgery. Where the surgery and anaesthesia have been without concern, anaesthesiologists rely on the recovery room nurses judgment with respect to discharge from the recovery room. [188] With respect to the possible causes of death, Dr. Samuels confirmed that Dr. Jensen would have been vulnerable to aspiration immediately after the surgery, during the time he was still sedated. Because Dr. Jensen did not become ill until well after that time, in Dr. Samuels’ view aspiration was not a likely cause of death. Further, there was no physical evidence in the Medical Examiner’s Report that would have supported this conclusion. [189] With respect to pulmonary embolism, based on Dr. Jensen’s symptoms, including the sudden onset of coughing in the day surgery ward, low oxygen levels and low blood pressure, Dr. Samuels’ initial impression was that Dr. Jensen had died of a pulmonary embolism. He was surprised that no pulmonary embolism was found in autopsy. [190] With respect to cardiac arrhythmia, this was a speculative possibility offered by the Medical Examiner but Dr. Samuels noted that there had been no evidence of any arrhythmia in Dr. Jensen’s electro-cardiograms. [191] With respect to medication given to Dr. Jensen, on a purely speculative basis, Dr. Samuel suggested that Dr. Jensen may have had an anaphylactic reaction to food or medication. If this were the case, he would have expected the reaction to occur within a half hour of what ever substance caused it. Dr. Samuels confirmed this reaction could be caused by codeine. He was, however, unable to pinpoint a specific cause of death, especially as the Medical Examiner’s Report did not contain any physical evidence that would have explained it. [192] With respect to the role of cerebral palsy, Dr. Samuels felt that the area of most concern when considering general anaesthesia for cerebral palsy patients is the possibility that their ability to clear secretions or vomitus from their mouth would be impaired if they have impaired control of their airway muscles. This leads to the potential for aspiration. In Dr. Jensen’s case this was addressed as Dr. Samuels would have expected, through the use of the most minimal amount of sedation possible to ensure alertness upon extubation. [193] Dr. Samuels did not feel it would be desirable to do a pre-admission clinic for all cerebral palsy patients scheduled for surgery. He described that accommodations are available for patients that have difficulty communicating. He stated that non-speaking patients used tablets so they can communicate in writing and translators usually accompany patients who don’t speak English or who use sign language. Sometimes, translators also accompany patients into the recover room.


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[194] With respect to recommendations, Dr. Samuels confirmed that even in hindsight there is nothing he would have done differently in this surgery. He was unable to offer any suggestions on improvements to practice or procedure. He did agree that a wrist-band system for patients with previous anaesthetic reactions, such as is in place to alert all practitioners to known allergic reactions, could be useful as a redundancy measure. In his opinion, the determination of whether such a wrist band is warranted in a particular case is best left to the anaesthesiologist to determine.

Dr. Joey Kevin Grochmal – Resident, Rockyview Hospital

[195] Dr. Grochmal received his Doctorate in Medicine in 2006 and at the time of Dr. Jensen’s death was a 1st year neurosurgery resident near the end of his one month ICU rotation. He was the physician called to the Code 66 in Dr. Jensen’s case. Dr. Grochmal was called at 1958, when the oxygen saturation level of Dr. Jensen was between 60% and 85% on 15 litres of oxygen by nasal prong. He testified that Dr. Jensen was afebrile (had no fever) but was diaphoretic (sweaty to the touch) and had normal heart sounds except for tachycardia (fast heart rate). His breath was raspy especially on the lower right lobe when breathing. His most obvious problem was his inability to oxygenate his blood. Dr. Grochmal was told that Dr. Jensen had not complained of any chest pain. Because of the urgency Dr. Grochmal did not consult the chart but relied upon staff information. [196] Shortly after 2000, Dr. Grochmal attempted to page Dr. Boiteau, the ICU intensivist for that day, but was unable to reach him. Dr. Grochmal ordered a chest x-ray in order to assess the reasons for the hypoxia. Usually the portable x-ray machines are available in 3 – 5 minutes but as Dr. Grochmal was not able to get a portable x-ray right away, he decided to admit Dr. Jensen to the ICU because of Dr. Jensen’s inability to maintain oxygen saturation above 70% on 15 litres of oxygen either by being masked or having assistance through nasal prongs. Dr. Grochmal was not aware that Dr. Jensen had previous difficulties breathing after anaesthetic. [197] The biggest problem in ICU was to oxygenate Dr. Jensen’s blood. His oxygen saturation was measured by an oxygen meter on his finger. Dr. Grochmal decided to intubate because of the low oxygen saturation level and he gave Ativan (anti-anxiety medication) and Propofol (sedative medication) to help Dr. Jensen tolerate the intubation procedure. This reduces the energy Dr. Jensen would have spent choking and trying to expel the tube. At about 2100, shortly after the intubation, Dr. Grochmal spoke to Dr. Boiteau on the phone. Dr. Grochmal believed that Dr. Boiteau told him to further resuscitate Dr. Jensen. Dr. Grochmal also recalled Dr. Boiteau having said that Dr. Jensen was very sick and that he should probably come in and assist Dr. Grochmal with treatment. [198] A radial arterial line was inserted by Dr. Grochmal at approximately 2202 (according to the chart, but this seems later than when it must have occurred). Dr. Grochmal explained that the arterial line goes into the wrist and up the arm and can be used to read blood gases. Dr. Grochmal was satisfied this arterial line went into an artery and not a vein because the blood that came out was pusitile, which means it came out in pulses, and this only occurs when a line is directly in an artery. The line also showed a wave form indicating a pulse. At one point the blood coming out of the arterial line was quite dark which indicates that the blood is not sufficiently oxygenated. Dr. Grochmal is unable to recall when the dark blood was noticed and it may have been later during resuscitation efforts. Dr. Grochmal was at Dr. Jensen’s bedside except when making orders or speaking with Dr. Boiteau. [199] Dr. Grochmal testified he ordered ventilation with a standard setting for adult normal lungs, which would allow the respiratory therapist to adjust the settings, and that he deferred to the therapist on ventilation settings at this point in his training. He could tell the ventilator was working since Dr. Jensen’s oxygen levels improved and his chest was rising and falling as the machine breathed for him. At 2108 Dr. Jensen was acidotic (meaning the pH in his blood was low) and his CO2 levels were low, but his oxygen levels were normal. The ECG indicated a normal rhythm but a fast heart rate.


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[200] He testified that a chest x-ray was performed at 2115 and it was relatively normal, except for a lower portion of the lungs being micro-collapsed which means that the air sacs in the lower part of the lung had collapsed because they were not getting as much air as usual. This could have resulted from Dr. Jensen lying on his back during surgery. The x-ray ruled out large scale aspiration or pneumonia, although Dr. Grochmal testified that this finding was not in keeping with the severity of what happened later. The chest x-ray also indicated that the nasogastric and endotracheal tubes were correctly placed although the respiratory therapist did advance the intubation tube about two centimetres. The x-ray did not indicate that the heart was enlarged. Dr. Grochmal arranged for a CT scan, but this was ultimately not performed. [201] Dr. Jensen’s oxygen level was relatively good for awhile, but it had dropped to 82% at 2147 then went back up to 97% at 2200. [202] Dr. Grochmal testified that Dr. Boiteau arrived at the ICU around 2200 and that he went immediately to examine Dr. Jensen. Dr. Boiteau decided that a central line needed to be inserted. However, since Dr. Jensen was positioned at a 45 degree incline, he had to be laid flat for the placement of the central line. As soon as this was done, Dr. Jensen’s vitals destabilized. Dr. Grochmal continued to insert the central line which was when the first cardiac arrest occurred. Blood pressure increasing drugs were immediately given for low blood pressure after the arrest. The evidence is, however, that he was still laying flat when a chest x-ray was done at 2357, since the x-ray was done front to back as a result of his position. The reason why Dr. Jensen’s situation worsened when laid flat was not fully explored by the Inquiry, nor were alternatives to this positioning, if any, were discussed. However, the sudden destabilizing of his vital signs suggest this action may have worsened his condition, notwithstanding that it may have become necessary in order to insert the central line. [203] Dr. Grochmal does not recall ordering Heparin, but he testified he would have done so as part of the standard order sheet for a patient being admitted to the ICU. This was a subcutaneous injection and is to prevent ICU patients from developing blood clots while lying still. This was not a treatment for a pulmonary embolus, and it would not be enough to break up a clot. It appears that the Heparin was never actually given to Dr. Jensen, although the order was made while Dr. Jensen was being resuscitated, so it could have been missed. [204] At 2239 Rocronium (a drug which induces paralysis) was administered. This decreases the amount of work a patient has to do in order to breathe and allows the patient to be more aggressively ventilated. [205] Eventually Dr. Jensen was put on an oscillator, which is a piece of equipment that can push air in and out of the lungs much faster than a ventilator. Because Dr. Jensen went from a slow heart rate to having no heart rate at all several times in the first little while, it is not likely that getting the oscillator there earlier would have helped. Given Dr. Jensen’s vital signs, it is likely that the oscillator would have just been keeping him artificially alive and would not have helped him to ultimately survive the incident. [206] At 2357 another chest x-ray was performed and this one was done front to back because Dr. Jensen was lying down. Normally it is done back to front (while a patient is standing). The heart appeared normal, but this projection is not the one from which heart size is normally recorded. Dr. Grochmal feels that an echocardiogram would have been a more accurate source of information about the size of the heart than an x-ray. [207] With respect to possible causes of death, aspiration was Dr. Grochmal’s initial thought on arrival for the Code 66 because Dr. Jensen appeared to be choking on aspirated food he had recently been eating. The initial presentation was consistent with aspiration. Large scale aspiration and pneumonia were ruled out by the chest x-ray given shortly after that. [208] With respect to pulmonary embolism, this, in Dr. Grochmal’s view, was more likely because the chest x-ray was clear, which ruled out large scale aspiration. A pulmonary embolism can sometimes result in an


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increased heart rate like what was observed in Dr. Jensen. The sudden slow heart rate before arrest could also have indicated a pulmonary embolism. Over the course of the night it looked more and more like pulmonary embolism because the symptoms fit. Dr. Jensen could not oxygenate himself and became worse when he was laid flat for the insertion of the central line. Further testing at 0000 or 0030 in which an echocardiogram was performed showed that the right side of the heart was enlarged and not moving much. [209] With respect to a pre-existing heart condition, Dr. Grochmal testified it is more typical for cardiac problems to cause lung problems than the other way around, but coughing is generally more indicative of lung problems. However, coughing can be a symptom of a heart problem. It is not clear in this case which way it went, in his view. He speculated that it maybe was a primary heart issue, perhaps a pre-existing one. [210] With respect to anaphylaxis as a cause of death, Dr. Grochmal felt this should have happened almost right after exposure to an allergen. He did not consider whether it might have been a food allergy. Anaphylactic shock doesn’t fit the symptoms because his blood pressure was never very low and he wasn’t swollen as Dr. Grochmal thought he should have been, had this been an anaphylactic episode. He testified that Dr. Jensen did have low blood pressure, but only after the first cardiac arrest and that in his view, this probably was not related to an anaphylactic reaction. [211] With respect to a reaction to anaesthetic, Dr. Grochmal was of the view that this is a far fetched explanation because the surgery was so much earlier than the problems. It would have been very unusual to react to the anaesthetic four hours later. In addition, the primary life threatening complication with an allergic reaction to anaesthetic would have been swelling of the throat so the airway closed and intubation would be difficult if not impossible. Dr. Grochmal testified that there were no difficulties intubating Dr. Jensen and that intubation would have prevented closing of the airway as a result of any swelling of the throat.

Dr. Paul James Emile Boiteau – Professor of Medicine and Head, Department of Critical Care Medicine, University of Calgary

[212] Dr. Boiteau received his Doctorate of Medicine and then completed a residency in internal medicine, a Fellowship in respiratory medicine and critical care medicine and a research Fellowship in cardiopulmonary investigation. In 1998 he was appointed as a Clinical Associate Professor of Medicine, Critical Care and Respiratory Medicine at the University of Calgary and since 2003 has been a Professor of Medicine and Head, Department of Critical Care Medicine at the University of Calgary. [213] It was the evidence of Dr. Boiteau that he first heard about Dr. Jensen’s condition when a nurse called to say that Dr. Jensen had been admitted to the ICU and that they had been unable to reach him on his pager. He testified that he spoke to Dr. Grochmal on the phone at approximately 2100 and at that point Dr. Grochmal had not finished the assessment on Dr. Jensen. According to Dr. Boiteau, Dr. Grochmal was to call him back when he had finished the assessment. When Dr. Boiteau had not heard from Dr. Grochmal in half an hour, he decided to drive to the hospital which takes about 25 to 30 minutes. Dr. Boiteau estimated that he arrived at the hospital at about 2200. Upon arriving at Dr. Jensen’s bedside, he noted Dr. Jensen’s blood gases were life-threatening. His oxygen level (O2) was low and his pH at 7.11 was below the 7.35 normal range, indicating to Dr. Boiteau that either his lungs or kidneys weren’t working. In addition, Dr. Jensen was not properly getting rid of carbon dioxide as he had a PCO2 level of 85, far above the normal range of 35 - 45. [214] The arterial line was already in place and Dr. Boiteau testified that he would have expected the dark blood which came out of the arterial line, given the low oxygen level Dr. Jensen was experiencing. At 2115 a chest x-ray was performed and the heart was not noticeably affected at this time. In Dr. Boiteau’s view, this supports his opinion that the lungs were the primary problem. He testified that Dr. Grochmal had already intubated Dr. Jensen to protect the airway and he was on a ventilator when Dr. Boiteau arrived. He testified that Dr. Jensen was given Fentanyl (a narcotic) and Ativan (a minor tranquillizer) so that he would not try to


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fight with the ventilator. Dr. Jensen was also given a drug to paralyze him so Dr. Boiteau would have control of his breathing and to ensure the machine was in synchrony with the patient. At 2259 Dr. Jensen was given Atrophine to prevent the heart from slowing down and Epinephrine to assist the heart functioning by making it contract more strongly. [215] They needed a central line8 to administer Vasoprin and Levopred to maintain circulation by stimulating blood pressure. At 2240 as they were attempting to insert the central line in Dr. Jensen’s neck, his oxygen saturation started to drop, the situation started to deteriorate and they had to abandon the procedure. Dr. Boiteau does not remember lying Dr. Jensen down for the insertion of the central line, and he testified this may have been done by “an echo”, which would avoid the necessity of having to lay Dr. Jensen down. Dr. Grochmal testified that Dr. Jensen was laid flat for the insertion of the central line. Dr. Boiteau testified that they took Dr. Jensen off the ventilator and bagged him manually. The first cardiac arrest occurred at 2305 at which point CPR was commenced. At 2307 bicarb was administered to counteract the acidity of Dr. Jensen’s blood and at 2326 a pulse was noted. They recommenced placement of the central line and had no problems with that. [216] Dr. Boiteau noted that at this time there were several respiratory therapists in the room helping as the therapist on shift was relatively junior (Ms. Pemberton, who had one year of experience). [217] Dr. Boiteau testified that he had considered attempting “proning” which is placing the patient upside down. Proning is a procedure which redistributes blood to the healthier parts of the lung; he stated that it has mixed results and can be risky. However, no one could find the machine or the instructional video and no one had done it in a long time, so ultimately they decided not to use this procedure. Since laying Dr. Jensen flat appears to have aggravated his condition, the question of whether proning him would have helped arises, but the Inquiry has been unable to answer this question. Dr. Jensen’s condition may have been too advanced to make a difference, but the evidence is not clear in this area. [218] Dr. Boiteau decided then to administer Nitric Oxide which causes the blood vessels around the functional part of the lungs to expand so more blood can reach the good part of lung. The nitric oxide machine was ordered at 2315 and received at 2356. Dr. Boiteau was asked if it may have helped if the nitric oxide machine had arrived earlier and according to Dr. Boiteau it is always possible, but given that Dr. Jensen was so sick, he thought it unlikely. [219] After trying the nitric oxide machine, Dr. Boiteau testified that he then decided to try the oscillator because they could not get Dr. Jensen’s oxygen levels up. He described the oscillator like a drum in that it pushes small amounts of gas at high frequency. It isn’t better than a ventilator, just different and is tried when everything else has failed. [220] At 2356 Dr. Jensen’s blood pressure dropped too low to feel a pulse and the second cardiac arrest took place. CPR was resumed until 0008 when a pulse of 68 was recorded. [221] Dr. Boiteau testified that he ordered a TEE9 which checks to see how the heart was functioning. At 0037 Dr. Jensen was placed on his side and a probe was inserted into his esophagus so his heart could be viewed. The results showed a dead right side of the heart.

8 A central line is a line placed in a large vein in the central circulation system to deliver drugs that might not be safe if given through smaller peripheral veins. There are three places a central line is used – the neck, the chest and the groin. If a central line is placed in the neck the patient is usually laid flat with the head turned to the side to allow for the insertion. 9 A TEE or transesophageal echocardiography is an ultrasound imaging exam using a probe inserted through the mouth and into the esophagus to provide a clear image of the heart. The clear image is possible because the heart and esophagus are close together and there are no boney structures between them to prevent the clear image.


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[222] Dr. Boiteau testified that he was not aware the family had concerns about previous breathing problems or about a previous ER visit with tachycardia. He would have expected this to have been on the anaesthesiologist’s report. [223] Dr. Boiteau testified that when oxygen saturation is below 75% the heart starts to fail. It becomes a cycle. The heart pumps less and the already depleted blood cells return slower to lungs that are not working. The pressure on the right side of the heart is lower than on the left because the left side circulates blood to the whole body and the right side only sends blood to the lungs so when the high pressure blood comes into the right side and the lungs are exerting back pressure because of swelling, then the right side of the heart becomes enlarged. [224] With respect to cause of death, Dr. Boiteau testified that pulmonary embolism was not a top consideration because Dr. Jensen was young and healthy. In addition, pulmonary embolism would not present with coughing. The patient would present with low oxygen, shortness of breath and low blood pressure. If the cause was pulmonary embolism, to have oxygen this low and have normal blood pressure would be very odd. If it was a pulmonary embolism, Dr. Jensen should have had low blood pressure from the start of his difficulties. The low blood pressure results from the clot blocking the blood vessels coming into the lungs. Dr. Boiteau testified that it was hard to imagine a clot being the cause of death, given that Dr. Jensen’s respiration rate was so high and his blood pressure came back up so quickly. In addition, Dr. Boiteau would have expected to find evidence of the clot at autopsy, and there was no evidence of a clot found. [225] With respect to any effect Heparin may have had in disintegrating any blood clot so that it would not be seen in the autopsy, Dr. Boiteau confirmed that Heparin disintegrates clots, but the dose that was given to Dr. Jensen was much too small. It was administered for purposes of prevention only and he didn’t believe the administration of this small amount of Heparin would have disintegrated any blood clot. [226] With respect to aspiration, the low oxygen levels along with normal blood pressure and coughing symptoms all fit aspiration. However, Dr. Boiteau testified that they would have expected to see some trace in the lungs on the autopsy but there was no evidence and there was also nothing on the chest x-ray that had been taken. Dr. Boiteau testified that it would be hard to be believe that Dr. Jensen’s death was the result of aspiration during the operation, but it is possible. He testified that it could be that Dr. Jensen’s cough reflex was suppressed and he had something in his lungs but did not feel the urge to cough until later. However, Dr. Boiteau would have expected that Dr. Jensen’s oxygen level would have dropped long before it did if this were the case. [227] With respect to anaesthetic being the cause of death, Dr. Boiteau did not notice anything to make him think there was a problem with the anaesthetic. He agreed with others who had already testified that such a problem would present in the operation itself or immediately in the recovery room. Four hours later would be very unusual. [228] The most common side-effect of anaesthesia is nausea and vomiting. If the patient is not conscious they cannot change position to protect the airway and get gastric contents in the lungs if this occurs. Since Dr. Jensen was watching television, his higher faculties appeared to be back in place, so he should have been able to protect his airway at this stage. [229] Dr. Boiteau stated the family would be in a better position to know if his swallowing was affected by cerebral palsy, because there are different types of cerebral palsy and this varies according to the individual. His evidence on this point suggests he was unaware that Dr. Jensen suffered from spastic quadriplegic cerebral palsy, which has a definite impact on his ability to swallow. Dr. Boiteau further testified there is a check list which the nursing staff are trained to follow prior to the introduction of food after surgery, but the nursing staff testified they were not aware of such a list and there is no evidence any swallowing testing was done prior to the introduction of the orange juice and food Dr. Jensen was given.


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[230] Dr. Boiteau also testified that anaesthetic can have an effect which could compound the difficulty in swallowing experienced by cerebral palsy patients who have the kind of cerebral palsy which involves difficulty co-ordinating their pharyngeal and larynx, resulting in difficulty swallowing and a consequential risk of aspiration. However, Dr. Boiteau felt it would be odd for this effect to occur four hours later. [231] With respect to anaphylaxis, Dr. Boiteau testified it would be very rare to see an anaphylactic reaction without a decreased blood pressure. In Dr. Jensen’s case, the blood pressure was dropping then returning to normal and this is not consistent with an anaphylactic reaction. Although allergic reactions can present all over the spectrum, true anaphylaxis would present with hives, swelling, red skin, hot to the touch, decreased blood pressure and difficulty breathing. [232] Dr. Boiteau testified that with respect to other possible allergic reactions, a condition called ‘water on the lung’ is a very rare reaction to narcotics, which manifests as shortness of breath. With ‘water on the lung’, the lungs are heavier that normal and this would be present at autopsy. However, heavy lungs could also be because of the resuscitation attempts. He testified that during CPR, pressure is caused within the heart, causing blood to build up and the pressure to be transmitted into the lung. When pressures are high in the blood vessel within the lung, then fluid weeps out into the lung. Another rare reaction is non-cardiogenic pulmonary edema, which is an immune reaction which causes the vasculature to become leaky and again results in water on the lung. It did not seem like Dr. Jensen had an allergic reaction because normally these do not make people sick enough to have to go to the ICU and Dr. Jensen’s symptoms were not consistent with allergic reaction. [233] He also testified that any non-anaphylactic (idiosyncratic) reaction could result on water on the lungs and this possibility cannot be excluded. However, if someone is going to get water on the lung from an idiosyncratic drug reaction, it would occur within about an hour of ingesting the drug. [234] With respect to a heart problem leading to Dr. Jensen’s death, Dr. Boiteau checked for communication between the heart chambers and did not find this to be a difficulty. Dr. Boiteau believes the lungs and the oxygen were the first problem which in turn affected the heart functions.

Dr. Gregory Schnell – Cardiologist

[235] Dr. Schnell has a BSc in Pharmacy and a Doctorate of Medicine. He completed residencies in internal medicine, anaesthesia, cardiology and Fellowships in Clinical Research in Contrast Echocardiography and Echocardiography. He is currently a Clinical Associate Professor and Director, Cardiac ICU Medicine at Foothills Hospital, Department of Cardiac Services, the Mona Libin Cardiovascular Institute, University of Calgary. He testified that he was called by Dr. Boiteau to look for a shunt or hole in the heart using a TEE10. He explained that prior to birth there is a hole between the upper chambers of the heart and after birth air enters the lungs and there is a pressure change between the two chambers which causes a flap between the chambers to slam shut (more or less) but there may still be a small hole for approximately 20% of the population. Lung injuries can put pressure on the right side of the heart and force blood in the other direction from this hole. [236] Dr. Schnell testified that he used a topical numbing agent in the back of Dr. Jensen’s throat to insert the probe and the results indicated that the right ventricle of Dr. Jensen’s heart was enlarged and barely moving at all. The left ventricle was under filled but the Doppler testing which was performed ruled out the possibility of a shunt between the atria (top chambers of the heart) and the possibility of there being either a large or small hole between the chambers of the heart. The TEE also indicated that there was no valve problem or peripheral effusion (water in the sac around the heart) and the only other explanation for Dr. Jensen’s condition was lung injury. Dr. Schnell testified that his first thought was pulmonary embolism.

10 See Note 5


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[237] Dr. Schnell confirmed that he looked at the ECG from when Dr. Jensen was in the ER the week before and it showed sinus tachycardia, a normal rhythm but just fast. He testified that this was the first time he had seen Dr. Jensen’s ECG and nothing in it suggested an underlying heart problem. In his view, the tachycardia was not necessarily related to a heart problem. It was also his view that the cardiac arrest did not cause the right ventricle dilation, which would have resulted from a lung injury. He also stated that the central line placement would not cause cardiac arrest. [238] Dr. Schnell testified that pulmonary embolism is the most consistent with the right ventricle being enlarged as it was. He testified that for Dr. Jensen to be in as much trouble as he was, the pulmonary embolism would need to be relatively large, not massive, but certainly not small. He said that chest pain, sweating, and coughing are symptoms of pulmonary embolism, and for some the initial symptom is a marked shortness of breath but no chest pain. For others the only symptom is fainting. However, they can also present as symptoms of other things. He felt that the blood pressure profile did not fit with an acute pulmonary embolism. [239] With respect to the cause of death being aspiration, Dr. Schnell testified that a very serious aspiration pneumonia could cause right ventricle enlargement but that pulmonary embolism is more consistent. However, if it was aspiration that caused Dr. Jensen’s death, there should have been changes on the lung autopsy but there weren’t. Symptoms of aspiration would be initial coughing and choking which would progress into pneumonia symptoms like fever and shortness of breath. [240] Dr. Schnell testified that he felt that Dr. Jensen’s lungs were the cause of his heart problem, not the other way around. The presentation in this case was not consistent with electrical heart problems, and the issue relating to oxygenation is not typical of a primary rhythm problem having to do with heart difficulties. Dr. Peter Singer – Deputy Chief Toxicologist, Alberta – 1988 – May 2010 [241] Dr. Singer has a BA in Science, and a PhD in Chemistry. He testified that he started with the Medical Examiner’s Office in 1984 and was the Deputy Chief Toxicologist of Alberta from 1988 until his retirement in May of 2010. He confirmed that he has testified in Inquiries at both Provincial Court and Court of Queen’s Bench approximately 50 times. His toxicology report was included as an exhibit (I-8) at the Inquiry. He testified that none of the drugs that were detected in post-mortem testing of Dr. Jensen’s blood gave him cause for concern, even in combination. He clarified that the drugs he was particularly concerned with were the “toxic” drugs; those that had a depressant effect on the central nervous system. These medications include benzodiazepines such as loraxepam (Ativan), Midazolam and narcotic analgesics (codeine). He confirmed that the amounts of these medications in Dr. Jensen’s blood were very small and he wouldn’t have expected any problems associated with those. [242] When given more specific information about the timing of the administration of the codeine, Dr. Singer again confirmed that there was not enough codeine present to account for death. However, he also stated that the 60mg dose of codeine that Dr. Jensen was given was sufficient to cause respiratory distress in some people, depending on their tolerance for opiates. He later clarified that he considered this prospect unlikely. He was unable to comment on whether Dr. Jensen’s underlying cerebral palsy would have made it more likely that he would have been one of that group. [243] In Dr. Singer’s opinion, Dr. Jensen’s death was not drug related. He testified that he had been unable to find any reports of cardio-toxicity associated with the F6H8 compound (Perfluorohexyloctane) that was used as the vitreous substitute during the surgery.


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Dr. Richard Merchant – Staff Anaesthesiologist, Royal Columbian Hospital, Westminster, British Columbia

[244] Dr. Merchant was qualified as an expert in the area of anaesthesiology and at the request of the Court, was a practicing anaesthesiologist from a jurisdiction outside of Alberta. Dr. Merchant was certified as a specialist in anaesthesiology and has been a staff anaesthesiologist at the Royal Columbian Hospital at Westminster, British Columbia since 1991. He is currently Department Co-ordinator, Research, Residents and Paramedical Trainees and Clinical Associate Professor, University of British Columbia, Department of Anaesthesia. [245] With respect to possible causes of death, Dr. Merchant testified that pulmonary embolism would have been a reasonable diagnosis except for the lack of corroborating findings on autopsy. The timing of Dr. Jensen’s death was also a factor in Dr. Merchant’s hesitation to accept that a pulmonary embolism had occurred. He testified that pulmonary embolisms tend to happen one to two days post-operatively, not within hours of surgery. [246] With respect to aspiration, he considered it a “relatively likely” cause of death. Failure of the protective reflex of the larynx, which usually closes to protect the lungs against any foreign material that might be present, can lead to aspiration of gastric contents. However, the autopsy did not show the presence of secretions that conclusively prove that the cause of death was aspiration pneumonitis, although there were some changes on the autopsy that were suggestive of this conclusion. In Dr. Merchant’s opinion, it was “a more likely proposition” that Dr. Jensen aspirated as he ate, in comparison with the possibility that there was a passive aspiration after the surgery when the tracheal tube was removed. The evidence is clear that Dr. Jensen’s difficulties happened after food and drink had been introduced. [247] Dr. Merchant felt the likelihood that aspiration was the cause of death was increased in the face of Dr. Jensen’s pre-existing problem of co-ordination of his oral and pharyngeal (throat) muscles, which might have placed him at greater risk of aspirating any gastric contents that were regurgitated. While Dr. Merchant did not have detailed information about Dr. Jensen’s cerebral palsy, he was aware that Dr. Jensen tended to produce excess saliva. He confirmed that Dr. Jensen’s speech distortion, difficulty in swallowing, and history of coughing were suggestive of bulbar muscle palsy. He also suggested that the on-going history of mild chronic aspiration, as suggested by Dr. Jensen’s history of swallowing difficulties and coughing, could have made Dr. Jensen more susceptible to a sudden aspiration of gastric contents. Dr. Merchant also noted that Dr. Jensen would have been at greater risk of this type of aspiration due to his cerebral palsy. [248] With respect to the codeine administered to Dr. Jensen, Dr. Merchant testified that when taken orally, codeine is absorbed within half an hour to an hour and that the codeine level peaks approximately one hour after the drug is administered. He also testified that the peak effect of an oral dose of Atasol is one to one-and-one-half hours after the drug is administered. He stated that there was no evidence of opioid induced respiratory depression and that this was not the cause of death. In Dr. Merchant’s opinion, it was entirely coincidental that Dr. Jensen went into a Code 66 within one-and-one-half hours after receiving codeine. In his view, if Dr. Jensen’s ability to breathe had been affected by codeine, this would have resulted in a decrease in his breathing rate and a sedative effect, rather than an increase in his breathing and anxiety. [249] Concerns regarding use of codeine in patients with decreased respiratory reserve were discussed with Dr. Merchant, including an exhibit11 entered as part of Dr. Singer’s testimony, that according to the manufacturer’s monograph, Atasol should be used with caution in patients with decreased respiratory reserve and is contraindicated in patients with convulsive disorders. In contrast to Dr. Singer, Dr. Merchant testified that there is no particular caution that needs to be observed when administering codeine to patients with decreased respiratory reserves. Dr. Merchant stated that in his opinion the contra-indication of Atasol for those with convulsive disorders was likely due to the caffeine content of the medication rather than the codeine, and he was unaware of problems with codeine in patients with convulsive disorders.

11 Exhibit 1, Tab 21


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[250] He testified that Dr. Jensen’s responses to drugs appear to have been normal, which suggested to him that by the time the codeine was administered, the anaesthetic used during surgery would have cleared Dr. Jensen’s system, making the possibility of an interaction between these medications remote. [251] Dr. Merchant was unaware until informed by Ms. Dawe, that Dr. Jensen may have had a seizure disorder which Ms. Dawe said was located in his right arm. It was somewhat unclear as well, if Dr. Jensen had a convulsive disorder because Dr. Jensen’s mother, Ms. Dawe, commented that from time to time Dr. Jensen would have spasms in his right arm. It was never clear even to Dr. Jensen’s neurologist if these were the result of seizures or just merely muscle strain on his arm. [252] Dr. Jensen had been on steroids prior to the surgery. Dr. Merchant testified with respect to the possibility of acute steroid withdrawal, and did not feel that this was a contributing factor to Dr. Jensen’s death. Steroids can suppress the body’s normal cortisol production, and if cortisol levels are low, the body does not react well to physiological stress. It was partly for this reason Dr. Jensen was given a steroid in the operating room. Dr. Merchant was unable to rule this out as an indirect cause but noted whether this problem even exists is uncertain. In his opinion, steroid withdrawal was “very unlikely” to have caused Dr. Jensen’s death. [253] With respect to anaphylactic shock as the cause of death, Dr. Merchant rejected this notion. He also ruled out a pre-existing heart condition since he found no evidence of any such condition and noted that Dr. Jensen had previous electrocardiograms that showed he had a relatively fast heart rate but no other abnormalities. [254] Pulmonary edema as a suggested cause of death was also discussed with Dr. Merchant. He concluded that this was unlikely because Dr. Jensen had been coughing, showing that air was moving both in and out of his lungs making negative pressure pulmonary edema (which is fluid within the lungs drawn there by the force of a patient’s efforts to breathe) an implausible cause of death. [255] In response to the suggestion of an idiosyncratic drug reaction, Dr. Merchant allowed that there was always such a possibility, but that would be an unusual single reaction in any patient with any drug. Based on Dr. Jensen’s actual clinical presentation, specifically the decrease in blood oxygen level and blood pressure, Dr. Merchant was able to say confidently that he was aware of no physiology that would cause those symptoms in relation to a narcotic drug and that the possibility that this was an idiosyncratic drug reaction to codeine causing Dr. Jensen’s death did not make sense to him. [256] Dr. Merchant concluded that even though Dr. Jensen’s oxygen saturation was measured at 93% when he was admitted to hospital, he would not have delayed Dr. Jensen’s surgery on the basis of this oxygen level. Dr. Merchant testified that oxygen saturation below 95% is abnormal, but 93% saturation would not normally caused a delay in surgery, however, if it was below 90% then he would delay surgery and to a work-up for hypoxia. In Dr. Merchant’s opinion anaesthetics did not cause nor contribute to Dr. Jensen’s death. He did agree that it would have been an extra precaution to decrease opiates and muscle relaxants. [257] Dr. Merchant’s opinion was that there were almost certainly several factors contributing to Dr. Jensen’s death. He view is that the ultimate cause of death could not be identified with any more precision than to say that it was a catastrophic event with respect to Dr. Jensen’s heart or lungs. [258] With respect to recommendations, Dr. Merchant’s point of view is that it would have been desirable for Dr. Jensen to have attended a pre-admission clinic. This was because Dr. Jensen was a complicated patient. He described the process of pre-admission clinics as “pretty wide-spread” and he was opposed to surgeons, and in particular ophthalmologists, providing advice regarding anaesthesia. However, in this particular instance, Dr. Merchant felt that even if Dr. Jensen had attended a pre-admission clinic with the anaesthesiologist, it is unlikely that this would have made any difference to the eventual outcome, although it could have done so.


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Dr. Juan Jose Ronco – Critical Care Unit and Associate Director of Intensive Care Unit, UBC, Vancouver General Hospital

[259] Dr. Ronco received his Doctorate of Medicine and undertook eleven more years of training in internal medicine, critical care and pulmonary medicine. He has instructed at the American College of Surgeons, has been a member of the Critical Care Unit at the University of British Columbia Vancouver General Hospital site, Associate Director of the Intensive Care Unit since 1994 and Clinical Professor of Medicine (Critical Care and Respiratory) at the Faculty of Medicine, University of British Columbia. [260] Dr. Ronco testified with respect to the causes of death in Dr. Jensen’s case. With respect to an air embolism, he testified that in eye surgery there is a possibility of an air embolism, but this could be ruled out in Dr. Jensen’s case, primarily because it would be signaled by changes in Dr. Jensen’s respiratory parameters while under the general anaesthetic during the course of surgery. There is no evidence of this happening in Dr. Jensen’s case. [261] With respect to a venous pulmonary embolism (a blood clot from an area of the body which breaks free and enters the circulatory system) Dr. Ronco testified that this could be ruled out as well, because a clot of a size necessary to cause Dr. Jensen’s death would almost certainly have been seen during the autopsy of Dr. Jensen’s pulmonary arteries. This was not the case. Dr. Ronco also noted that pulmonary changes were visible on Dr. Jensen’s x-rays, and this is not usual in cases of pulmonary embolism. [262] With respect to respiratory failure, Dr. Ronco testified that Dr. Jensen demonstrated progressive hypoxemic and hypercarbic respiratory failure. These refer to a low level of oxygen and a high level of carbon dioxide in the patient’s blood, and although these conditions can occur individually, in Dr. Jensen’s case they occurred in combination with one another. [263] In addition, Dr. Jensen demonstrated progressive anxiety which Dr. Ronco testified may have been an incipient manifestation of a respiratory distress. This would especially be true given that Dr. Jensen had an underlying anxiety disorder. [264] However, Dr. Ronco was unable to determine with certainty what triggered this process of respiratory failure. It may have been a reaction to the surgery, a pulmonary embolism, a cardiac condition, aspiration, or a reaction to the post surgery medication. It was his conclusion that the cause of death was primarily a lung problem of unknown cause leading to very serious respiratory failure, leading in turn to an inordinate strain on Dr. Jensen’s heart. Dr. Ronco concluded that the most likely cause of death was “acute hypoxemic respiratory failure”, but noted this could not be determined with certainty because there is no hard evidence to support this conclusion. [265] As to the possible causes of respiratory failure, Dr. Ronco suggested that it may have been aspiration pneumonitis. He testified that this usually results in lung damage due to the biochemical composition of what has been aspirated rather than due to the aspiration of particulate material. He also confirmed that the absence of particulars, particularly food particles, in Dr. Jensen’s lungs does not rule out aspiration. In addition, aspiration pneumonitis can be caused by aspiration of even a small quantity of gastric contents, particularly if the material aspirated is very acidic. Gastric acidity is higher after a period of fasting such as Dr. Jensen observed prior to the surgery and it is for this reason that some anaesthesiologists give medication intended to lower the acidity of gastric contents before surgery begins. [266] According to Dr. Ronco, the first symptom of aspiration pneumonitis would be coughing, the sensation of shortness of breath, and systemic responses to a reduction in oxygen levels such as loss of consciousness. On further questioning, Dr. Ronco conceded that there is so little evidence of aspiration pneumonitis, it cannot even be said to be the probable cause of death. He testified that it would be highly


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unusual for aspiration pneumonitis, if it was developing prior to Dr. Jensen’s hospital admission or prior to the time when he was served dinner, to have caused severe respiratory distress at the time of the Code 66. Despite this, it was Dr. Ronco’s conclusion that aspiration was, from his point of view, “high in the differential” in terms of determining what caused Dr. Jensen’s death. [267] When asked about the possibility that the codeine that Dr. Jensen had been given had any significance, Dr. Ronco stated that he would have “thought twice” about giving this medication only if there had been overwhelming and quite powerful evidence of previous difficulties associated with this medication. He stated that usually this medication is not associated with significant side effects and in his opinion it is unlikely that an idiosyncratic drug reaction would be likely to cause overwhelming respiratory failure. [268] Dr. Ronco also noted that there was no evidence that the respiratory failure in Dr. Jensen’s case was related to the Perfluocarbons and/or Silicone oil used during the surgery. In his Report12, he also noted that medical literature shows isolated cases in which this has resulted in a clinical presentation similar to Dr. Jensen’s, but that all remains in the territory of speculation. [269] With respect to the effectiveness of the resuscitation efforts, Dr. Ronco discussed the two forms of re-oxygenation used: the nitric oxide and oscillation. Dr. Ronco supported the use of nitric oxide in this case because the nitric oxide is not only intended to improve oxygenation, but also acts as a vasodilator, which was an additional benefit in Dr. Jensen’s case. This is because it was suspected that Dr. Jensen’s respiratory failure was complicated by a malfunction of the right ventricle of his heart. Dr. Ronco confirmed that he would have taken the same resuscitation steps as he saw in evidence in Dr. Jensen’s case. [270] He also testified that in his opinion the intubation and ICU admission were done in reasonable time frames. [271] Dr. Ronco did, however, comment that he may have induced paralysis earlier because Dr. Jensen exhibited a violent reaction to the ventilator which is described as chest heaving. Dr. Ronco testified that it is usual to attempt ventilation without paralysis, however, because paralysis itself has side effects. He was not critical of the use of the ventilator without paralysis in Dr. Jensen’s case. [272] Dr. Ronco indicated that were he dealing with Dr. Jensen’s case today he would attempt ECMO13 or extracorporeal membrane oxygenation. However, this technology was not available in 2007 and is still not available at the Rockyview General Hospital. [273] Dr. Ronco was asked about the appropriateness of care provided to Dr. Jensen. Part of this Inquiry concerns whether Dr. Jensen’s oxygen levels should have resulted in a more concerted response from medical personnel. Following the surgery, at one point Dr. Jensen’s oxygen saturation level was 93%. Dr. Ronco testified that this was not a normal level, but also stated that this level is not so low as to be considered abnormal. [274] He did suggest that where there are two consecutive measurements showing decreased oxygen saturation, he would have expected a corresponding increase in the frequency of vital signs checks. [275] With respect to the placement of the central line, Dr. Ronco noted that the central line placement is not a preventative or strategic decision and did not relate to the concurrent cardiac arrest. Dr. Ronco was questioned about a two-and-a-half hour time frame which passed between the time Dr. Boiteau was first paged and his arrival at the hospital. Dr. Ronco testified that there was nothing in the timeline that led him to believe that something that should have been done took too long. However, he also indicated that the level of care a first year student is able to provide is different from that which an intensivist is able to offer. With respect with the procedure at Vancouver General Hospital, it is expected that an intensivist will arrive back at the hospital within 20 to 30 minutes of receiving a call.

12 Exhibit 1, Tab 12, p.4 13 See Note 3


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[276] Part of Dr. Ronco’s evidence dealt with the level of expertise that could be expected of a resident monitoring the ICU overnight. According to Dr. Ronco, the resident tasked with this duty is usually in his or her second or third year of training, depending upon which specialty they are training for. He testified that at a minimum the ICU would be monitored in their second year of residency. At the time of Dr. Jensen’s death, Dr. Grochmal, who was monitoring the ICU, was a 1st year neurosurgery resident, near the completion of his one month ICU training rotation. [277] With the respect to the role that cerebral palsy played, Dr. Ronco stated that patients with cerebral palsy ought to be treated with the utmost concern because they are very prone and vulnerable to deteriorate. In his opinion, heightened levels of monitoring and protective measures would potentially be beneficial. Dr. Ronco would have considered Dr. Jensen a high risk for aspiration because he had cerebral palsy. However, it was his opinion that even if Dr. Jensen did aspirate, the combination of the cough suppressant he had been given and the underlying cerebral palsy would not have made it more difficult for Dr. Jensen to deal with the aspiration. Therefore, the cough suppressant, in his opinion, would not have aggravated Dr. Jensen’s situation. [278] Dr. Ronco did note that patients with severe cerebral palsy present a concern to physicians in that there is a decrease in the physiological reserve of their respiratory system in addition to difficulties with swallowing. The swallowing difficulties associated with cerebral palsy makes serving a meal post surgery an important medical consideration. According to Dr. Ronco, a higher degree of monitoring was required due to Dr. Jensen’s increased risk of aspiration while eating. He later noted that the level of monitoring in the day surgery unit was appropriate to the level of alertness required for a cerebral palsy patient. [279] While Dr. Ronco noted that cerebral palsy patients present special concerns for medical personnel, he also noted there was nothing on the record that confirmed cerebral palsy as a factor in what happened. Whether or not cerebral palsy was in any way implicated in Dr. Jensen’s death, in his view, depended upon what the cause of death had been. If Dr. Jensen’s death was in fact caused by an embolism then Dr. Ronco was of the view that the cerebral palsy had no role in the outcome. If on the other hand, Dr. Jensen died after aspiration, then based on the assumption that patients with cerebral palsy face a higher risk of aspiration, the cerebral palsy was a factor. [280] With respect to recommendations, Dr. Ronco noted that due to the uncertainty regarding what may have caused Dr. Jensen’s death, it is very difficult to entertain suggestions regarding ways of preventing future occurrences. He was unable to offer any recommendations, and was of the opinion that Dr. Jensen’s death was not preventable. Despite having said this, however, in his view patients with cerebral palsy should be more closely monitored. Dr. Ronco was also of the opinion that initially there should have been a plan in place for Dr. Jensen to remain in hospital overnight following the surgery, rather than being transferred from day surgery onto an overnight basis. [281] Dr. Ronco had no concrete suggestions concerning a better way in which residents and other hospital staff could contact doctors who were off-site. He did state, however, that it was important to put “intermediate layers of care” in place which would buffer the delay in the response time by very experienced physicians, who obviously cannot live on site twenty-four hours a day. [282] Dr. Ronco also testified that had he been contacted by the charge nurse and advised of the lab results of the ventilation and resuscitation events as they stood at 2100, he would have likely attended the hospital. [283] There was also a concern expressed with respect to the location of the nitric oxide and oscillation machines. It had been suggested that there might have been a delay in providing treatment to Dr. Jensen because of the location of these machines and the process through which the hospital staff had to go to access them. Dr. Ronco testified that at the Vancouver General Hospital this equipment is kept within the floor plan of the ICU.


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[284] Despite these suggestions regarding ways in which the care provided may not have been optimal, Dr. Ronco came to the conclusion that there was no treatment available that could have been used earlier to prevent the deterioration. Although at one point Dr. Ronco indicated that he would have paralyzed Dr. Jensen earlier, he later testified that he would not have done anything different in Dr. Jensen’s care.

ALBERTA HEALTH SERVICES CHANGES IMPLEMENTED AFTER THE DEATH OF DR. JENSEN - [285] Mr. Waite, the solicitor for Alberta Health Services has been particularly accommodating to the family through out the course of this Inquiry. It is important to note that Alberta Health Services has already implemented a number of changes which the evidence at this Inquiry has identified as areas requiring attention. They are as follows:

1. At the time of Dr. Jensen’s death, it was not unusual for a first-year resident to be left in charge of the ICU at night. There was no suggestion in the Inquiry that Dr. Grochmal’s lack of experience contributed to Dr. Jensen’s death, with Dr. Boiteau and Dr. Ronco confirming that neither of them would have done anything differently. Despite this, in 2009, a policy was instituted that requires the ICU to be staffed with a more senior resident or bedside physician (a family doctor with additional ICU training) through the night.

2. In 2007, the nitric oxide and oscillator equipment used by the respiratory therapists was kept

in a storage room in the pool room in the rehabilitation unit, which is located on the floor below the ICU. To access this equipment, a therapist had to go downstairs, get the key from respiratory therapy, unlock two doors, one to the pool room and one to the storage room, before returning upstairs with the equipment to the ICU. In January of 2007 this equipment was moved and is now in a storage spot right outside of the respiratory therapy department. It is still in a locked room but with access by way of a keypad rather than by key.

3. The therapists involved in Dr. Jensen’s care also reported difficulties with the instructions for

the checkout procedures for the nitric oxide machine. Since 2007, the hospital has developed an easier to read set of instructions and the checkout procedure can now be completed quicker.

RECOMMENDATIONS FOR THE PREVENTION OF SIMILAR DEATHS - [286] There are a number of areas in evidence at this Inquiry which ought to be raised in the context of the prevention of similar deaths. It is recommended that Alberta Health Services examine each of these areas and determine the best course of action to address the concerns and questions raised by the evidence. 1. THE NEED FOR ENHANCED MONITORING OF COMPLEX PATIENTS THROUGHOUT THEIR HOSPITALIZATION INCLUDING PRE-OPERATIVE CARE AND POST-OPERATIVE CARE, EVEN IN CASES OF MINOR SURGERY. [287] The evidence at this Inquiry is that Dr. Williams booked Dr. Jensen’s surgery on an urgent but not emergency basis. By the time the booking documents were received by the hospital, it was likely too late to divert Dr. Jensen to a pre-admission clinic. Dr. Williams’ concern about this surgery was focused on the eye


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problem itself. When he saw Dr. Jensen alert in the TV room after surgery he had no concerns about Dr. Jensen’s condition other than the need to monitor Dr. Jensen’s pain, which was why Dr. Jensen’s status was changed from day surgery to a 24-hour patient status. Dr. Ronco testified a complex patient like Dr. Jensen likely required a 24-hour booking status from the outset to ensure enhanced monitoring of his complex condition. [288] The evidence is clear that Dr. Jensen’s condition changed when food and drink were introduced as part of the nursing care. Dr. Merchant testified that Dr. Jensen’s type of cerebral palsy made him a “complicated patient” and that patients with cerebral palsy can deteriorate very quickly, which is what appears to have happened after the introduction of food and drink in Dr. Jensen’s case. Dr. Merchant further testified that significant care ought to be taken when determining when to introduce food and drink to a patient such as Dr. Jensen. [289] Dr. Ronco noted that “patients with cerebral palsy ought to be treated with the utmost concern because they are prone and vulnerable to deteriorate” and he testified that a higher degree of monitoring was required due to Dr. Jensen’s increased risk of aspirating while eating. His evidence specifically linked the swallowing difficulties associated with cerebral palsy to the need for a higher degree of monitoring patients such as Dr. Jensen who would experience increased risk of aspiration while eating. [290] There was a dearth of evidence concerning when and if food and drink are appropriate for patients with the complexities that Dr. Jensen had. It appears he was treated the same as any other patient would be with respect to this subject, and given his sudden and rapid deterioration following the introduction of food and drink, the evidence strongly suggests that some means of enhanced monitoring for patients with complex conditions is important, not only with respect to the issue of anaesthetic but with respect to care throughout the hospitalization even in cases of minor surgery. Whether a pre-admission clinic could ensure this type of enhanced monitoring and scrutiny for such complex patients throughout their hospitalization, is not clear from the evidence in this case. [291] There is also evidence from Dr. Boiteau that there was a check-list for nurses to follow prior to introducing food after surgery, but the nursing evidence is that no such check-list existed or was followed. Even if such a list does exist, it is recommended that specific patient complexities like the complications evident in Dr. Jensen’s type of cerebral palsy be given special consideration particularly because of the inherent difficulty in swallowing caused by his condition. The difficult surgery and the general anaesthetic to which Dr. Jensen had just been exposed may require a type of enhanced monitoring of post-operative care due to the existing complications in his medical health to begin with. [292] While the cause of death is not certain in this case, there is considerable evidence consistent with aspiration. Dr. Ronco did not rule out aspiration pneumonia as a cause of death and testified that even a small quantity of gastric contents can cause aspiration, particularly if it is acidic. Gastric acidity is higher after the period of fasting Dr. Jensen had undergone in connection with the surgery. Some form of enhanced care and or monitoring would address not only the anaesthesiology requirements for complicated patients such as Dr. Jensen (which appears to have been addressed), but all other unique patient needs such as careful consideration of the introduction of food and drink, its nature and timing after surgery. [293] Of note is that when Ms. Tuck heard Dr. Jensen coughing in the T.V. room as if he had “accidentally gotten something down the wrong tube”, she noticed that he was bright red and coughing. It was then that she gave him the orange juice. [294] The second time during the course of Dr. Jensen’s hospitalization that his condition suddenly deteriorated was in the ICU. When Dr. Grochmal laid Dr. Jensen flat to insert the central line, his vital signs immediately deteriorated. The evidence does not address whether alternative positioning for patients like Dr. Jensen could have been accommodated and in light of the evidence of Ms. Wright, it may be that laying patients with similar swallowing difficulties flat ought to be avoided if possible. An enhanced monitoring


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system could identify this need, in the event a patient’s condition deteriorated to a place where they were sent to the ICU. An advanced understanding of this area of treatment by ICU would be important given the time constraints upon the ICU staff, whose primary concerns are to deal with life threatening conditions. [295] Of note too, is that Dr. Boiteau testified he considered proning Dr. Jensen after this sudden deterioration took place but neither trained staff nor equipment needed for this purpose were readily available to accomplish this. [296] The evidence at the Inquiry is that the instructions of the attending physician govern the care of patients both pre-operatively and post-operatively. Because the eye surgery was considered minor day surgery, the physician’s instructions in this case appear to have focused on the subject of on-going pain as a result of the surgery which turned out to be more difficult than anticipated. The complexity of Dr. Jensen’s medical condition does not appear to have been specifically addressed in terms of the post-operative care he received prior to his admission to the ICU. When Dr. Williams last saw Dr. Jensen, his only concern was with respect to the degree of pain Dr. Jensen would experience, and the evidence does not include reference to the enhanced monitoring Dr. Ronco and Dr. Merchant believed important for patients such as Dr. Jensen, despite the minor nature of the surgery. 2. CONSISTENCY WITH RESPECT TO MONITORING GUIDELINES FOR NURSES IN THE DAY SURGERY UNIT. [297] There is conflicting evidence from various nurses regarding the monitoring program that should have been applied to Dr. Jensen. It is noted from the evidence that the recovery room nurses expect an oxygenation saturation level to be maintained at 90%, whereas the day surgery unit nurses expected, as least in the person of Ms. Martinson, oxygenation saturation levels to be maintained above 88%. [298] In the opinion of Ms. Tuck, Dr. Jensen’s primary care nurse, vital sign monitoring on a hourly basis was appropriate for Dr. Jensen. The more frequent vital sign monitoring, consisting of every 15 minutes for three times, then every 30 minutes for two times and then on a hourly basis, was in Ms. Tuck’s understanding, applicable for patients who had had open incision surgery under a general anaesthetic but not applicable to eye surgery patients. Under the actual policy, this protocol is applicable to 24 hour general anaesthetic patients, not to general anaesthesia day surgery patients. [299] In contrast, Ms. Martinson initially testified that it was her understanding that the more frequent monitoring policy was applicable to all patients who had been under general anaesthesia. She stated in subsequent testimony that it is not unusual to follow this protocol for eye patients, who are monitored every hour for 3 hours and then every four hours. Eye patients, even those who have had general anaesthesia, are checked in accordance with the general anaesthesia policy only if the doctor’s notes indicate that this is needed. [300] While both nurses believed that the general anaesthesia protocol did not apply to Dr. Jensen by virtue of the fact that he had undergone eye surgery, Ms. Stewart testified that to the best of her knowledge there was no special protocol in place with respect to monitoring eye patients. [301] The issue is further complicated by the fact that different monitoring policies are in place for day surgery patients as opposed to 24-hour patients. After the completion of surgery, Dr. Jensen was reclassified by Dr. Williams, who altered his admission status from day surgery patient to 24-hour patient because of concerns that Dr. Jensen would have more pain following surgery than was initially expected. This reclassification occurred between 1525 and 1644.


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[302] In January of 2007, the day surgery policy mandated the following timelines for vital sign monitoring:

Day surgery patient 24 Hour patient

General anaesthesia - on arrival - on arrival

- every hour thereafter* - every 15 minutes (x2)

- on discharge - every 30 minutes (x2)

- every hour (x3)

*the final page of this document notes that the standard is every hour for 3 hours, then every 4 hours

- every 4 hours (48 hours) - twice daily (5 days) - daily until discharge

Peripheral blocks - on arrival - once per shift

- on discharge

[303] There is no mention of a particular “eye protocol” that would support the nurses’ belief that less frequent monitoring was required in these cases. There is an ambiguity within the policies themselves that was discussed by Ms. Stewart in her testimony; the formal policies mandate assessment on arrival and then go on to set out the frequency for follow up, whereas the informal document does not stipulate that assessment occur on arrival. This leaves open the possibility that the nurses might interpret the hourly (x3) directive as inclusive of the initial assessment, which appears to have occurred in this case, as when Dr. Jensen arrived back in the day surgery unit from the recovery room, Ms. Tuck noted his chart for vital monitoring at 1615, 1715 and 1815. 3. REVIEW OF COMMUNICATION PROTOCOLS AND PRACTICES AT ROCKYVIEW GENERAL HOSPITAL REGARDING TRANSFER OF CARE OF PATIENTS. [304] Evidence at the Inquiry was unclear regarding whether communication regarding Dr. Jensen’s oxygen requirements when he was transferred from the recovery room to the day surgery unit was made through the porter who transferred him from the recovery room to the day surgery unit. The evidence of the nursing staff was clear that this would not have been an unusual procedure. Ms. Stewart testified that it would be common practice for nurses to ask porters to relay this type of information, but noted that specific instructions regarding oxygenation would have to be confirmed through a patient’s chart. [305] Ms. Martinson, a nurse in the day surgery unit, confirmed that her usual practice is to ask the porter whether a patient had been on oxygen. [306] One of the two recovery room nurses, Ms. Renkas, also testified that she would have told the porter what rate of oxygen Dr. Jensen had been on in the recovery room, with the expectation that he would put back on oxygen in the day surgery unit. She confirmed that passing this message via the porter was the usual procedure. [307] The evidence at the Inquiry was that Dr. Jensen transferred from the recovery room with nasal prongs, indicative that he ought to have been receiving oxygen once he arrived in the day surgery unit.


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However, the day surgery unit staff believed this to be unnecessary, given that there was at least one reading where Dr. Jensen had an oxygenation reading in excess of 90% while on room air. Since Dr. Jensen’s oxygenation levels deteriorated quickly once his difficulties arose, his family questions whether continuous oxygenation in the day surgery unit would have left him in a more stable condition with respect to oxygenation. I note that although his oxygenation levels in the day surgery unit fluctuated on room air, in each of the three tests they remained at 90% or better until the introduction of food and drink took place, which was accompanied by the drop in oxygenation levels and the onset of significant difficulties. [308] In order to protect public and individual confidence in the system, it would be important to review the practice of passing what may be important medical information through non-medical personnel such as hospital porters.

4. PAGING AND FOLLOW-UP PROCEDURES WITH ON-CALL PHYSICIANS.

[309] Dr. Grochmal testified that he first contacted Dr. Boiteau at 2000 but it wasn’t until 2200 that Dr. Boiteau arrived at the ICU. Whether an earlier arrival by Dr. Boiteau was likely to have made any difference in the outcome in Dr. Jensen’s case, given he was the experienced intensivist on call in the ICU for that evening, was the subject of considerable concern by Dr. Jensen’s family. However, the expert medical evidence suggested that while it was possible, it was not likely as Dr. Grochmal had provided appropriate treatment. Although Dr. Boiteau and Dr. Ronco agree that experience is a significant asset for treating patients in ICU, there was no evidence in the Inquiry that linked the delay in Dr. Boiteau’s arrival at the ICU to Dr. Jensen’s deterioration and ultimate death. Dr. Boiteau considered the same initial diagnoses as did Dr. Grochmal, firstly aspiration, then embolism when a chest x-ray ruled out aspiration. Dr. Boiteau testified that Dr. Grochmal took the right steps in his treatment of Dr. Jensen. [310] All participants in the Inquiry, including Dr. Jensen’s family, Alberta Health Services and counsel for the physicians, Mr. Peacock agree that it is “important . . . that the ICU staff be able to contact the intensivist on call on an emergent basis.”14 Alberta Health Services accepts that Dr. Jensen’s case indentifies the need for a “formal protocol with respect to what steps should be taken by the nursing staff when the on call physician is not available.”15 [311] The review as envisioned by Alberta Health Services would lead to putting in place a formal protocol regarding the steps that should be taken when a page does not prompt a response and the timeframes within which those steps should be taken. Dr. Boiteau testified that he did not know his pager had died. The pagers are on rechargeable batteries but only some hospital pagers have a warning system to indicate that the batteries are running low. The hospital may wish to consider that as they replace old hospital pagers, all new ones have low-battery warning systems. The hospital should also consider a system where the batteries are checked for full charge before a physician takes a pager to ensure they will operate for the whole shift. 5. THE USE OF ECMO (EXTRACORPOREAL MEMBRANE OXYGENATION) EQUIPMENT. [312] Dr. Ronco commented in his evidence that he would have attempted to use an ECMO machine in a situation like Dr. Jensen’s, but this technology was not available in 2007.

14 Counsel for the physicians, Mr. P. Peacock, submissions from Gowlings LLP, p.13, para. 59 15 Alberta Health Services Submissions, p.25, para. 109


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[313] Ms. Goulard testified that even in 2010 the only ECMO machine in Southern Alberta is at the Foothills Hospital. She indicated that this equipment can only be operated by a cardiovascular intensive care specialist, and therefore resource allocation will undoubtedly be an issue with respect to Alberta Health Services’ ability to provide this medical equipment. It would be desirable to have this equipment and the personnel required to operate it more extensively in Calgary and elsewhere. It seems to the Inquiry that only one being available at the Foothills Hospital for a centre as large as Calgary in inadequate. 6. REQUEST FOR LEGAL AUTHORIZATION FROM PARENTS IMMEDIATELY AFTER NOTIFICATION OF DEATH. [314] Mr. Jensen, Dr. Jensen’s father, was especially concerned about being asked to sign documents immediately after receiving the news that his son was dead. While such documentation was needed, the immediate request for his written authority was very difficult for him to handle at that time. Some protocol to address the manner and timing in which such authorizations can be received was needed in this case and may be beneficial in future cases. CONCLUSION – [315] The totality of evidence at this Inquiry suggests that complex patients with significant and multiple underlying health issues require some form of enhanced treatment and care, despite the nature of the surgery, even if the surgery itself is relatively minor in nature. It is not certain that this enhanced care could have saved Dr. Jensen’s life, but from the perspective of confidence in the medical system itself, it would have been important in this case.

DATED November 30 , 2011

at Calgary , Alberta.

Judge S. L. Van de Veen A Judge of the Provincial Court of Alberta

report to the minister of justice and attorney general · report to the minister of justice : and...

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