How far could your head be up your ass???
This past week I recieved what is supposed to be the final report from the Coroner on Matthew’s brief life and death. As I allude to in the title of this posting, the presiding coroners have their heads firmly implanted in their collective asses. I have taken the liberty of uploading the three pages of the report here. The irony of this report being issued on Matthew’s second birthday was not lost on us.
It doesn’t take long in reading this report to notice that it defies logic. I will also point out that the Doctor issuing this report is an emergency room physician and has no speciality in neonates or drug toxicology.
You will notice under Medical Cause of Death
(1) No Anatomical or Toxicological cause of death.
Yet, only a few lines down at item
(2) Other Significant Conditions Contributing to Death
Exposure to venlafaxine in utero.
By What Means Natural
As a layperson I read this to mean that having been exposed to venlafaxine in utero is a Natural way to die. Anybody left scratching their head at this point?
In paragraph 2 of this page Dr. Saunders reports on the medications Matthew was exposed while in utero. He goes on to describe what Tylenol 3 is and Effexor.
What he fails to mention at this point is that Health Canada and the FDA have both issued strong warnings regarding the fact that upwards of 30% of babies exposed to this drug will have moderate to severe withdrawal symptoms, respiratory distress, PPHN, prolonged QT syndrome, and like Matthew, sudden death.
Two more paragraphs after this, he notes that Christiane was administered 100 micrograms of Fentanyl for pain just 45 minute before delivery. This fact in and of itself raises red flags with most of the doctors I have spoken with over the last two years. Most jurisdictions throughout North America have established protocols that dictate newborns exposed to this potent opioid within several hours of birth MUST be monitored for the first number of hours after birth.
In Matthew’s initial assessment, the doctor and nurses were throwing the idea of administering NARCAN around, but never did. This could have been vital.
Dr. Saunders goes on to explain how Matthew was assessed. At 2:35 AM, he was reported to have “normal colour and a heart rate of 160 per minute with a respiratory rate of 70 per minute.” The following picture was taken of Matthew during the aforementioned assessment.
A person does not have to have any specialized medical training to notice that his coloring was anything but NORMAL. Each and every doctor and nurse that I have shown this picture to in 2 years(about 40) has said that his coloring is not normal. This coupled with a respiratory rate of 70 should have been a red flag for any of the medical staff treating Matthew. It certainly was for us.
Christiane argued with the doctor and nurses that he looked like an eggplant. We were told that this was normal. Prior to Matthew we had 4 other babies of our own and had experience with other people’s newborns. Our experience told us this was not normal. Why didn’t we fight more?
The final paragraph under Investigative Findings speaks to Dr. Saunders overall investigative ability. It notes that at 3:20 AM the infant was checked by the midwife. If you will read back to the very first paragraph on this page it says he was found at 3:30 AM by his nurse to be limp and cyanotic. Anybody see a problem here?
There is actually a couple of problems with this anomally. First, at 3:20 AM Matthew was still very much alive. That was the time when I was in the hallway with him complaining to the nurse that he was breathing funny and “clucking”. Only to be told to get back in our room as I was going to disturb the other patients on the ward. It was not for another 10 minutes that someone came in to the room. By this time he had gone in to full cardiac arrest.
This time anomally is just one of many factual innaccuracies that Matthew’s birth record and three subseuent doctor’s reports are riddled with.
This brings us to page three of his report.
This page is supposed to have summed up any medical testing and expert opinions regarding Matthew’s cause of death. What this page fails to mention is that very early on the pathologist , Dr. Angelica Oviedo, stated in her report that her findings were consistent with a neonatal diagnosis of Persistent Pulmonary Hypertension.
It is mentioned that samples of Matthew’s brain tissue were sent to the USA. This was to Dr. Hannah Kinney at Harvard. What is not mentioned here is that there was a defect in Matthew’s brain stem and she postulates “….we speculate that the duplication of the dentate gyrus in our case is a reflection of excessive neurogenesis associated with prenatal ssri exposure…..and represents a direction of further research.”
One “expert” was consulted on this case. This was Dr. Tim Oberlander. The report cites him as a consultant in Complex Behavioral Conditions. That was not why he was consulted. It was in fact his supposed expertise in drug exposure during pregnancy that brought him in to the fray.
When Dr. Oberlander first came on board, he verbalized to me that when all was said and done, he would issue a recommendation establishing a protocol for neonates exposed to these drugs in utero. Over the one year that I conversed with Dr. Oberlander, his demeanor and stance on SSRI’s seemed to shift. Culminating in a 6 page report that is summed up here
“Matthew’s death is consistent with sudden infant death syndrome(SIDS). At this point it remains unclear how prenatal exposure to a serotonin reuptake inhibitor (SRI) antidepressant(Effexor) might have contributed to his death, if at all.”
IF AT ALL????!!!! Are you f#$%ing kidding me? SIDS?
SIDS is a diagnosis of exclusion. It should only be applied to an infant whose death is sudden and unexpected and remains unexplained after the performance of an adequate postmortem investigation including:
- an autopsy; another autopsy
- investigation of the scene and circumstances of the death;
- exploration of the medical history of the infant and family.
It’s number 2 here that is the kicker. All the signs and symptoms were there.
The drug warnings and exposure that were ignored. The obvious respiratory distress that Matthew was in that went ignored for 40 minutes.
The best that you professionals can come up with is SIDS? Then by rights his cause of death should be listed as undetermined and not NATURAL. I will be pushing for this to be changed to, at a minimum ACCIDENTAL.
There were glaringly obvious mistakes made along the way with Matthew, yet the one person who has the ability to impliment change to ensure this doesn’t happen to another family signs off saying “No recommendations are made.”
I really wish he would have added, “I don’t give a shit about the death of your son.” Because that is how this report has left us feeling.
After I came down off the ceiling, I phoned the Coroner’s Office and spoke with dickhead’s boss. She encouraged me to put all my concerns in to writing and send them off to the Chief Coroner for the Province. Which I am doing. As well as sending this to every media outlet, politician, and medical authority that I can think of.
We are somewhat fortunate in that this issue doesn’t die here. In British Columbia we have a panel, much like a Coroner’s Inquest, called the Child Death Review Board that must now look over the facts of this case. I will be lobbying them heavily. The Coroner’s Service of BC’s tagline is “We are a fact finding agency, not a fault finding agency.”
I’d be left more at ease had Barney Fife headed up this investigation.
I’ll keep you posted.