Under Pressure

August 9, 2011 at 9:11 am Leave a comment

The following is an email that I received the day before our story ran in the paper.

Good afternoon Mr. Schultz:

Thank you for taking the time to return my call this afternoon.

As I mentioned, your letter to the Honourable Christy Clark makes reference to your correspondence to Ms. Lapointe dated on or around May 20, 2011.  I was away from the office at this time and I would greatly appreciate it if you could e-mail me a copy of this correspondence.  I do apologize for any inconvenience this may cause you but I am very appreciative of your help.  I understand you are away at the moment and I look forward to receiving your e-mail at your earliest opportunity.

Kind regards,

Claire

 

Claire R. Leek | Executive Administrative Assistant to the Chief Coroner

Metrotower II, Suite 800 – 4720 Kingsway, Burnaby BC  V5H 4N2
Phone: (604) 660-8219 | Blackberry: (604) 992-9323 | FAX: (604) 660-7766

 http://www.pssg.gov.bc.ca/coroners

 

 What does this mean exactly? Did someone actually receive my letter or not? It’s interesting how the Coroner’s Secretary says,”I was away from the office at this time”. Sounds to me like a nice way to say we lost your letter and nobody is going to ever accept responsibility for it.

Then our story hit the paper and the TV and what do you know? I recieved the next email from the Coroner’s office.

Good afternoon Mr. Schultz:

 Please accept my apologies for the delay in replying to your e-mail dated August 2, 2011.  I have spoken with my colleague, Ms. Kellie Kilpatrick, Director of the Child Death Review Unit and sought the information you requested.  Kellie has asked me to share the following with you.

 The child death review methodology includes the following:

  • The case reviewer examines the Coroner’s file;
  • She determines if there is additional information that may inform the review – this may require seizing records and files held by other agencies;
  • In most cases, a letter is sent to parents advising of the review, explaining what it means, how their child’s information will be used, and inviting them to participate in sharing their perspective, experiences, concerns, and helping us understand who their child was in life;
  • All child deaths are then presented and reviewed by the CDRU multi-disciplinary team;
  • Protective factors, risk factors and other observations are considered and a determination is made re: preventability;
  • Recommendations are researched, considered and made to improve the health and well-being of children.

Matthew’s case was assigned to Paediatric Medical Case Reviewer Tansey Ramanzin and her initial review was completed on June 3.  Matthew’s case has been identified as one where a letter will be sent to you.  You will likely receive the letter next week.

Should you choose to meet with Tansey it is possible to meet in person (on the lower mainland), talk on the phone or correspond in writing – this will be dependent upon your wishes. Many of our courageous parents share what they have learned and their views on prevention with the hope that other families do not have to experience the unthinkable  – the loss of their child.  

Matthew’s death is scheduled for review by the multi-disciplinary team on September 20, 2011. The deliberations of the multi-disciplinary team are protected under the legislation but any action items or recommendations arising would be shared with you.

Kellie has also asked that I extend the deepest condolences of her Unit to you and Matthew’s family.

I hope you find this information useful Mr. Schultz. 

Yours truly,

Claire

 

Claire R. Leek | Executive Administrative Assistant to the Chief Coroner

Metrotower II, Suite 800 – 4720 Kingsway, Burnaby BC  V5H 4N2
Phone: (604) 660-8219 | Blackberry: (604) 992-9323 | FAX: (604) 660-7766

 http://www.pssg.gov.bc.ca/coroners

Amazing how people are moved to action when the media is breathing down their neck. Two dead babies whose parents are screaming for justice; Who gives a shit?  Media discussing how inept your Ministry is; We’ll move you to the front of the line Mr. and Mrs. Schultz.

The Child Death Review Unit is just not good enough though. I have little faith that they are anymore than a simple extension of the rest of the bumbling Coroner’s Service. We’re not even allowed to sit in on the deliberations. Why? Are you afraid that I may call you all fucking idiots?

So, Since the Chief Coroner’s Office lost my original request for a Jury Inquest, I obligingly sent a revamped, updated version of it to Chief Coroner Lapointe’s attention. Here it is in its entirety.

1959 Sage Place

Merritt, BC  V1K 1G2

 

 August 5th, 2011                                        

 

 

Lisa Lapointe, Chief Coroner

Metrotower II Suite 800 – 4720 Kingsway

Burnaby, B.C. V5H 4N2

Dear Lisa;                                

On February 21, 2009, our son Matthew was born and died at Royal Inland Hospital in Kamloops, BC. At the time, we were left in utter shock as to what had transpired, and today we are still as shocked by how ineffectual and apathetic the BC Coroner’s Service has been with handling our case.

Beginning on the morning of Matthew’s death we have encountered ignorance, unprofessionalism, complacency and at times, utter incompetence in dealing with various members of the Coroner’s Service. Although I understand a good, thorough investigation can take time, I find it absolutely inexcusable that the investigation of Matthew’s death took 2 years to the day for Dr. Robert Saunders to issue his “Final Report”. Yes, we were issued the final report on his 2nd birthday/anniversary of his death. The irony was not lost on us.

The findings of this “exhaustive” investigation were lackluster at best. Although much information was shared with the various investigators involved with our case, each and every concern that was brought up was categorically discounted. Coroner Saunders relied heavily, almost exclusively on the medical opinion of Dr. Tim Oberlander, Professor of Developmental Pediatrics at UBC. Dr. Oberlander’s report is full of factual inaccuracies and even outright fallacy. One of the very bold statements that he made when reporting to Coroner Saunders was, “To date there have been no reported cases of SIDS following prenatal SRI exposure.” This statement in and of itself indicates to me that there was never any investigation done. Dr. Oberlander is a Clinical Researcher by profession, and yet I, as a layperson without any university education whatsoever, was able to find at least 3 cases on the Health Canada MedEffect Database, and no less than 8 cases on the US FDA equivalent, in about 20 minutes using my home computer.

Tim Oberlander seemed to be very understanding at the outset of our journey, even stating that he would be making recommendations about newborn monitoring after exposure to these drugs. By the end of the investigation he was singing a very different tune. I would be remiss if I didn’t mention that the very agencies that Dr. Oberlander works at, the Child and Family Research Institute at BC Children’s Hospital as well as UBC, receive heavy funding from Pfizer, the manufacturers of the drug Effexor which he was investigating. In fact, in December 2009, Pfizer made an extremely generous funding announcement of $9 Million to these agencies. I would never be able to prove it, but that certainly would be enough money to compel him to silence. Regardless, it represents a huge conflict of interest.

It was this discounting of evidence, incompetence of investigation and failure to make any recommendations that spurned me to request a formal inquest into Matthew’s death. This was done in the form of a letter sent to your office on or about May 20, 2011.

There were numerous aggravating factors that contributed to Matthew’s death. Any one of these factors by themselves should warrant a recommendation from a body whose mandate is to make “recommendations to improve public safety and prevent death in similar circumstances.” (emphasis added)

Officially, Coroner Saunders would like Matthew’s death to forever be enshrined in history as “consistent with a finding of SIDS” and “Natural”. However, there are a multitude of issues that render those findings obsolete. Some of those being:

–         Matthew’s exposure to the antidepressant Effexor which has a well known risk of adverse reactions in the neonatal period.

–         The narcotic Fentanyl was administered to my wife within 45 minutes of  delivery.

–         Failure to have a clear, well established protocol for administration of Fentanyl in Labour and Delivery unlike other jurisdictions in Canada, such as that from Nova Scotia found here: http://rcp.nshealth.ca/sites/default/files/clinical-practice-guidelines/fentanyl.pdf

This protocol states in unequivocal terms the following:

Neonates who DO NOT require naloxone at birth, but whose mothers receive

Fentanyl within four hours of delivery, must be observed for at least TWO hours post delivery in labour and delivery. (emphasis is from original protocol)

–         Failure to have a clear, well established protocol for monitoring of newborns exposed to psychotropic medications, like those set out in the Journal of Obstetrics and Gynecology Canada in April 2009 and other publications.

–          Both Effexor and Fentanyl use the same CYP450 enzyme pathways to metabolize and would definitely interact with each other, as well as previous codeine exposure. Although genetic testing for polymorphisms of these enzymes in both Matthew and my wife Christiane were recommended very early on, they were never completed and I demand that they do be completed.

–         Toxicology results were requested by myself, especially for Fenatnyl and those have never been forwarded to me, although I received the assertion they would be. If I am not mistaken a urine sample should have also been collected from Matthew and frozen. I would also like to have a complete toxicology done on this sample including for Fentanyl.

–         Histological findings on Matthew’s autopsy were consistent with a diagnosis of Pulmonary Hypertension. Gail Holotuk argued with me that that was not the case. In the pathology report, Matthew’s lungs had “marked capillary congestion”. This is consistent with a diagnosis of Pulmonary Hypertension and I have the literature to prove it.

–         Misdiagnosis and discounting of obvious respiratory distress.

–         Matthew’s brain cell growth anomaly that is a confirmation of previous findings in rat models exposed to these drugs.

–         Understaffing on the maternity ward.

–         Repeated failure of hospital staff to listen to patient concerns.

–         Similar neonatal issues with 3 of our previous children exposed to the medication Effexor. Our 7 year old have been born 5 pounds at full term and suffering from Persistent Pulmonary Hypertension himself. To this day he still has autonomic regulatory issues.

–         Health Canada warnings issued in 2004 and 2006 regarding the potential for adverse reactions in newborns from all SSRI/SNRI medications that never made it to doctor’s hands. Effexor was not even listed as a risk factor in Matthew’s birth record, although it had been for some of our previous children.

As I stated already, any single one of these issues could have and should have resulted in the Coroner issuing a recommendation to prevent a tragedy like this from happening to another family. The pathologist who performed Matthew’s autopsy at BC Children’s Hospital, Dr. Angelica Oviedo, rendered the opinion that Effexor was likely the cause of Matthew’s death. In fact she felt so strongly about this that she made a report to Health Canada’s Canada Vigilance Adverse Reaction Online Database. In comments made to me in July 2010, shortly before the addendum was issued to Matthew’s autopsy, she told me, “His lungs didn’t make the switch.” Meaning that he was still suffering from what she referred to as “Persistent Fetal Circulation” or as is commonly referred Persistent Pulmonary Hypertension.

Yet, Coroner Saunders has chosen to do nothing. And the result of this has been another baby dying under very similar circumstances, the mother having dealt with the same hospital, same doctors, and same medication even. Alas, these are not isolated incidents; but for now I do not need to speak of the other cases I know of.

Greyson Rawkins, whose mother Nicole Rawkins also took this drug in a much higher dose throughout nursing and pregnancy, was born in January 2011 at Royal Inland Hospital in Kamloops, BC as well. Your office is also investigating his death. At present his brain is also being examined for anomalies, and I am quite optimistic that a similar anomaly will be found with his brain. Something I have found very interesting, is the fact that in Greyson’s case his cause of death was deemed UNDETERMINED although there is compelling published evidence that even exposure to Effexor via breastmilk is highly toxic to a baby and can cause serious respiratory distress. Yet in Matthew’s case, his death was deemed NATURAL. Is it really the position of the BC Coroner’s Service that it is perfectly natural for a 2 hour old baby to die in a hospital setting? Especially after the family fought with hospital staff over his color and breathing difficulty, only to be downplayed and at one point kicked back in our room because we were “disturbing other patients”. Especially after being exposed to not one, but two medications that have the very common side effect of causing respiratory distress in newborns.

Successive coroners failed to listen to us. Matthew was in distress immediately at birth, and he was until he died. We fought with Dr. Poelzer and the nursing staff over this. Yet this fact was continually ignored by Coroners Holotuk and Saunders even in to the final Coroner’s Report.  We have pictures that show his cyanosis and how briefly after he received 100% oxygen his color pinked up a little, yet we were continually told that he had facial bruising and that his symptoms were normal. I guess death is normal as well. No one from the Coroner’s Service has ever looked at these pictures.

In April 2009 when speaking with Gail Holotuk via telephone, I had a heated exchange with her over the fact that we argued with hospital staff over Matthew’s breathing. This telephone conversation culminated in her saying to me, and I quote, “Why didn’t you say something about his breathing?” I was floored. Not only had I told her on numerous occasions that we were complaining about Matthew’s breathing, the tone of her voice was shifting blame to me. I called her a stupid bitch and hung up the phone. Dr. Oviedo the pathologist gave heed to these concerns somewhat and issued the autopsy addendum in July 2010. But it still seems that respiratory distress was not an objective finding of any coroner investigating Matthew’s death.

Effexor or venlafaxine as it is generically called is a drug known as an SNRI (serotonin and norepinepherine reuptake inhibitor) which falls into the class of drug known popularly as antidepressants. Chemically, these drugs are not dissimilar from amphetamines or cocaine. Although the prescribing of antidepressant medications during pregnancy is not an indicated use, pregnant women are increasingly marketed to, and estimates put the number of women taking these drugs during pregnancy around 15-20%.

There is compelling evidence available that these drugs should not be prescribed to pregnant women. The strongest example of this was compiled in a study published January 2010, entitled “Are antidepressants safe in pregnancy? A focus on SSRIs”.  This study was compiled by the Therapeutics Initiative at the University of British Columbia and states clearly when specifically discussing the prescribing of antidepressants in pregnancy, the harms exceed the benefits in this setting”.  Again, it would seem the BC Coroner’s Service chooses to ignore information like this.

 

There are several things that I am seeking from you in your capacity of Chief Coroner. Firstly, based on the shortcomings, errors and even apparent conflict of interest on the part of the main expert consulted, I am seeking to have this case reopened and that a formal inquest be held. There is overwhelming evidence that Matthew’s death should be listed as ACCIDENTAL, and I am seeking that this be changed from the present finding of NATURAL.

Secondly, the genetic testing previously mentioned that has never been carried out. I request a full screen of all CYP450 enzymes on Matthew’s blood as well as my wife Christiane. This must be done, and I am well within my rights demanding it, as it was something we were told was going to be done. This is vital to the health of any of our children as well as pinpointing the causes of Matthew’s death.

At this time, as I have a need to consult with experts outside the sphere of influence of the BC Coroner’s Service, I would also request copies of any and all files related to the investigation of Matthew’s death. This would include test results, interviews, investigative notes, pictures (as graphic as they might be) etc. as well as an inventory of any biological samples of Matthew’s that might still be in the possession of the BC Coroner’s Service or any other agency .

I look forward to your response.

Sincerely and respectfully.

 

 Amery Schultz

1959 Sage Place

Merritt, BC V1K 1G2

250-315-5632  email: amery_s@telus.net

So,  after sending this email, I again receive an email from the Chief Coroner’s Secretary.

Good afternoon Mr. Schultz:

Thank you for your e-mail and attached letter to Chief Coroner Lapointe.  Chief Coroner Lapointe will respond to you in full in due course.

Yours truly,

Claire

 

Claire R. Leek | Executive Administrative Assistant to the Chief Coroner

Metrotower II, Suite 800 – 4720 Kingsway, Burnaby BC  V5H 4N2
Phone: (604) 660-8219 | Blackberry: (604) 992-9323 | FAX: (604) 660-7766

http://www.pssg.gov.bc.ca/coroners

 

She’s going to “respond to me in full in due course.”

WHAT THE HELL DOES THAT MEAN?!?!?!

Tomorrow? Next week? Next month? When she’s met with the Coroner’s who botched Matthew’s case and can formulate a good enough bullshit excuse as to why they don’t need to reopen the investigation?

The evidence seems pretty strong to me that Effexor by itself or in combination with Fentanyl caused Matthew’s oh so evident Respiratory Distress, that nobody seems to have a recollection of other than us, his parents.

Matthew’s death was not natural. Plain and simple. Any one of the points that I list in my most recent letter to the Chief Coroner confirms that statement.

 

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Entry filed under: Congenital Heart Defect, coroner, Effexor, Infant Death, Infant loss, mothers act, Patent Ductus Arteriosis, Pregnacy, psychiatry, SSRI, Transposition of the Great Arteries.

Kamloops This Week – HOW DID THESE BABIES DIE? Question unites grieving families Sometimes Moving Forward, Means Letting Some Things Go.

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