Inquests: Antonniazi Inquest

Background:
In December, 1998, the family of Mr. Gino Antoniazzi contacted the Psychiatric Patient Advocate Office (PPAO) due to a number of concerns the family had with respect to his care at the Lakehead Psychiatric Hospital (LPH). The PPAO advocate on site at LPH assisted them in bringing forward to the appropriate hospital clinical staff their concerns in addition to issues related to his capacity and ability to consent to treatment.

At the end of December, 1998, Mr. Antoniazzi developed a decubitus ulcer (commonly known as a bedsore or pressure sore). In spite of a series of treatments his ulcer deteriorated. In the weeks leading up to January 19, 1999 he continued to experience an overall decline in his health. On January 19, 1999, he was transferred to an acute care facility where he died on January 30, 1999. There had been no autopsy.

At the time of his death, Mr. Antoniazzi was 68 years old, and was said to be suffering from multi-infarct dementia. He had been transferred from a local facility, Pioneer Ridge, to a psychogeriatric unit at LPH in March of 1998. Throughout the course of his stay at Lakehead, issues arose regarding the communication among members of the health care team, and between the team and family members. There was also confusion as to when Mr. Antoniazzi became incapable of consenting to treatment, and whether hospital staff were aware that he had given his daughter a power of attorney for personal care in 1996.

Following Mr. Antoniazzi's death, the PPAO lobbied the Regional Coroner for an inquest. When the coroner’s investigation determined an inquest would be held, the PPAO sought and was granted standing. The basis for standing was that the PPAO had both a direct and substantial interest in this inquest (which is the test under the Coroners Act). The PPAO met the test for standing by virtue of having advocated on behalf of Mr. Antoniazzi, and because the local advocate was to be called as a witness. As well, the PPAO was able to provide assistance to the jury as a public interest intervenor.

The inquest into the death of Mr. Antoniazzi took place in Thunder Bay from March 27 – 31, 2000. Some of the issues discussed at the coroner’s inquest included:

1. Communication among members of the health care team, and between hospital staff and the Antoniazzi family;
2. The need to assess a patient’s capacity to consent to treatment on a timely basis;
3. The development and treatment of the decubitus ulcer; and
4. Documentation in the clinical record.

We would like to thank our advocate at LPH, Ms Pauline Bodnar, for her actions on behalf of Mr. Antoniazzi and his family and Ms. Mary Jane Dykeman for her able representation of the PPAO at the inquest. As well, we extend our condolences to the family of Mr. Antoniazzi and acknowledge their strength throughout this difficult process. We also thank the jury for its time and attention to this matter.

Coroner's Inquest Into The Death of Gino Antoniazzi 

The jury ruled that the cause of death was septicemia. The jury also found that the death was by natural causes.

Jury Recommendations:

Communication

1. That the LPH develop a comprehensive and regularly updated orientation package for patients, families and representatives on both of its psychogeriatric units, in consultation with the facility’s stakeholders including the patient advocate and the Family CAN group.
2. That as part of the orientation package and process, patients (and where appropriate, their families and representatives) be advised of the existence of the Psychiatric Patient Advocate Office (PPAO) and be provided with a copy of the PPAO’s rights guides.
3. That where possible, a pre-admission orientation meeting be held for prospective psychogeriatric patients and upon patient consent, also for their families or representatives. Where it is not possible to have a pre-admission orientation meeting, an orientation should be held on arrival, or as soon as reasonably possible after arrival, for patients, and with patient consent, for their families and representatives.
4. That within one week of admission, a follow-up meeting involving necessary health care professionals should be held to deal with issues of:
   1. confidentiality
   2. the patient's wishes with respect to the role, if any, of the patient's family or representative in patient care
5. That multidisciplinary meetings involving the health care team and the patient (and with patient consent, designated family member(s) or personal representative(s)) be held on a regular basis of not less than every three months or in the event of a significant change in patient status, a multidisciplinary meeting will be called in a timely fashion
6. That the LPH make information available to agencies and health care professionals as to the psychogeriatric facilities and services at the LPH.
7. That agencies or health care professionals who refer clients to the LPH inform themselves and their patients/families of the psychogeriatric facilities and services available at LPH.
8. That the LPH mandate its health care professionals (where the patient or the patient’s substitute decision-maker consents) to communicate all significant developments to a designated family member or personal representative immediately in the case of a serious health implication, otherwise within 24 hours.
9. That all health care professionals working at LPH must wear tags or badges that identify them by name and professional designation.

Education/Training

Education and training must be provided on an ongoing basis.


10. That mandatory in-service training on consent and capacity issues be provided to all health care professionals working on psychogeriatric units.
11. That the LPH provide and require its nurses, providing care to psychogeriatric patients, to attend the following in-service training programs:
    1. wound care
    2. psychiatric medication and treatment for psychogeriatric patients
    3. documentation standards

Documentation

12. That legal documentation relating to a patient (such as the Form 14 and Powers of Attorney for Personal Care) be filed in a clearly identifiable area of the patient’s chart.
13. That all health professionals conform to the documentation standards mandated by their governing bodies and by LPH.
14. That PGP1 and PGP2 adopt the same documentation procedures.
15. That LPH ensure that there are appropriate and random audits of documentation procedures.

Patient Management

16. That the LPH ensure that there is a patient care plan for each patient and that it is regularly reviewed and revised at multi-disciplinary meetings.
17. That the LPH maintain adequate nursing staff and supervision of nurses on each of its psychogeriatric units.
18. That the LPH continue to undertake continuous quality improvement (CQI), including chart auditing, clinical education and incident analysis for nurses on psychogeriatric units.
19. That the LPH address through its Medical Advisory Committee (MAC) the following issues:
    1. physicians’ obligations under Ontario’s consent and capacity legislation
    2. the importance of physician participation in multi-disciplinary meetings
    3. documentation obligations and expectations
    4. the need to communicate in a timely fashion with a designated family member or personal representative (where the patient or the patient’s substitute decision-maker consents)
20. That the Coroner send this Jury’s recommendations to all Ontario provincial psychiatric hospitals that provide care to psychogeriatric patients for the hospitals’ review and consideration.
21. That all health care training facilities in Ontario develop and maintain current, curriculums, with respect to legal obligations of health care professionals.
    
22. That the family practitioner be kept informed of patient admissions to medical facilities (with consent of patient or designated decision maker).
    
23. That LPH re-evaluate:
    1. patient information flow
    2. the relevancy of duplication of notes
    3. the documenting/recording process with regard to the following:
    • charts, cardex, doctor’s book, nurse’s notes, cheat sheets,
    • progress notes, report book, doctor’s orders
    and consider location and redundancy as well as recording methods.
24. The city of Thunder Bay must create incentives to attract more medical practitioners. The shortage, in excess of 35 General Practitioners and Specialists, is a causal factor in the deteriorating level of health services provided within all City medical facilities.
25. That the Federal and Provincial governments review psychiatric hospital closure and continuing psychiatric care in Northwestern Ontario with regard to the extremely large land mass that comprises Northwestern Ontario.

< Back

RIGHTS - EMPOWERMENT - RECOVERY