Editorial: Death by bureaucracy: how Quebec health care failed Mark Blandford

It should come as no surprise that the director of professional services responsible for St. Mary’s Hospital resigned last month, barely two years after her appointment.

Since March, 2014, Dr. Louise Ayotte had final authority in clinical decisions affecting seven health institutions in the West Island health authority, CIUSSS, which includes St. Mary’s.

As the Montreal Gazette’s Aaron Derfel revealed in a series of solid investigative reports, Blandford, a well-known documentary filmmaker, died after being refused surgery at his local hospital, St. Mary’s. He had gone by taxi to the ER complaining of excruciating abdominal pain. It turned out to be a ruptured aortic aneurysm in his abdomen.

Veteran vascular surgeon Carl Emond was called and asked to perform surgery. He declined, saying he had been ordered to no longer carry out that procedure, even though he wanted to because, given the patient’s
unstable condition, there was still a “slim chance” of saving his life.

Some critics have argued that, given the traditional role of physicians saving lives in all circumstances, Emond should have operated. This is unreasonable and unfair since physicians operating in hospitals must function according to established rules and protocols. Failure to do so could lead to sanction, suspension, or cancellation of hospital privileges.

More important is the failure by administrators responsible for hospital situations such as the one at St. Mary’s to allow for flexibility and judgment so emergency life-saving procedures could be performed when an available and experienced surgeon is ready to operate.

According to two well-placed sources who spoke to The Gazette on condition of anonymity, it was Dr. Ayotte herself, former director general at Lakeshore General Hospital, who appears to have been involved directly. When reached on the phone, she gave the order to transfer Blandford to the MUHC facility in the distant Glen site, the sources recounted.

In making that call, Ayotte was standing by the decision, explained in her November 23 letter to St. Mary’s clinicians, that administrative reforms initiated by Health Minister Gaétan Barrette and unspecified “budgetary issues” were the context in which vascular surgery was eliminated as a procedure at St. Mary’s.

This was no comfort to the ailing 73-year-old Blandford, who died before any surgery could be performed. Why could he not have been transferred to the nearby Jewish General? This surely is one of the questions that will have to be answered.

This version of events has not been denied, and Dr. Ayotte has made no public comment. Her resignation could be interpreted in various ways. Initially, Benoît Morin, director-general of the CIUSSS, who accepted Dr. Ayotte’s resignation, insisted on CBC that the decision not to operate on Blandford at St. Mary’s was Emond’s to make.

Witnesses who spoke anonymously to The Gazette do not agree. Dr. Ayotte has now assumed the role of director of professional services at the des Laurentides health authority in St. Jérôme.

Blandford’s death raises many questions and Ayotte’s resignation – the reasons were never specified – underscores the need for answers. Lessons must be learned because we are all Mark Blandford. The Quebec coroner’s office is investigating in an attempt “to clarify the probable causes and the circumstances” of Blandford’s death and, if needed, to make recommendations to prevent similar deaths. For now it is being done behind closed doors. It takes an average of about a year for reports to be completed.

This investigation should take the form of a full public inquiry, so witnesses are called to clarify, under oath and in public view, what was done and why, so everyone can learn whether more could have been done to save Mark Blandford’s life.

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