HAY RIVER - A coroner's investigation has found that a Hay River woman died last year as the result of an "accident" during treatment at Stanton Territorial Hospital in Yellowknife.

Kay Lewis: CEO of Stanton Territorial Health Authority says recommendations from coroner always welcomed as a way to improve services. - NNSL file photo

The case involves the death of 62-year-old Mary Leona Poitras, a resident of Woodland Manor, who died in hospital in Hay River on June 27, 2010.

According to the report – written by Hay River coroner James Forsey – the cause of death was peritonitis, an inflammation of the lining of the abdomen following a colonoscopy and hot snare polypectomy, which is a process to remove small growths known as polyps.

"At autopsy, there was inflammation of the lining of the abdomen (peritonitis) arising as a result of a perforation of the colon at a site where one of the polyps had been removed during the colonoscopy," the report reads. "Three other visible sites, where polyps have been removed, were still intact."

According to the report, Poitras underwent a gastroscopy and colonoscopy at Stanton Territorial Hospital on June 23, 2010.

She was transferred back to Hay River on June 25, 2010.

At Woodland Manor, the woman complained of severe abdominal pain and nausea and was taken to the H.H. Williams Memorial Hospital where unsuccessful attempts were made to stabilize her vital signs and diagnose the problem.

As a result of the death, the coroner has made three recommendations to the NWT's chief medical health officer, Stanton Territorial Health Authority, and Hay River Health and Social Services Authority.

The first is that the three organizations review the medical care given to Poitras considering the procedure, potential for complications and undiagnosed condition afterward.

Secondly, the coroner recommended that, when patients are transferred between departments and hospitals, relevant medical records accompany them. In the case of Poitras, it was noted she had no accompanying records and each department was unaware of what had happened in the previous department.

The final recommendation is that medical records contain the procedures needed or given, the results and a list of the signs of expectations or complications that may arise, along with what action needs to be taken if negative symptoms occur. It was noted Poitras was displaying symptoms of peritonitis, but it went undiagnosed as there was no prior history for staff to assess.

Cathy Menard, the chief coroner of the NWT, said the report is not designed to assign blame for the death.

"We don't look at fault or blame and so we wouldn't look at that that way," she said. "But we would say it was accidental."

Menard said the coroner's goal is to look at the who, what, when, where and why of a case, and determine if future deaths can be prevented.

She noted the coroner's office had previously made recommendations concerning the sharing of medical records.

"It's important that the accompanying records from each department follow that person to where they go," she said, noting they could help a facility when somebody is having difficulty.

Kay Lewis, CEO of Stanton Territorial Health Authority, said recommendations from the coroner are always welcomed as an opportunity to look at ways to improve services.

However, she clarified the situation regarding the transfer of medical records.

"Actually, we can't transfer records. We transfer information," she said. "The records are retained for privacy reasons and operational reasons within the health institution. But when a patient is transferred elsewhere or back to their primary care physician, then there is a copy of a discharge summary that goes to them, as well as a discharge that goes to staff on the other end and communication on that line."

Lewis said it is standard practice everywhere in the world for a hospital to retain medical records.

She said there will be a review of the Poitras case to look into whether it met normal standards of care.

"Without that specific review, it's difficult to comment on actually what information was transferred and not," Lewis said. "You have to look at it in the full context of all the parties, and what paper and verbal information was transferred."

A discharge summary lists things like medications, patient status and any procedure that has occurred.

Lewis also noted there is a territorial endoscopy committee which is implementing territorial clinical guidelines for screening and follow-up care, patient information, staff training, and performance indicators to monitor and evaluate program and patient outcomes.

"So that will ensure that we have best practice and standardization of care across the territories regarding endoscopy," she said.

Endoscopy means any process using scopes.

Asked whether the coroner's report indicates that an error may have been made in Poitras' care at Stanton Territorial Hospital, Lewis responded, "The bowel is tissue that is quite easily penetrated and, when you're removing polyps, it can happen. It's a risk that can happen."

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