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Statement by Dr. Kevin Smith following review of incident at Greater Niagara General Site

Posted Nov 7th, 2011

Our organization has completed its review of the incident at Greater Niagara General Hospital.

On Saturday, October 8, Ms. Doreen Wallace fell at Greater Niagara General Hospital Site. The family understandably expressed concerns about the way in which the organization responded to Ms. Wallace’s distress.

Our review confirmed that several individuals acted in an exemplary fashion including the security guard and housekeeper as first responders, the ICU nurse who came to the patient’s assistance before, and an Orthopedic Surgeon, who assessed and transported the patient to the Emergency Department.

Unfortunately we failed to transfer the patient to the Emergency Department from the lobby until 20 minutes had elapsed. Despite the best of intentions our effort was uncoordinated, resulting in Ms. Wallace receiving less than appropriate initial assessment and institution of treatment. Our quality of caring missed the mark.

In our follow up we have been in regular contact with the family, and are incorporating their suggestions and considering their observations as we improve our approach and processes.

This incident does represent poor judgment by some members of our team, as well as management’s failure to ensure the clarity of our processes and procedures for assisting individuals in distress and communication of our standard of care.

I would be remiss if I did not also recognize the significant morale and demoralization reported by some staff, who clearly expressed feeling consistently overwhelmed. This must be a longer term issue we must address, including a review of ER staffing models. You will hear more from me with respect to the process and timeline to do so in the very near future.

Human resource policies have been followed with respect to individual performance in this case. Immediate actions have been taken to re-educate staff and clarify our processes.

NHS’s policy for response to any visitor in distress will be to ensure a rapid response and transport to the most appropriate clinical setting, calling a code as appropriate. A small working group has been struck to review all NHS codes to ensure we are aligned with peer hospitals to be completed by November 18, 2011.

Each of us will be called to apply sound judgment to determine the safest, fastest, most effective and compassionate way to support persons in distress. Those needing assistance outside NHS sites will be addressed on a case by case basis, recognizing the risks for patients and staff. We have also worked closely with our EMS colleagues to ensure aligned practices and improved communication with respect to 911 calls.

Niagara Health System