How did 80-year old Ambrose Wald fall out of a hospital chair specifically designed to stop patients from falls?
It's a question to which his daughter Irene Wald, a nurse of almost 35 years, has never received an answer.
"There's a flaw in the way that the fall happened. No real investigation took place as to what happened to my dad," says Irene.
"My intent is that we learn from this event so we who work in the circle of healthcare can prevent it from happening to anybody else."
Ambrose Wald survived World War Two, emigrated from Europe to Canada in 1952 and worked as a welder at IPSCO.
He was approachable. He loved to laugh and share his favourite Reader's Digest jokes with his family. He died five days after his fall.
Losing her father was hard enough for Irene. Having no answers about why and how he fell from the chair — feeling that no one at the hospital cared enough to investigate — added to Irene's grief.
Irene says Father's Day 2008 was a great day for the Wald family. They feasted on barbecue steak, corn on the cob, wine and lemon pie. They even played cards without the normal banter and teasing arguments.
That night, Ambrose awoke with severe abdominal pain. Irene rushed him to the local hospital at 8 a.m. He was examined at 9 a.m. and diagnosed with a bowel obstruction.
The family waited all day for the on-call surgeon. They found out later the on-call surgeon was booked with elective surgeries and wasn't available for emergencies.
At 6 p.m. Ambrose went into shock. He was immediately taken into surgery and a portion of his bowel removed.
"He had an ischemic bowel. What that means is the gut starts to die. There's no blood flow in it, so all that gut starts dying, and when it dies, all that infection and sepsis spreads through the whole abdominal cavity and whole body," says Irene.
Ambrose survived the surgery and stayed in hospital for three weeks. As a long-time nurse, Irene was aware of the danger of falls so she asked one of the nurses not to get her dad out of bed unless Irene was there to help. Irene and her mom visited Ambrose every day.
One day when Irene and her mother arrived, they were told Ambrose had fallen, but suffered no injuries. No one seemed to know the cause of the fall.
Staff placed him in a Broda chair, a chair providing support and restraint, and left him unattended. A passerby noticed he was on the floor with the chair tipped over him.
Later, Ambrose complained of chest pain to his wife and daughter.
"The doctor came. He wanted to do some CAT scan of his chest. By that point, my father basically refused anything more. I think the fall was the ultimate. He just seemed to resign himself that nothing was going to improve. He died five days later."
Ambrose didn't like hospitals. At age 70, he had an aortic aneurism repaired. The aneurism had atrophied a kidney. The surgeon inadvertently nicked Ambrose's bowel and aborted the surgery. When Ambrose went back for a second surgery, there were complications. He ended up with an ischemic leg, gangrene set in and he had a partial leg amputation.
A year after Ambrose's death, Irene asked for the incident report about his fall.
"It gave no information. There was no investigation as to how a Broda chair could tip over or how someone could fall out of it. The manager didn't interview staff who were involved that day because there were no comments. It was just a tick box kind of report.
“The manager ticked off ‘Problem Solved’ at the bottom of the form. There was no learning as to was it an equipment failure or what. There was no learning at all," says Irene.
Irene's conversations with risk management at the hospital revealed that incident reports were filed without any assessment or evaluation.
"I was left disappointed,” she says. “Even though an incident report was filled out, nobody was really interested in doing anything about it. There was no learning. It wasn't even identified that my father died five days after that fall. It gave me the impression that nobody really cared or nobody was really interested."
Irene says if the people filling out the incident report lack the education to do it, or don't see its value — or if the manager doesn't see value in processing the report — that's a system failure.
"Obviously there are big flaws in the way incident reports are processed. I do believe that the people in risk management acknowledge these flaws are there. That doesn't give me any resolution. What gives me a bit of peace of mind is I've been invited in some of the processes to bring change to some of the incident reporting," says Irene.
She did get some peace when the emergency director acknowledged that any patient presenting with the problems her father did would not experience the same delay.
Now nearing retirement, Irene plans to be more involved with Patients for Patient Safety Canada. Patients for Patient Safety Canada is a patient led program of the Canadian Patient Safety Institute. Patients for Patient Safety Canada keeps the focus on the patient and adds a perspective that only the patient and family can provide.
"I'm already involved with a few different connections and projects that are coming up, so I'm very hopeful that the culture is changing in healthcare,” she says.
“The more I've been talking to different contacts in my health region surrounding my dad's incident, I now see a vision of where I'm heading and getting involved in trying to prevent harm from being done."
Irene's message to those working in healthcare:
"When you're looking after patients, put that patient in perspective. That could be your mother or father laying there. When I look after a patient, that's my mother laying there, my father, or it could be my child. It sets you in a totally different perspective of care, of how you look after people."