Dawn Ostrem
Northern News Services
Inuvik (Jun 18/01) - Effie Blake's family sat quietly through the three-day coroner's inquest into the death of the mother, grandmother and sister.
They heard doctors acknowledge that they failed to diagnose the 57-year-old Fort McPherson teacher with tuberculosis, and health administrators describe a global shortage of medical professionals.
The jury's recommendations:
|
But after the six-member jury returned with 13 recommendations last Friday, Maria Blake said she somehow expected more. The family thanked everyone, but now they want action. They want the system fixed.
"We understand that doctors make mistakes," Ruby Blake said near the end of the inquest.
"We can learn from these mistakes ... We sincerely hope this type of situation will never happen again because it is a horrible experience that no one should have to go through."
Effie Blake died in Edmonton five months after her children repeatedly took her to a nursing station in Fort McPherson and then to doctors in Inuvik.
Although nurses and a radiologist suspected Blake might have TB, Dr. Jason Waechter did not test for the disease and treated her with antibiotics.
"She had been improving," Waechter said when he explained why Blake was released from hospital. She was not tested for TB until she was transferred to Yellowknife, six weeks after she first sought treatment.
"They are so used to stepping on people and getting away with it," Maria, Effie's youngest daughter said.
"They are so used to people not saying anything about their system," Ruby added.
The jury recommended that more money be found for staff and equipment; that nurses have greater authority to order tests and that information in old health records should be accessible.
The nurse at the health centre in Fort McPherson was never shown orientation and TB protocol guides that might have alerted her to the presence of the disease in the isolated community.
Dr. Waechter could not remember ever being told that the cases of latent TB were five to 15 times higher than the national average in the North.
An acute-care nurse at Inuvik hospital suspected TB or cancer in Effie Blake but did not have the authority to order a test for either disease.
During the inquest 33 documents were entered as exhibits but it was Maria's and Ruby's words that moved the jury, the public, the lawyers and Chief coroner Percy Kinney.
"It is very important we understand the human side of these things," Kinney said. "We sit up here with our pens and papers and laptops as part of our job but we have to remember."
Effie Blake was a tough, good-natured lady who raised five kids on her own, her family said.
Her students knew her for her famous floral porcelain tea cup she carried around the school and for giving them treats.
Her kids saw her as a wonderful mother, a strong woman and an avid berry-picker.
"She would be sitting at home or be up town and someone out of the blue would ask her to come and pick berries and she would be ready in a matter of minutes," Maria said.
Her son Les said she always took a cup to carry them in, "or sometimes a bag or a large pail and she would be up and out the door."
After his mother died, Les wanted to see her hospital file. He was granted permission only if he signed a release.
"It was pretty sneaky," Maria added.
"It said in small print he agreed not to take legal action."
The coroner's inquest was strictly a fact-finding mission, a way to try and improve the system. Everyone involved expected the recommendations put forward by the jury would do that.
Teri Lynn Bougie, a lawyer for the public trustee who is handling Blake's estate, left the question civil suit open.
"If the public trustee office is satisfied there was negligence then the family, in consultation with the public trust, may very well decide to sue," she said.
"I'm not sure we are going to have to make a recommendation (to the public trust). The GNWT may already recognize something went wrong here."
The jury's final recommendation reflected the family's dissatisfaction with the way the Inuvik regional hospital board treated them. It proposed a person be designated to respond to all family inquiries.
"I sent a letter of complaint about unsatisfactory treatment (to the board)," Maria said.
"I tried calling and calling and never got a response," Maria said.
"I even asked them to put my letter on the agenda to discuss how my mother was treated but it never happened. Still, no one has talked to me."
Chronology:
- Feb. 22: Effie Blake visits Fort McPherson nursing station with a dry cough, given chest X-ray and prescribed a cough syrup.
- Apr. 9: Blake returns to health centre unable to walk and coughing up blood-laced sputum, medevaced to Inuvik Regional Hospital.
- Apr. 16: Blake released from hospital as an outpatient after a slight improvement attributed to drugs prescribed for pneumonia.
- Apr. 18: Radiologist Dr. George Malcolm Goff read another chest X-ray of Blake's infected right lung and noted that it would be prudent to check for TB.
- May 5: Family asks to change doctors.
- May 9: Dr. Wouna Chaloner, who treated many TB victims in South Africa, saw Blake as an outpatient and continued treating her for pneumonia.
- May 15: Dr. Abraham de Klerk, chief of staff, sees Blake as an outpatient and tries to admit her thinking she has cancer but she refuses.
- May 18: Most recent chest X-ray shows a fluid build up in chest, radiologist calls Dr. de Klerk who puts in a chest tube and sends Blake to Yellowknife the next morning.
- May 19: Blake is put into the isolation ward at Stanton Regional Hospital and tested for TB.
- May 23: TB is confirmed and Blake is medicated for it.
- June 1: Blake is flown to Edmonton. Dr. Anne Fanning is asked to look into her case. Fanning found that Blake had latent TB in 1966 but did not receive medication at that time.
- July 18: Blake dies of septic shock brought on by pneumonia that resulted from pulmonary tuberculosis.
