ONTARIO
SUPERIOR COURT OF JUSTICE
BETWEEN:
SUDESH MANGAL, VINCENT RAVI MANGAL, by his Litigation Guardian, SUDESH MANGAL and SARINA MANGAL, by her Litigation Guardian,
SUDESH MANGAL
Plaintiffs
– and –
WILLIAM OSLER HEALTH CENTRE, BRAMPTON MEMORIAL HOSPITAL CAMPUS, DR. INDIRA CHANDRAN, DR. SHELDON GIRVITZ, DR. JORDAN BOHAY, DR. KEITH LOUIS, DR. AZHAR MALIK, DR. A. SINGH, DR. I. GOLD, DR. D. PRICE, DR. A. MACDONALD, DR. D. DUBOIS, DR. J. DOE #1, DR. J. DOE #2, NURSE CARON HALL, NURSE AMY ROMYN, NURSE TARA BENFORD, NURSE CONNIE BRAIN, NURSE MARY BELL, NURSE K. GRAVAC, NURSE T. ELLIS, NURSE ANN BOTTING, NURSE IRIS PERRY, NURSE V. GUTWEIN, NURSE J. DOE #1 and NURSE J. DOE #2
Defendants
Richard M. Bogoroch & Linda Wolanski, for the Plaintiffs
Simon A. Clements & Anna L. Marrison, for the Defendant, William Osler Health Centre
Nina Bombier & Ryan Stewart Breedon, for the Defendants, Dr. Indira Chandran, Dr. Jordan Bohay and Dr. Sheldon Girvitz
HEARD: January 28, 29, 30 & 31, February 1, 4, 5, 6, 7, 8, 11, 12, 14, 15, 19, 21 & 25, 2013
1On February 16, 2004, Sharon Mangal was admitted to William Osler Health Centre- Brampton Memorial Hospital Campus for an elective caesarean section and a tubal ligation. The surgery was carried out on the same morning.
2Ms. Mangal’s blood pressure during the surgery was within normal limits. There were no bleeding problems. Her blood loss during the surgery was average for a caesarean section. The baby was delivered as a footling breech; the feet were delivered first followed by the body. A healthy baby girl was delivered without complications.
3Medically, Ms. Mangal’s pregnancy was notable for two reasons: during her pregnancy she developed high blood pressure and the size of a fibroid in her uterus had increased.
4I was given a glossary of medical terms which I have considered along with the evidence when attempting to translate medical language into simple English.
5A uterine fibroid is a benign growth in the wall of the uterus. Dr. Catherine Cowal, an obstetrician called as an expert witness by the defendant doctors, testified that the presence of a uterine fibroid, while not uncommon, creates a slightly higher risk of bleeding after delivery.
6Ms. Mangal’s high blood pressure was treated with a drug known as Labetalol. Ms. Mangal was told not to take Labetalol after midnight on the day of her surgery. Labetalol suppresses the heart rate and, therefore, inhibits the heart’s ability to beat faster to sustain blood pressure. It also causes blood pressure to fall lower in the face of bleeding. There was no evidence suggesting Ms. Mangal disregarded this instruction. I am satisfied that she followed it.
7Sharon Mangal had had a previous caesarean section on March 14, 2000. On that occasion, Ms. Mangal gave birth to a healthy baby boy without complications.
8The previous caesarean section was, like the caesarean section in these proceedings, performed at the William Osler Health Centre-Brampton Memorial Hospital Campus. The obstetrician, who carried out the March 14, 2000, caesarean section, was Dr. Indira Chandran, who also performed the caesarean section referred to in these proceedings. Dr. Indira Chandran is a defendant in these proceedings.
9Following the delivery, on February 16, 2004, at approximately 9:35 a.m., after Dr. Chandran had finished suturing Sharon Mangal, Dr. Jordan Bohay, who was the anaesthesiologist during the surgery and is himself a defendant in these proceedings, remained with her when nurse Michelle Jackson transferred her to the Post-Anaesthetic Care Unit.
10Dr. Bohay testified that, when he and Ms. Mangal arrived at the Post-Anaesthetic Care Unit, she was stable, conscious, her oxygen saturation was 100%, her blood pressure was within an acceptable range and her vital signs were within normal limits. Dr. Bohay left written standard orders for Ms. Mangal’s nurse, Michelle Jackson, and left Ms. Mangal in her care. There is one nurse for each patient in the Post-Anaesthetic Care Unit.
11Sharon Mangal was pronounced dead on February 16, 2004, at 5:23 p.m. Her examination, diagnosis and treatment by the doctors and nurses, who attended to her on February 16, 2004, are the subject-matter of this litigation.
The parties remaining in this proceeding
12The claims of the plaintiffs against Dr. K. Louis, Dr. A. Malik, Dr. A. Singh, Dr. I. Gold, Dr. D. Price, Dr. D. Macdonald, Dr. D. Dubois, Nurse Caron Hall, Nurse K. Gravac, Nurse Amy Romyn, Nurse Tara Benford, Nurse Connie Brain, Nurse Mary Bell, Nurse T. Ellis, Nurse Ann Botting, Nurse Iris Perry and Nurse V. Gutwein were dismissed on consent without costs on January 24, 2013. All cross-claims by and against these defendants were also dismissed on that date.
13The remaining defendants are as follows:
Dr. Indira Chandran, Sharon Mangal’s treating obstetrician, received her medical degree in Madras, India in 1962. She obtained a diploma in obstetrics and gynaecology in Madras in 1967. Dr. Chandran moved to Hong Kong and practiced as an anaesthetist and an obstetrician from 1976 to 1989. Dr. Chandran came to Canada in 1989. She attended McMaster University and was licensed as an obstetrician in Canada in 1994. Since that time, Dr. Chandran had practiced as an obstetrician in Brampton Ontario and enjoyed privileges at the defendant, William Osler Health Centre.
Dr. Sheldon Girvitz was the obstetrician on call throughout February 16, 2004, at William Osler Memorial Health Centre-Brampton Memorial Hospital Campus. Dr. Girvitz performed and assisted in a second surgery on Ms. Mangal on February 16, 2004, in an unsuccessful effort to stop her from bleeding.
Dr. Girvitz graduated from McMaster Medical School in 1984. He completed a residency in obstetrics and gynaecology at the University of Toronto in 1989. He has been a practicing obstetrician and gynaecologist at the William Osler Health Centre since 1990. At the time he testified, Dr. Girvitz indicated that approximately 60% of his practice was composed of patients with high-risk problems. In 2004, Dr. Girvitz had been at the William Osler Health Centre for fourteen years and I infer that his practice at that time was similarly composed of high-risk patients.
Dr. Jordan Bohay was the anaesthesiologist for both surgeries performed on Ms. Mangal on February 16, 2004. He also examined, diagnosed and treated Ms. Mangal throughout February 16, 2004. Dr. Bohay graduated in medicine from the University of Manitoba in 1996. He then completed a five-year residency in anaesthesiology. He began practicing as an anaesthesiologist in 2001. When these events occurred, Dr. Bohay had been practicing for two and a half years.
The William Osler Health Centre employed and is, therefore, vicariously liable for the conduct of the nurses referred to in these proceedings.
14The plaintiffs in this matter are Sudesh Mangal – Sharon Mangal’s husband; and Vincent Mangal and Sarina Manga – Sharon Mangal’s children. I was informed that Sarina Mangal’s first name is misspelled in the Statement of Claim.
The expert witnesses
15The plaintiffs called four expert witnesses.
Dr. Sam Schulman, who was licensed to practice in Sweden in 1978 and received his specialist licence there in 1984. He also received a sub-specialty licence in the diagnosis and treatment of coagulation and bleeding disorders as well as haematology in 1985. He received a PhD in medicine in 1985 from the Karolinska Institute in Sweden. He was licensed to practice medicine in Israel in 1992 as a haematologist. In 2004, he was recruited by the Department of Medicine at McMaster University in Hamilton, Ontario. He sees patients with blood-clotting disorders and consults with other physicians concerning these problems. He is currently a professor at McMaster University.
Dr. Wilfred Cassar-Demajo, who is an anaesthesiologist and a specialist in internal medicine with a fellowship in intensive care. He was licensed to practice in Ontario in 1978. He has a fellowship in anaesthesia from the United Kingdom and from Ireland. He teaches anaesthesia as an assistant professor at the University of Toronto. He teaches in the intensive-care training program. He has been a staff intensivist at the Toronto Western Hospital since 1998, although the emphasis there is on neuro-sciences.
Dr. Gary Dildy, who is an O.B.G.Y.N. with a sub-specialty in maternal fetal medicine. He is licensed in Texas, Louisiana, Utah, Montana and Idaho. He maintains an active practice. He is a professor and Vice-Chairman of Quality and Patient Safety Maternal Fetal Medicine Department of Obstetrics and Gynaecology at Baylor College of Medicine in Houston, Texas. Baylor College of Medicine is part of the Texas Medical Center which employs over 100,000 people and is comprised of over fifty institutions. It is the largest medical centre in the world by a factor of three. Dr. Dildy obtained his fellowship in maternal fetal medicine in 1991. He has taught at the faculty of the University of Utah and the Louisiana State University School of Medicine. He maintains an active practice primarily in obstetrics.
Nurse Ann Holden, who is a registered nurse with a Bachelor of Science in Nursing from the University of Windsor and a Master of Science from McMaster University. Ms. Holden began practicing as a registered nurse in 1978. Between 1978 and 1981, she worked as a staff nurse at the Children’s Hospital in Buffalo as a labour and delivery nurse. She worked as a public health nurse in Ottawa from 1982 to 1988. From 1989 to 1992, she was a nurse educator for the Maternal and Child Program at St. Joseph’s Health Centre in Hamilton, Ontario. From 1993 to 2001, she taught nurses the standard of care in labour and delivery and postpartum at Trafalgar Memorial Hospital in Oakville. Ms. Holden has also held senior management positions at St. Joseph’s Healthcare and Humber River Regional Hospital. From 2005 until the present, she has been manager of the Family Birthing Centre at St. Joseph’s Health Centre in Toronto.
I have provided a very brief summary of the qualifications of these witnesses. I have not referred to their many publications. All of these witnesses are very well-credentialled. For the reasons that follow, I have accepted some, but not all, of their opinions.
16The defendant doctors called two expert witnesses:
Dr. William Noble, who is an anaesthesiologist and a specialist in intensive care. He started practicing anaesthesia in 1970 at St. Michael’s Hospital and remained there for his entire career, retiring in 2010. He had an active clinical practice in anaesthesia for forty years. He provided anaesthesia during caesarean section procedures continuously until 2006. In addition to his anaesthesia practice, Dr. Noble practiced in intensive care units. St. Michael’s Hospital had a level-two obstetrical designation, which meant it was willing to deal with the more severe obstetrical issues. He was the head of the Department of Anaesthesia at St. Michael’s Hospital for seven years. He taught at the University of Toronto.
Dr. Catherine Cowal, who completed her residency in obstetrics and gynaecology at the University of Toronto in 1991. Dr. Cowal practices obstetrics and gynecology at the Mississauga Hospital site of Trillium Health Partners. She teaches at the University of Toronto. Approximately 50% of Dr. Cowal’s practice is comprised of both low and high-risk obstetrics. Dr. Cowal indicated that she delivers approximately 400 babies per year.
As I did with the expert witnesses called by the plaintiffs, I have provided a very brief summary of the qualifications of these witnesses. Both of these witnesses are well-credentialled. I have accepted a portion of Dr. Noble’s evidence and all of Dr. Cowal’s evidence.
17The defendant, William Osler Health Centre, called one expert witness:
- Nurse Barbara Scott, who is a registered nurse with a nursing diploma from Centennial College, a Bachelor of Science in Nursing from Ryerson University and a Masters Nursing Degree from the University of Toronto. Ms. Scott received her nursing diploma in 1986. Ms. Scott was a labour and delivery nurse for ten years from 1987 to 1997 at Scarborough Grace Hospital. She also has experience as a perinatal nurse. Ms. Scott was the Patient Care Manager at the Family Maternity Centre at Scarborough Hospital from 2006 to 2009. From 2009 to the present, she has been the Patient-Care Director for the Maternal Newborn & Child Care Program at Scarborough Hospital.
I have similarly abbreviated Ms. Scott’s qualifications. I have accepted portions of her evidence.
Prior to 9:35 a.m.
18Sudesh Mangal was with his wife in the operating room during the caesarean section. Mr. Mangal indicated that his wife was conscious throughout that surgery and, during his testimony, he repeated some of the conversation that passed between them during the caesarean section.
19When Ms. Mangal returned to the Post-Anaesthetic Care Unit at 9:35 a.m., she complained of being cold. Mr. Mangal testified that, in response, the nurse (Michelle Jackson), whose name he could not remember, provided her with warm blankets.
20After the surgery, Dr. Chandran left written orders concerning Ms. Mangal’s care. Dr. Chandran’s written orders initiated an established “Managed Care Plan” and provided for certain exceptions to that plan which were peculiar to Ms. Mangal. Dr. Chandran then returned to her office across the street from the hospital.
21Dr. Chandran testified that she expected Nurse Jackson to contact one of the obstetricians at the hospital or herself if she had concerns. Dr. Chandran made it clear that the nurse’s decision to contact a doctor depended upon the nurse’s degree of concern. “It is her decision what she wants to do. She is a trained post-operative nurse. Whatever she decides, you will have to ask her what her concerns were”.
22There was no dispute that Dr. Chandran’s decision to return to her office after the caesarean section reflected the standard practice for an obstetrician when his or her patient is in stable condition after a caesarean section.
23Because Dr. Chandran had returned to her office, the obstetrician immediately responsible for Ms. Mangal’s care was the obstetrician on call, Dr. Sheldon Girvitz.
The early morning after 9:35 a.m.
24Mr. Mangal testified that, at one point, he was advised by Nurse Jackson that the situation with his wife was normal and that he could go home. Mr. Mangal then left the hospital to look after their son. Mr. Mangal could not be certain of the time when he received this advice, but thought that it was around 11:30 a.m. Later that day, Mr. Mangal was called back to the hospital and arrived prior to the second surgery.
25Doctor Gary Dildy, an obstetrician and gynaecologist called as an expert witness by the plaintiffs, testified that there was nothing amiss as far as Ms. Mangal’s condition was concerned between 9:35 a.m. and 10:35 a.m.
26A nursing note, dated 10:35 a.m., recorded moderate lochia and a small amount of blood on Ms. Mangal’s right side. Lochia rubra or lochia is bright red blood that typically comes from the vagina after vaginal or caesarean delivery. It is red and thick or jelly-ish in appearance. The evidence established that postnatal mothers typically bleed. In fact, the evidence established that abnormal bleeding was common in 6% of caesarean section patients. Nurse Jackson observed and charted this bleeding and viewed it as a normal event.
27The 10:35 a.m. nursing note also recorded that Ms. Mangal’s fundus was firm and 3 fingers above her belly button. Ann Holden testified that you should think of the uterus as a balloon or a ball. The top portion of the uterus is called the fundus. She also testified that, when you place your hand on the abdomen, the top of the uterus or the fundus should be at the level of the bellybutton. There was no dispute that the fundus can be higher than the bellybutton if the patient has a uterine fibroid.
28At 9:35 a.m., the fundus was at the level of Ms. Mangal’s belly button. The fact that, by 10:35 a.m., the fundus had risen was a change in Ms. Mangal’s condition which required monitoring. An increase in the height of the fundus can be a sign of bleeding. However, it can also be a sign of blood clots in the uterus. Nurses will massage the fundus so that blood clots are expressed through the vagina.
The late morning prior to 12:35 p.m.
29In a note, dated 11:30 a.m., Nurse Jackson recorded that Ms. Mangal had a firm fundus which was now 4 fingers above her belly button and that Ms. Mangal had a large amount of lochia rubra on the pads underneath her. Finally, the nursing note recorded that, when Nurse Jackson massaged Ms. Mangal’s fundus, blood clots were expressed from her vagina.
30The note discloses that the fundus had risen from 3 fingers to 4 fingers above the bellybutton; however, it also discloses that the fundus was firm. A firm fundus is capable of supporting a conclusion the uterus is firm because it has contracted.
31A common cause of postpartum bleeding is a soft uterus or a uterus which has failed to contract.
32Nurse Jackson did not immediately report these observations to the obstetrician on call nor did she contact Dr. Chandran. Rather, she continued to monitor Ms. Mangal.
33A few minutes later, in a nursing note, dated 11:37 a.m., Nurse Jackson recorded blood pressures taken shortly after that time, specifically between 11:39 a.m. and 11:43 a.m. The readings were as follows: 85/51 at 11:39 a.m., 81/52 at 11:42 a.m. and 82/53 at 11:43 a.m.
34Dr. Bohay, the anaesthesiologist during Ms. Mangal’s caesarean section, had left standard written orders at 9:35 a.m. requiring Nurse Jackson to administer certain fluids (Ringers Lactate) and to notify a physician if Ms. Mangal’s systolic pressure (the upper reading) fell below 90. The evidence established that it was standard practice for a nurse to take more than one reading to confirm low blood pressure.
35Immediately after the 11:43 a.m. blood pressure reading, Nurse Jackson carried out Dr. Bohay’s order. She initiated a bolus (a single large dose) of Ringers Lactate and she notified Dr. Bohay of the drop in blood pressure.
36Nurse Jackson found Dr. Bohay in the operating room which is located about twenty feet from the Post-Anaesthetic Care Unit. Dr. Girvitz was also there. Dr. Girvitz was performing a caesarean section and Dr. Bohay was his anaesthesiologist. When Nurse Jackson told Dr. Bohay about the low blood pressures, Dr. Bohay ordered 250 mL of a fluid called Pentaspan.
37Nurse Jackson did not tell Dr. Bohay or Dr. Girvitz about the large amount of lochia rubra, the height of Ms. Mangal’s fundus or the expression of blood clots.
38Dr. Bohay testified that he ordered a 250 mL dose of Pentaspan to see if Ms. Mangal’s blood pressure would respond to Pentaspan. Dr. Bohay testified that Ms. Mangal had received a spinal anaesthetic during the caesarean section and that a spinal anaesthetic always causes a drop in blood pressure. Dr. Bohay testified that the blood loss which occurs during the caesarean section also causes a drop in blood pressure. Dr. Bohay testified that he did not think that Ms. Mangal’s drop in blood pressure demonstrated significant low blood pressure.
39Dr. Bohay testified that he intended to check on Ms. Mangal at the completion of the caesarean section and I am satisfied that is what he did. He testified that he assessed Ms. Mangal at 12:30 p.m. and came to the conclusion that her blood pressure had responded to the Pentaspan and that she was stable.
40Doctor Catherine Cowal, an obstetrician, testified that mild low blood pressure is common after surgery.
41Dr. Sam Schulman, a haematologist, testified that Pentaspan is a standard first-line response to low blood pressure.
42Dr. Cassar-Demajo, an anaesthesiologist, expressed the opinion that Dr. Bohay’s decision around 11:43 a.m. to order Pentaspan was appropriate, although he had other criticisms of Dr. Bohay’s actions and omissions at that time.
43Dr. Dildy testified that, in his opinion, the order for Pentaspan was “in this circumstance, at that moment, that would be okay”.
44Dr. Dildy found that the blood pressures taken at 11:39 a.m. (85/51), 11:42 a.m. (81/52) and 11:43 a.m. (82/53) indicated that Ms. Mangal’s systolic pressures (the upper number) had crossed a threshold.
45Dr. Dildy interpreted Nurse Jackson’s 11:30 a.m. note to mean that Ms. Mangal was actively bleeding at that time. He did concede that it was up to Nurse Jackson to explain her note.
46Dr. Dildy observed that Ms. Mangal was post-operative, bleeding, with the blood pressures described and discharging lochia rubra outside the normal range and that, therefore, a complete blood count test and coagulation studies should have been ordered no later than 12 noon and repeated at 12:55 p.m..
47A complete blood count test counts all the cells that are circulating in the blood. Coagulation studies measure how long it takes blood to form blood clots in a test tube.
48Ms. Jackson’s 11:30 a.m. note provided the following with respect to blood: “… lochia rubra large amount on pads massaged fundus moderate amount of clots expressed….”. Ms. Jackson indicated that her note: “lochia rubra large amount on pads” meant that the pads underneath Ms. Mangal were almost full of this bright red blood. Ms. Jackson testified that she had re-positioned Ms. Mangal during the morning and that, in her experience, this can cause lochia pooled inside the uterus to come out onto the pad.
49Ms. Jackson testified that her note meant that there was no continuing vaginal loss and no active bleeding at the incision site or elsewhere.
50I accept Nurse Jackson’s description of her note. I am satisfied that she did not intend to convey in her note that Ms. Mangal was actively bleeding at 11:30 a.m. Accordingly, I do not accept Dr. Dildy’s opinion that a complete blood count and coagulation studies should have been ordered.
51In addition, I am cautious about accepting Dr. Dildy’s opinion because there is an element of hindsight in his observations. This was partially acknowledged by Dr. Dildy, when he testified, “I think, looking at this case, and looking at it, in hindsight, but also trying to look at it from a perspective standpoint….”. Even partial hindsight, in my opinion, is a most unfair way to assess the negligence of a professional person.
52Nurse Jackson testified that the lochia rubra was “a large amount but it was not concerning”. I do not accept this aspect of her evidence. I do not feel that it completely reflects her thinking. Nurse Jackson testified that she was following the practice of “charting by exception”. Nurse Barbara Scott, who was called as an expert by the defendant, William Osler Health Centre, testified that charting by exception meant that assessments which were concerning or required a nursing intervention were documented. It also meant that a normal finding was not charted. Nurse Jackson charted her observation concerning the large amount of lochia rubra because it was concerning.
53I am satisfied that Nurse Jackson thought the large amount of lochia rubra and the expression of a moderate amount of blood clots were more than usual. At the same time, Nurse Jackson knew that postpartum patients bleed and she knew that bleeding does not automatically mean haemorrhaging.
54I am satisfied that Ms. Jackson thought that the discharge of lochia rubra did not require the urgent attention of an obstetrician.
55Dr. Cassar-Demajo was critical of the amount of Pentaspan ordered by Dr. Bohay. It was his opinion that the amount (250 mL) of Pentaspan given was inadequate because it did not return Ms. Mangal’s systolic blood pressure to an appropriate level. Dr. Cassar-Demajo’s observation is, arguably, correct but it is also hindsight. Dr. Cassar-Demajo did not suggest that Dr. Bohay should have known that a larger dose of Pentaspan was required when he first ordered 250 mL.
56Dr. Bohay attended upon Ms. Mangal at 12:30 p.m. He did not order a larger dose of Pentaspan. The nursing note at 12:25 p.m. records her blood pressure at 89/60, her oxygen saturation at 100% and her pulse at 83. Dr. Bohay concluded that Ms. Mangal was stable and did not require further fluids. I would not have accepted Dr. Bohay’s conclusion in this regard had it not been for the fact that his conclusion was confirmed by Dr. Girvitz, who very thoroughly examined Ms. Mangal between 12:35 p.m. and 12:55 p.m.
57Dr. Bohay’s failure to order a larger dose of Pentaspan at 12:30 p.m. was not conduct which fell below the standard of care expected of a reasonable and prudent anaesthesiologist with his experience.
58Dr. Cassar-Demajo testified that he would have ordered other fluids besides Pentaspan. Dr. Cassar-Demajo also thought that Dr. Bohay should have sent a blood sample to the lab to check Ms. Mangal’s haemoglobin level and should have ordered coagulation studies. He also thought that Dr. Bohay should have taken steps to make sure that blood was available for Ms. Mangal and ordered a blood transfusion.
59Dr. Cassar-Demajo thought that a blood transfusion was required because Ms. Mangal’s blood pressure was low, she was bleeding and she was in shock.
60Dr. Cassar-Demajo obviously did not examine Ms. Mangal on February 16, 2004. His conclusions concerning her condition are drawn from his reading of her hospital record. Dr. Cassar-Demajo agreed that, in determining shock, one does not just look at blood. He testified that one looks at the patient’s colour and mental condition.
61Nurse Jackson testified that Ms. Mangal was not actively bleeding at the incision site or elsewhere when she made her notes recorded at approximately 11:30 a.m. and recorded the various low blood pressures on or about 11:45 a.m. Dr. Girvitz arrived to examine Ms. Mangal at 12:35 p.m. and came to the same conclusion. Dr. Girvitz recorded his conclusion in an On Call Note which he made shortly before 1 p.m. and before it was apparent to him that further surgery was required. Therefore, on the question of bleeding, there is evidence from the doctor and nurse, who each assessed Ms. Mangal on February 16, 2004, which is inconsistent with Dr. Cassar-Demajo’s conclusion inferred from Ms. Mangal’s hospital record.
62As far as Ms. Mangal’s colour and mental condition are concerned, Nurse Jackson testified that there was nothing unusual about Ms. Mangal’s colour and that she was alert and responsive throughout the time that Nurse Jackson was providing one-on-one care for her. Dr. Girvitz gave similar evidence concerning Ms. Mangal’s condition.
63Shock, according to the evidence, results from a failure of the organs of the body to get sufficient oxygen. The lack of oxygen can cause the patient to fall in and out of consciousness and appear anxious. Ms. Mangal exhibited none of the symptoms and, accordingly, neither Nurse Jackson nor Dr. Girvitz concluded that she was in shock.
64Dr. Cassar-Demajo’s opinion is predicated on the finding that Ms. Mangal was bleeding in circumstances where the nurse and doctor who actually examined her concluded that she was not.
65Dr. Cassar-Demajo’s opinion is predicated on a finding that Ms. Mangal was in shock in circumstances where the doctor and nurse who personally assessed Ms. Mangal did not think that she appeared or presented herself as someone in shock.
66I do not accept Dr. Cassar-Demajo’s opinion that Dr. Bohay’s conduct fell below the standard of a reasonable and prudent anaesthesiologist with his level of experience because he failed to order fluids, blood tests and a transfusion because I am satisfied, on the evidence, that, at 11:45 a.m., Ms. Mangal was not bleeding or in shock.
Nurse Jackson’s Compliance with Dr. Bohay’s orders
67Nurse Jackson informed Dr. Bohay immediately about the low blood pressure readings at 11:43 a.m.
68Nurse Jackson informed Dr. Bohay of the low blood pressure because, in her experience, it was the responsibility of the anaesthesiologist to deal with that problem. In addition, it was Dr. Bohay who issued the orders at 9:35 a.m. requiring Nurse Jackson to notify a physician if Ms. Mangal’s systolic pressure fell below 90. Dr. Bohay’s order did not specify whether the physician should be an obstetrician or an anaesthesiologist. Ms. Jackson cannot be faulted for notifying the doctor, who made the order concerning low blood pressure readings, that Ms. Mangal was experiencing low readings.
69In response to the information about the low blood pressure readings, Dr. Bohay ordered Pentaspan. The hospital record discloses that the Pentaspan was hung at 11:45 a.m. As indicated, the last confirmatory low blood pressure reading was recorded at 11:43 a.m.
70I am satisfied that Nurse Jackson very promptly executed Dr. Bohay’s orders that a physician be notified if Ms. Mangal’s systolic pressure fell below 90 and that Pentaspan be administered.
Was Nurse Jackson required to report her observations?
71Nurse Ann Holden testified that Ms. Mangal should have been seen by an obstetrician no later than noon. She testified that Nurse Jackson should have arranged this because Ms. Mangal had an abnormal fundal height, was bleeding more than normal, had low blood pressure readings and expressed blood clots when her fundus was massaged.
72Dr. Girvitz testified that he and Nurse Jackson knew each other well from working together at the hospital and that she never hesitated to ask him to assess her patients. Dr. Girvitz’s evidence was confirmed by what happened in this case. Specifically, Dr. Girvitz testified that, after he had completed the surgery, which he was performing at 11:43 a.m., he was approached by a nurse and asked to assess Ms. Mangal. Dr. Girvitz could not remember which nurse approached him; however, Nurse Jackson testified that she was the one. Dr. Girvitz thought he was in the Post-Anaesthetic Care Unit when he was approached; Nurse Jackson thought that he was in the hallway leading into the unit. Dr. Girvitz was not certain of the time that he was approached. However, he testified that he went to see her without delay. Hospital records record that Dr. Girvitz was in to see Ms. Mangal at 12:35 p.m.
73Dr. Girvitz testified that he was told that Ms. Mangal had had “several gushes of blood”. Dr. Girvitz recorded this fact in his On Call Note, which he made in the Post-Anaesthetic Care Unit immediately after concluding his assessment.
74Nurse Jackson obtained her nursing diploma from Humber College. After completing the college course, she took an additional course in obstetrical nursing. She began working at Peel Memorial Hospital (William Osler Health Centre) in September 1999 and moved to labour and delivery in 2001. When these events occurred, she was working approximately thirty hours per week and had been working in labour and delivery for approximately three years.
75I am satisfied that, in 2004, when these events occurred, Nurse Jackson had sufficient experience to make a reasoned assessment about the need for an obstetrician to immediately assess Ms. Mangal. Nurse Jackson concluded that Ms. Mangal was not actively bleeding at 11:45 a.m. Dr. Girvitz reached a similar conclusion at 12:35 p.m.
76I am satisfied that Ms. Mangal was not actively bleeding at 11:45 a.m.
77I am satisfied that Nurse Jackson was paying attention to whether Ms. Mangal was bleeding. Nurse Jackson knew that postpartum patients bleed. Her decision at 11:45 a.m. that blood pressure was the issue that required the attention of the anaesthesiologist and that she would continue to monitor Ms. Mangal for bleeding was a reasonable conclusion that she was entitled to draw. I infer that one of the gushes of blood occurred sometime after 11:45 a.m. and that, as a result, Nurse Jackson re-assessed the necessity of Ms. Mangal being seen by an obstetrician and approached Dr. Girvitz, who came to assess Ms. Mangal minutes later.
78Ms. Holden testified that, by noon at the latest, Nurse Jackson should have asked a physician to attend. I am satisfied that Dr. Girvitz was approached shortly after noon by Nurse Jackson. As indicated, Dr. Girvitz attended at 12:35 p.m.
79I am not satisfied that Nurse Jackson’s conduct fell below the standard expected of a registered nurse of average competence when she failed to inform Dr. Bohay or Dr. Girvitz on or about 11:43 a.m. that Ms. Mangal had, on or about 11:30 a.m., expelled a large amount of lochia rubra and expressed blood clots when the top of her uterus was massaged.
80I am satisfied that Nurse Jackson did notify an obstetrician about Ms. Mangal on or about noon.
Dr. Girvitz’s assessment 12:35 p.m. – 12:55 p.m.
81There was a nursing shift change shortly before 12:30 p.m. and Nurse Jackson was replaced by Nurse Sandra Smout. Nurse Jackson testified that, despite the shift change, she remained in the Post-Anaesthetic Care Unit when Dr. Girvitz, in response to her request, examined Ms. Mangal.
82I infer from the fact that Nurse Jackson told Dr. Girvitz about the gushes of blood that Nurse Jackson generally reported her observations about Ms. Mangal to Dr. Girvitz.
83The fact that Dr. Girvitz was in to see Ms. Mangal is recorded in the 12:35 p.m. nurse’s note as follows: “Dr. Girvitz in to see pt. vag exam done small amt clots. Fundus high now 2 FB above umbilicus. BP 88/58”.
84Dr. Girvitz testified that it took him approximately fifteen minutes to examine Ms. Mangal; Nurse Sandra Smout testified that Dr. Girvitz’s examination took closer to twenty minutes. Nurse Smout testified that Dr. Girvitz left Ms. Mangal shortly before 1 p.m. After completing his examination of Ms. Mangal, Dr. Girvitz wrote his On Call Note and left written orders concerning Ms. Mangal.
85Dr. Girvitz described his examination of Ms. Mangal. Immediately after his examination, Dr. Girvitz made and signed an On Call Note and issued written orders before leaving the Post-Anaesthetic Care Unit.
86Before describing Dr. Girvitz’s assessment of Ms. Mangal, I should record that, throughout her time in the Post-Anaesthetic Care Unit, Ms. Mangal was connected to a pulse oximeter. A pulse oximeter continuously monitors blood pressure, pulse and oxygen saturation. If Dr. Girvitz looked at the monitor, this information was continuously available.
87Dr. Girvitz testified that he reviewed Ms. Mangal’s operating room chart and he reviewed the Post-Anaesthetic Care Unit record before his examination. Dr. Girvitz testified that he then introduced himself to Ms. Mangal. He described her as calm. He told her that the nurses felt that she had had more than the usual amount of bleeding and he asked for and received permission to perform a physical examination.
88Dr. Girvitz testified that he felt Ms. Mangal’s abdomen and was surprised by how big her uterus was. Nurse Smout told him that Ms. Mangal had a fibroid. Dr. Girvitz testified that he thought the fibroid might have been the reason for the bleeding. He looked at Ms. Mangal’s vaginal area and determined that she was not bleeding. Dr. Girvitz indicated that the nurses had not provided him with an estimate of Ms. Mangal’s blood loss. He had been told that it was more than usual and, as a result, was trying to quantify it. An estimate of the blood loss should have been charted; however, Dr. Girvitz had Nurse Jackson and Nurse Smout with him at Ms. Mangal’s bedside and was, therefore, able to make inquiries of them. Whatever estimate of blood loss they were able to make was available to Dr. Girvitz and I attach no significance to the failure to chart this information.
89Dr. Girvitz testified that every patient who has a baby will have bleeding and, in some cases, there can be a considerable amount of bleeding but the patient will not be haemorrhaging.
90Dr. Girvitz testified that he placed a gloved hand inside Ms. Mangal’s vagina. He found a small amount of blood present and no blood clots. He did this because he wanted to make sure that there was no obstruction preventing blood from flowing from the uterine cavity into the vagina. He determined that there was no obstructing clot in the vagina and no excessive blood coming from the uterine cavity.
91Dr. Girvitz testified that he took Ms. Mangal’s blood pressure and found it to be 90/60. He noted her heart rate and found it to be 78.
92Dr. Girvitz concluded that Ms. Mangal had had more than the usual amount of bleeding in the recovery room and that her bleeding had stopped.
93Dr. Girvitz testified that a patient who is in shock from haemorrhaging may be unconscious or close to unconscious, pale or sweating or confused or anxious. Dr. Cowal testified that a post-caesarean section patient with internal bleeding will typically exhibit a distended abdomen, shortness of breath and shoulder tip pain. Dr. Girvitz did not observe any of these symptoms when he assessed Ms. Mangal. He described Ms. Mangal as pleasant and able to respond to his questions without difficulty. In this regard, Mr. Mangal testified that, at some point in the morning, he was told he could go home and did. Obviously, Mr. Mangal would not have left his wife if she had exhibited any of these symptoms at the time he was considering leaving.
94Dr. Girvitz testified that Ms. Mangal’s heart rate was inconsistent with someone who was haemorrhaging.
95In his On Call Note, prepared at the time of his examination, Dr. Girvitz noted that:
Ms. Mangal had had two pregnancies and had given birth to two babies;
Ms. Mangal had had a repeat caesarean section performed by Doctor Chandran;
Ms. Mangal was known to have a large fibroid; and,
Since her operation, Ms. Mangal had had several gushes of blood.
Dr. Girvitz testified that this portion of his note was a repetition of information provided by the nurses.
96In his On Call Note, Dr. Girvitz also:
Wrote the letters BP for blood pressure, but did not record the pressure;
Recorded Ms. Mangal’s heart rate was 78;
Recorded that Ms. Mangal did not have a fever. Dr. Girvitz indicated that, sometimes, an infection can cause bleeding and that is why he was concerned about Ms. Mangal’s temperature;
Recorded that the lowest blood pressure noted by the nurses was 78/49;
Recorded that Ms. Mangal’s uterus above the umbilicus was firm. Dr. Girvitz testified that the fact that the uterus felt firm was important because the most common cause of postpartum bleeding is a spongy or soft uterus;
Noted small amounts of lochia rubra in the vagina; and,
Noted no clots in the vagina.
97In his On Call Note, Dr. Girvitz recorded his diagnosis which was:
- “Postpartum bleeding more than usual but not acute hemorrhage.”
Dr. Girvitz then signed his note.
98After making this note, Dr. Girvitz wrote out orders, as follows:
NPO. Dr. Girvitz testified that this meant that Ms. Mangal was not to be given anything to eat or drink. Dr. Girvitz testified that he made this order because Ms. Mangal had been bleeding and might have to go back to the operating room even though she was stable when he examined her.
CBC. Dr. Girvitz testified that this was an order for a complete blood count. Dr. Girvitz indicated that he made this order because Ms. Mangal had been bleeding and he knew her pre-operative haemoglobin. Dr. Girvitz testified that he wanted to estimate how much of a problem the bleeding had been. The results of this test were phoned to the Post-Anaesthetic Care Unit at 1:28 p.m. By 1:28 p.m., there had been a significant decline in Ms. Mangal’s blood pressure and it was clear that she was likely bleeding. By 1:28 p.m., other orders for Ms. Mangal’s care had been given and were being implemented. Accordingly, the importance of these results was diminished at that time.
“I V R the\L Ms. 20 units/Syntocinon at 250 mL/hr, for the next 4 hours and then to be reassessed.” Dr. Girvitz testified that Syntocinon causes the uterus to contract. Dr. Girvitz testified that he ordered this drug because he thought the cause of the bleeding might have been the uterine fibroid and he was afraid that the fibroid could start the bleeding again. He thought Syntocinon would help the uterus continue to contract. Dr. Girvitz thought that the longer the uterus was contracted the less likely there would be future bleeding. Dr. Girvitz testified that you cannot give Syntocinon for longer periods than necessary and that he expected to discontinue the Syntocinon and reduce the volume of Ringers Lactate by 50% after four hours.
CBC. Dr. Girvitz testified that this was a repeat of his earlier order and that it was just an error. He thought the nurse might have been talking to him and that, as a result, he wrote the CBC order twice.
“Will stay in the recovery.” Dr. Girvitz stated that there was one-to-one nursing in the Post-Anaesthetic Care Unit and he knew that other patients would be coming into the unit. Dr. Girvitz testified that he was concerned that the nurses would transfer Ms. Mangal to a ward because she appeared to be stable. Dr. Girvitz testified that there are very few nurses on the wards and that, if Ms. Mangal were transferred there, she would get less attention. Dr. Girvitz indicated that he wanted to be the one to decide when Ms. Mangal would be moved to a ward and that he did not want the nurses to have that responsibility.
“Cross and type 2 units”. Dr. Girvitz testified that this order meant that he wanted the nurses to draw additional blood at the same time as they were drawing blood for the complete blood count test. He wanted the nurses to send the additional sample of blood to the blood bank so that they could prepare two units of blood which matched Ms. Mangal’s blood in case she needed it. Dr. Girvitz testified that he knew this takes time and he wanted blood available. Dr. Girvitz testified that he did not intend to give Ms. Mangal a transfusion at that point in time. Nurse Smout entered this order in the computer which had the effect of notifying the lab.
“Please inform Dr. Chandran of patient’s condition and that I have seen her.” Dr. Girvitz testified that he wanted Doctor Chandran to know why he had seen her patient in case Doctor Chandran was needed later. Dr. Girvitz testified that he expected Dr. Chandran to call him later to find out how Ms. Mangal was doing. Dr. Chandran was notified.
“Leave Foley in”. Dr. Girvitz testified that the Foley is a tube that drains urine from the bladder into a clear plastic bag which hangs over the side of the bed. The Foley is useful in letting you see the volume of urine coming from the patient. Dr. Girvitz testified that when a person haemorrhages the kidneys stop producing urine. Nurse Jackson at 9:35 a.m recorded “Foley draining well.” Elsewhere in the notes, it is recorded that Ms. Mangal’s urine output was 800 mL. Dr. Girvitz also testified that he did not want Ms. Mangal getting up to go to the washroom.
99Nurse Smout ticked off each of the orders as she read them or, where required, carried them out.
100Dr. Girvitz testified that he did not order coagulation studies at this time because those studies were not required because Ms. Mangal was not bleeding, her blood was not watery and he did not observe an inability to form blood clots.
101The Society of Obstetricians and Gynaecologists of Canada published, in April 2000, a Guideline entitled, “Prevention and Management of Postpartum Hemorrhage”. This guideline recommends coagulation screening when a clinician is “confronted with excessive ongoing bleeding”. I am satisfied that Dr. Girvitz decision not to order coagulation studies is entirely consistent with this Guideline and entirely consistent with his assessment that Ms. Mangal was not experiencing excessive ongoing bleeding.
102I found Dr. Girvitz to be a most impressive witness. I accept his evidence in its entirety without qualification. He performed a very thorough examination of Ms. Mangal; he made a contemporaneous reasonable note; and he left written comprehensive cautious orders which left open the option of a return to the operating room. He turned his mind to the possibility that she might be acutely haemorrhaging and concluded that she was not.
103It is clear from Dr. Girvitz’s written orders that he was satisfied Ms. Mangal was stable. Specifically, he ordered that Ms. Mangal remain in the Post-Anaesthetic Care Unit because he was concerned that the nurses would think that Ms. Mangal was stable and transfer her to a ward.
104Finally, Dr. Girvitz’s On Call Note records “postpartum bleeding more than usual but not acute hemorrhage”. This demonstrates to me that Dr. Girvitz considered whether Ms. Mangal might be acutely haemorrhaging and concluded that she was not. When Dr. Girvitz came to this conclusion, he knew about the various low blood pressures; he knew about the gushes of blood; he had the benefit of the Post-Anaesthetic Care Unit record containing notes about, among other things, a large amount of lochia rubra and the expression of clots; he had the benefit of the presence of Nurse Jackson who had been with Ms. Mangal during her caesarean section and had been caring for her throughout the morning after the surgery; he had the benefit of the presence of Nurse Sandra Smout who was replacing Ms. Jackson; and, finally, he had the benefit of having thoroughly examined Ms. Mangal. Dr. Schulman agreed that he would defer to Dr. Girvitz’s 12:35 p.m. assessment of the clinical significance of any bleeding.
105For the sake of completeness, I am satisfied that Dr. Girvitz’s opinion would not have been any different if he had been asked by Nurse Jackson to assess Ms. Mangal at 11:45 a.m. when Nurse Jackson told Dr. Bohay about the low blood pressure readings. The evidence suggests that Ms. Mangal’s condition worsened with the passage of time. Dr. Girvitz thought Ms. Mangal was stable at 12:35 p.m. and I am satisfied that he would have come to the same conclusion if he had examined her at 11:45 a.m.
The need for a blood transfusion
106Doctor Schulman testified that blood could have been given to Ms. Mangal at 12:30 p.m. Dr. Schulman was of the opinion based on his review of the hospital records that Ms. Mangal was actively bleeding at this time.
107Dr. Bohay testified that he examined Ms. Mangal at 12:30 p.m. There is no nurse’s note to this effect. The plaintiffs challenged this assertion; however, I have decided to accept this portion of Dr. Bohay’s evidence.
108The evidence established that the practice is that the anaesthesiologist accompanies the patient back to the Post-Anaesthetic Care Unit after a caesarean section. The evidence established that Dr. Bohay did this at 9:35 a.m. at the completion of Ms. Mangal’s caesarean section.
109At 11:43 a.m. when Nurse Jackson informed Dr. Bohay about Ms. Mangal’s low blood pressure, he was participating in a caesarean section with Dr. Girvitz. At the completion of that caesarean section, Dr. Bohay, following the usual practice, would have accompanied that patient back to the Post-Anaesthetic Care Unit. The evidence established that there are only two beds in the Post-Anaesthetic Care Unit.
110I am satisfied that Dr. Bohay could not help but see Ms. Mangal when he was there. It seems reasonable to me that Dr. Bohay would take that opportunity to assess Ms. Mangal’s response to the Pentaspan which he had ordered and about whom he had received a report less than an hour earlier.
111Dr. Bohay testified that he concluded that Ms. Mangal responded to the Pentaspan. Dr. Cassar-Demajo also concluded that Ms. Mangal appeared to respond to the Pentaspan. Dr. Cassar-Demajo testified that, because Ms. Mangal’s blood pressure responded to the dose of Pentaspan ordered by Dr. Bohay, it was not necessary for Dr. Bohay to order a transfusion at 12:30 p.m.
112I have already found that both Dr. Girvitz and Nurse Jackson concluded that Ms. Mangal was not actively bleeding at that time. Accordingly, I reject this assertion by Dr. Schulman that blood should have been transfused to Ms. Mangal at 12:30 p.m.
113I am satisfied that Dr. Bohay’s failure to order a transfusion when he assessed Ms. Mangal at 12:30 p.m. did not fall below the standard of care expected of a reasonable and prudent anaesthesiologist with Dr. Bohay’s experience.
Did the results of the 12:55 p.m. complete blood counts test ordered by Dr. Girvitz indicate a transfusion?
114Dr. Cassar-Demajo thought that blood should have been given at the very latest when the results of the complete blood count test ordered by Dr. Girvitz were known. The results of this complete blood count test were known at 1:28 p.m. Some context is necessary concerning complete blood count test results.
115As part of her pre-operative assessment, Ms. Mangal was given a complete blood count test on February 13, 2004. Doctor Schulman, a haematologist, described the results of the February 13, 2004, test as normal. The test revealed hemoglobin at 117 and platelets at 230, 000.
116As indicated, Dr. Girvitz ordered a complete blood count test. As indicated earlier, a complete blood count test counts all the cells in the blood. According to the hospital records, the blood sample for that complete blood count test was drawn at approximately 12:55 p.m. I will refer to this as “the 12:55 p.m. test” because the results are a snapshot of Ms. Mangal’s blood at 12:55 p.m. when the sample was drawn. It was received by the laboratory nine minutes later at 1:04 p.m. and the results were phoned to the Post-Anaesthetic Care Unit at 1:28 p.m.
117I am satisfied that the nursing staff implemented Dr. Girvitz’s order for a complete blood count promptly, that the laboratory at the William Osler Health Centre performed the complete blood count test promptly and that the results of that test were promptly reported to the Post-Anaesthetic Care Unit.
118The 12:55 p.m. test disclosed that Ms. Mangal’s hemoglobin was 76 and her platelet count was 154,000. A comparison of this test result with the pre-operative complete blood count test result of February 13, 2004 indicates that, at 12:55 p.m., Ms. Mangal’s haemoglobin count and platelet count had each declined by approximately 35% from their pre-operative levels. Doctor Schulman testified that 154 is the low end of the normal range for platelets.
119Dr. Cassar-Demajo thought that the drop in haemoglobin suggested that Ms. Mangal was bleeding and had suffered significant blood loss.
120Dr. Girvitz testified that the haemoglobin result suggested to him that there had been blood loss which, in the circumstances presented by Ms. Mangal, he attributed to blood lost during the caesarean section and post-delivery. Dr. Girvitz testified that he also thought that Ms. Mangal’s haemoglobin had been diluted by the fluids which she had received in the Post-Anaesthetic Care Unit (Ringers Lactate continuously since 9:35 a.m., a bolus of Ringers Lactate around 11:45 a.m. and 250 mL of Pentaspan around the same time). In addition, Dr. Girvitz testified that Ms. Mangal was not bleeding, was not pale, was not drifting in and out of consciousness, anxious or otherwise presenting symptoms of shock.
121Dr. Girvitz testified that a haemoglobin count of 76 constituted a mild depression. He called it the kind of result that he had seen many times. He said it was not in a range where he would have seen the need for transfusion. He testified that he had prescribed iron tablets and sent patients home with a haemoglobin level of 76. Dr. Girvitz also testified that knowing Ms. Mangal’s haemoglobin level of 76 would not have resulted in any different written orders than the ones he issued.
122Doctor William Noble, an anaesthesiologist, testified that the decision to give a blood transfusion to a patient with a haemoglobin count of 76 is a “balance of judgments”. According to Doctor Noble, if the anaesthesiologist formed the clinical judgment that the patient was stable and was likely to remain stable, the anaesthesiologist would be justified in deciding not to transfuse. Doctor Noble testified that, had he known the results of the complete blood count test, he would not have ordered a transfusion because Ms. Mangal’s platelet count of 154 was within the normal range.
123Doctor Catherine Cowal testified that a haemoglobin count of 76 and a platelet count of 154 would not have prompted her to order a transfusion.
124Doctor Schulman agreed that there is no rule or guideline requiring or suggesting a transfusion in a clinically stable patient with a haemoglobin count of 76. I recognize in making this observation that Doctor Schulman did not consider Ms. Mangal to be clinically stable. Dr. Girvitz obviously did.
125Dr. Girvitz left written orders for two units of blood to be prepared after he examined Ms. Mangal. I am satisfied that Dr. Girvitz turned his mind to Ms. Mangal’s need for blood. His decision to have blood available, but not to order a transfusion, was a decision that he was entitled to make at that time. I am satisfied that his decision was made after a thorough examination of Ms. Mangal and that his decision in that regard should be respected.
126I am satisfied that the results of the complete blood count test ordered by Dr. Girvitz did not indicate a blood transfusion was necessary.
The blood transfusions at 2:05 p.m. and 2:23 p.m.
127Ms. Mangal’s condition changed dramatically and I will shortly discuss the facts surrounding that change. When he was advised of the change in Ms. Mangal’s condition, Dr. Bohay ordered a blood transfusion at 1:13 p.m. The first unit of blood was given to Ms. Mangal at 2:05 p.m. A second unit of blood was administered at 2:23 p.m. The second unit was administered with pressure. Administering the blood with pressure means that it will be transfused faster.
128Dr. Schulman criticized the administration of these two units of blood. Doctor Schulman testified that, at 2:05 p.m., Ms. Mangal should have received two units of blood hung with pressure.
129If Dr. Schulman’s evidence is evidence that Dr. Bohay’s conduct fell below the standard expected of a reasonable and prudent anaesthesiologist with Dr. Bohay’s experience because he failed to order that the first unit of blood be administered with pressure and if I were to accept Dr. Schulman’s evidence in that regard, I would decline to attach any significance to such a breach of the standard. I would decline to do so because Dr. Schulman attached no significance to the failure to administer the first unit of blood under pressure.
130Dr. Dildy held the opinion that blood should have been administered to Ms. Mangal around 1:30 p.m.
131If Dr. Dildy’s evidence was some evidence concerning the standard of care of the nursing provided to Ms. Mangal after 1:13 p.m., I decline to rely on this aspect of his evidence to conclude that Nurse Smout breached the standard of care expected of a registered nurse of average competence by not administering blood sooner than 2:05 p.m. Nurse Holden, who offered expert nursing evidence on behalf of the plaintiffs, did not offer such an opinion. Nurse Holden offered no opinion concerning the nursing standard of care following 1:10 p.m.
Would coagulation studies ordered at 11:45 a.m. have disclosed a clotting disorder?
132As indicated, Dr. Dildy thought that coagulation studies also should have been ordered on or about 11:45 a.m. Coagulation studies are two basic coagulation tests measuring how long it takes blood to clot. There is a third coagulation test called a fibrinogen test. Dr. Dildy said that, while he typically ordered this test as well, there was some professional variation in this regard.
133I found Dr. Dildy’s opinion in this regard difficult to follow because he testified that he saw no evidence of a clotting disorder until 1:13 p.m. When I considered this aspect of Dr. Dildy’s testimony, it was not clear why coagulation studies ordered at 11:45 a.m. would have suggested a clotting disorder. However, this does not entirely end the matter.
134Ms. Mangal did, in fact, develop a clotting disorder known as Disseminated Intravascular Coagulation (DIC) on February 16, 2004.
135Doctor Schulman, who is a haematologist, described DIC. As a result of this clotting disorder, the body begins attempting to clot blood inside the blood vessels. Small clots are formed. The blood in the blood vessels moves the clots along. The small clots are then caught in different organs where they block the delivery of oxygen. The lack of oxygen produces symptoms such as decreased consciousness, bluish skin coloration and decreasing organ function. Doctor Schulman testified that blood clots form everywhere and, eventually, the body runs out of clotting factors and uncontrolled bleeding at the surgery site and elsewhere occurs. The DIC syndrome gathers momentum as it progresses. The inference from Dr. Schulman’s evidence is that the coagulation disorder is progressive.
136Accordingly, the question arises whether a coagulation study ordered at 11:45 a.m. or thereabouts would have disclosed this disorder? Dr. Schulman testified that coagulation studies are used to calculate a DIC score.
137As indicated, Ms. Mangal had a complete blood count test three days before her surgery on February 13, 2004, and, as well, on February 16, 2004, she had the 12:55 p.m. test ordered by Dr. Girvitz. A comparison of the results of the two tests reveals a 35% decline in both haemoglobin and platelets as of 12:55 p.m. February 16, 2004.
138Dr. Cassar-Demajo testified that, if you have DIC, your platelets fall markedly. Platelets are not consumed proportionally with haemoglobin. A proportionate decline in haemoglobin and platelets is inconsistent with the DIC clotting disorder because when that disorder manifests itself, platelets are consumed first. In addition, Ms. Mangal’s platelet count, according to the 12:55 p.m. test, was 154 which is at the lower end of the normal range. In short, Ms. Mangal was not in DIC at 12:55 p.m. It is not clear why coagulation studies ordered at 11:45 a.m. would have suggested DIC. No witness suggested that this was likely or possible. Coagulation studies on a blood sample drawn at 1:30 p.m. indicated what Dr. Schulman called “non-overt” or “brewing” DIC. Dr. Schulman did not suggest that coagulation studies ordered at 11:45 a.m. would have indicated “non-overt” or “overt” DIC.
139Accordingly, I am satisfied that, had Dr. Bohay ordered coagulation studies at 11:45 a.m., the results of those studies would not have suggested the clotting disorder (DIC) which Ms. Mangal later manifested. In addition, I am satisfied that Dr. Bohay’s failure to order coagulation studies at 11:45 a.m. did not fall below the standard of care expected of a reasonable and prudent anaesthesiologist with Dr. Bohay’s experience.
Did the results of the 12:55 p.m. complete blood count test suggest that coagulation studies should be ordered?
140Doctor Schulman interpreted the results of the complete blood count test as an indication that Ms. Mangal was bleeding. Doctor Schulman thought that the results of the 12:55 p.m. complete count test suggested that coagulation studies should have been ordered immediately and that the failure to do so fell below the standard of care expected of a reasonable and prudent obstetrician of his experience.
141The timing of these matters should be kept in mind. The results of the 12:55 p.m. test were ’phoned back to the Post-Anaesthetic Care Unit at 1:28 p.m.; accordingly, no one could have ordered coagulation tests based on those results before 1:28 p.m. Dr. Bohay had ordered coagulation studies at 1:13 p.m. because Ms. Mangal’s blood pressure dramatically dropped at 1:10 p.m.
142Dr. Girvitz testified that, had he known that Ms. Mangal’s haemoglobin declined from 117 to 76 when he arrived to examine her at 12:35 p.m., he would have concluded that the decline was due to blood lost during and after the caesarean section and dilution due to the fluids administered to Ms. Mangal (Ringers Lactate & Pentaspan) since 9:35 a.m.
143Dr. Girvitz was aware of the possibility that Ms. Mangal could be bleeding, but he came to the conclusion that she was not. Dr. Girvitz cannot be expected to behave as though he thought Ms. Mangal was bleeding when that was not what he thought. Dr. Schulman agreed that he would defer to Dr. Girvitz’s 12:35 p.m. assessment of the clinical significance of any bleeding. Dr. Girvitz’s opinion was one he came to after a thorough assessment of Ms. Mangal, the details of which he recorded at the time. In my view, it would be most unreasonable not to accord an appropriate degree of deference to Dr. Girvitz’s opinion under the circumstances.
144Similarly, Dr. Girvitz did not think Ms. Mangal was in shock when he was in to assess her at 12:35 p.m. Dr. Girvitz based his conclusion on the fact that he did not think Ms. Mangal was actively bleeding and that she did not otherwise present symptoms associated with shock.
145Accordingly, Dr. Girvitz did not think, when he was writing out his orders, that he was dealing with a patient who was in shock or was haemorrhaging. As a consequence, the results of the 12:55 p.m. complete blood count test would not have suggested to Dr. Girvitz that coagulation studies should be ordered.
The effect of the delay in reporting the results of the 1:30 p.m. coagulation test
146For the sake of completeness, Dr. Bohay ordered coagulation tests at 1:13 p.m. The evidence of Nurse Smout established that she and Dr. Bohay drew the blood for that test shortly after 1:30 p.m. (the 1:30 p.m. coagulation test). That sample was received by the lab at 2:19 p.m. For reasons that are not clear, the results of the 1:30 p.m. coagulation test were not reported until 3:34 p.m. It took thirty-three minutes to obtain the results of the 12:55 p.m. complete blood count test. Coagulation tests are different tests, but Dr. Schulman testified that they take about the same time to complete. Accordingly, one would expect the 1:30 p.m. coagulation test results shortly after 2 p.m.
147There was an unacceptable delay in reporting these results back to the Post-Anaesthetic Care Unit. The results of these coagulation studies suggest that Ms. Mangal should receive coagulation factors in addition to packed red blood cells. This could have been a serious matter but for the fact that, based on observations of Ms. Mangal made shortly after 2 p.m., Dr. Bohay ordered coagulation factors to be administered at approximately 2:23 p.m. As a result, the delay in reporting back the results of the 1:30 p.m. coagulation test did not delay the administration of coagulation products.
Had the 1:30 p.m. coagulation test been performed earlier, would the result have suggested that plasma be administered earlier?
148Ms. Mangal developed the clotting disorder known as DIC which is discussed elsewhere. I reference it now because plasma is a coagulation factor and, therefore, helpful in responding to DIC.
149This is perhaps an appropriate place to deal with an assertion by Doctor Schulman that, had the 1:30 p.m. coagulation test been carried out earlier, fresh frozen plasma would have been provided to Ms. Mangal earlier which would have improved her ability to form blood clots and avoid DIC. Fresh frozen plasma is a coagulation product; it helps the blood form blood clots.
150I do not accept this testimony of Doctor Schulman because the 12:55 p.m. complete blood count test result was inconsistent with DIC. Specifically, Ms. Mangal’s platelets were in the normal range and, in addition, Ms. Mangal’s haemoglobin count and platelets count fell proportionately from their pre-operative levels. As the clotting disorder DIC develops, platelets are consumed first and not proportionately with haemoglobin.
151Doctor Schulman’s description of the DIC clotting disorder made it clear that the disorder became progressively more catastrophic with the passage of time.
152The inference I draw is that, had the 1:30 p.m. coagulation test sample been drawn prior to 12:55 p.m., it would not have revealed a clotting disorder and would not have resulted in an order for the administration of plasma. Finally, plasma apparently cannot be indiscriminately administered because there are risks associated with the transfusion.
Nurse Jackson’s failure to record nursing interventions
153The charting practices of Nurse Jackson and Smout were criticized. Specifically, they were criticized for: failing to record her interventions such as providing warm blankets, failing to record temperature readings, blood pressure readings, urine output and the failure to record orders given by Dr. Bohay at 1:13 p.m.
154I do not wish to leave the impression that interventions, with the exception of the provision of warm blankets and the recording of Dr. Bohay’s orders, were not recorded. The criticism was that they were not recorded frequently enough.
155This is, of course, a civil proceeding alleging negligence. It is not a disciplinary proceeding dealing with deficiencies in charting practices.
156The Post-Anaesthetic Care Unit record records Ms. Mangal’s temperature to be 33.9° at 9:40 a.m. and 34.6° at 11:10 a.m. There was evidence that the nursing staff knew that the devices recording temperature routinely recorded body temperature 1° lower than was actually the case. There was evidence that the temperature recording devices were later replaced for this reason.
157Dr. Girvitz testified that, when he assessed Ms. Mangal between 12:35 p.m. and 12:50 p.m., she did not have a fever and her body was not cold to the touch.
158Dr. Girvitz also testified that Ms. Mangal made no complaint to him about being cold. I find this significant because Ms. Mangal did complain about being cold at 9:35 a.m. when she first arrived at the Post-Anaesthetic Care Unit and, as a result, was given warm blankets.
159Urine output was referenced twice. At 9:35 a.m., the following was recorded: “Foley draining well”. In addition, total urine output was recorded at 800 mL. Nurse Holden testified that, once Ms. Mangal became unstable, her urine output should have been monitored every hour. Dr. Girvitz thought Ms. Mangal was stable at approximately 12:50 p.m.
160Blood pressure readings were frequently recorded but not at five-minute intervals, which is required by the defendant, William Osler Health Centre’s, Guidelines.
161As indicated, when Ms. Mangal complained of being cold she was given warm blankets. This nursing intervention was not charted.
162There was no suggestion that Dr. Girvitz lacked any information when he was assessing Ms. Mangal. Dr. Girvitz knew from the hospital records that Ms. Mangal’s temperature had been low (33.9°, 34.4° and 34.6°) and that the last reading was at 11:10 a.m. He knew that Ms. Mangal was wrapped in warm blankets because he could see her. Had he been concerned about her temperature, he could have simply taken it. Dr. Girvitz had available approximately eighteen different blood pressure readings recorded in the hospital records between 9:35 a.m. and 12:35 a.m. He was able to see her urine output because the urine was collected in a clear plastic bag, which hung at the side of the bed, and the hospital record recorded urine output at 800 mL when the bag was discarded. Ms. Mangal’s oxygen level, blood pressure and pulse were continuously available on a pulse oximeter, which was also at the side of the bed. Dr. Girvitz also had the benefit of the report from Nurse Jackson, who had been with Ms. Mangal since the caesarean section and who remained with her during Dr. Girvitz’s assessment despite the fact that her shift was changing. In this regard, Nurse Jackson reported to Dr. Girvitz that Ms. Mangal had had several gushes of blood during the morning, although each time this happened had not been charted. If Nurse Jackson and Nurse Smout had not been present during his assessment and had Dr. Girvitz, as a result, been deprived of important observations about Ms. Mangal due to charting omissions, then the charting omissions identified in the evidence could have had significant repercussions in terms of liability.
163I am satisfied that no charting omission impaired the defendant physicians’ determination of how to treat Ms. Mangal.
Ms. Mangal after 1 p.m. – the decision to return to surgery
164Nurse Smout testified that she continued to check Ms. Mangal every five minutes from 12:35 until 1:10 p.m. when Ms. Mangal’s circumstances changed. Nurse Smout testified that, between 12:35 p.m. and 1:10 p.m., there was no change in Ms. Mangal’s vital signs, fundus and she made no complaint of pain. Nurse Smout testified that there was no bleeding that she observed from Ms. Mangal’s incision or vagina. Dr. Girvitz was present with Nurse Smout from 12:35 p.m. until shortly before 1 p.m. and obviously did not notice any change in Ms. Mangal’s condition or he would have changed his assessment.
165At 1:10 p.m., Ms. Mangal’s blood pressure dropped significantly. Nurse Smout promptly paged Dr. Bohay at 1:13 p.m. and told him that Ms. Mangal’s blood pressure was 67/42 and 66/38. Dr. Bohay testified that he concluded Ms. Mangal was probably bleeding.
166Dr. Bohay gave Nurse Smout a number of orders over the phone and then proceeded to the Post-Anaesthetic Care Unit arriving there shortly before 1:30 p.m. Dr. Bohay ordered:
a second intravenous;
two units of blood as quickly as possible;
a complete blood count test;
coagulation studies; and,
notification of Dr. Chandran.
167Dr. Bohay’s actual telephone orders are not recorded; however, Nurse Smout, at 1:13 p.m., recorded the following: “spoke with Dr. Bohay – see orders”. In addition, the orders which Dr. Bohay said that he gave were carried out. For example, Nurse Smout records establishing asecond intravenous at 1:30 p.m.
168I am satisfied that Dr. Bohay gave the orders which I have described. I do not excuse the failure to chart the orders; rather, I attach no significance to the failure to do so in the determination of the treatment which Ms. Mangal should have received.
169Dr. Cassar-Demajo testified that he would have given similar orders. I hasten to add that Dr. Cassar-Demajo thought that these interventions should have occurred sooner. I reference his evidence only to demonstrate the appropriateness of the orders.
170When Dr. Bohay arrived at the Post-Anaesthetic Care Unit, he realized that blood had not yet been obtained and so he ordered more Pentaspan. While Dr. Bohay was there, the second intravenous was established and blood samples were drawn on or about 1:30 p.m. for the complete blood count test and the coagulation studies which he had ordered.
The timing of the decision to return to the operating room
171Dr. Bohay made no inquiry about his order that Dr. Chandran be notified despite thinking that Ms. Mangal was bleeding.
172Dr. Bohay testified that he wanted Dr. Chandran paged partly as a courtesy. He testified that he knew Dr. Girvitz was involved with Ms. Mangal. Dr. Bohay gave no order to the nurses to contact Dr. Girvitz. In addition, notifying Dr. Chandran was more than a courtesy, given Ms. Mangal’s circumstances, and Dr. Bohay’s sense that this was a courtesy may have conveyed a lack of urgency in this regard to Nurse Smout.
173Dr. Chandran was not contacted until 1:43 p.m.; Dr. Chandran attended upon Ms. Mangal nine minutes later. Dr. Chandran then contacted Dr. Girvitz at approximately 2 p.m. and he promptly attended upon Ms. Mangal.
174It was only Dr. Chandran or Dr. Girvitz, the treating and on-call obstetricians, who were likely going to order a return to surgery to correct the cause of the bleeding, which Dr. Bohay thought was the reason for the drop in Ms. Mangal’s blood pressure. Dr. Bohay certainly could not give that order.
175Dr. Bohay testified that the Pentaspan, in his view, worked because Ms. Mangal’s blood pressure went up to 84/52. Dr. Bohay testified that he found this reassuring. I have difficulty with this aspect of his evidence. Dr. Bohay left written orders at 9:35 a.m. that a physician was to be notified if Ms. Mangal’s systolic pressure fell below 90. I do not understand his conclusion that the Pentaspan worked and that he was reassured when the Pentaspan did not restore Ms. Mangal’s blood pressure to at least 90. In this regard, it should also be remembered that Ms. Mangal’s systolic pressure at the completion of her caesarean section was 112.
176Dr. Bohay testified that he thought Ms. Mangal was stable. I do not understand this conclusion, given that Ms. Mangal’s blood pressure was below 90 and that he had ordered a transfusion.
177Dr. Bohay left Ms. Mangal without ensuring that either Dr. Chandran or Dr. Girvitz was aware of her condition. Dr. Bohay was notified by telephone that Ms. Mangal’s blood pressure had dropped again. He responded to the telephone call by ordering a third intravenous. Dr. Bohay then received another phone call telling him that Ms. Mangal was returning to surgery.
178Dr. Bohay testified that he anticipated large blood loss and transfusions and concluded that the operating room on the Labour and Delivery floor was not satisfactory and that the main operating room was required. Accordingly, he contacted the charge nurse responsible for the main operating room and arranged to have Ms. Mangal’s surgery there.
179Ms. Mangal was taken to the main operating room at approximately 2:33 p.m.
180It was Dr. Dildy’s view that Doctor Chandran or Dr. Girvitz, or both, should have decided to return to the operating room around 1:30 p.m. Dr. Cassar-Demajo offered a similar opinion.
181The defendants called Dr. Catherine Cowal, who provided an expert opinion regarding the obstetrical care provided by Dr. Chandran and Dr. Girvitz. Dr. Cowal agreed, during her cross-examination, that Ms. Mangal was in severe shock at 1:10 p.m. and that, as a result, she should have been seen and assessed sooner than 1:52 p.m., which was the time when Dr. Chandran returned to the hospital.
182It was Dr. Cowal’s opinion that, if Dr. Bohay was concerned that Ms. Mangal’s condition had changed between the time he saw her at 12:30 p.m. and the time he saw her at 1:13 p.m., then he should have communicated directly or, through the nurse, with Dr. Chandran and Dr. Girvitz.
183This is, perhaps, an appropriate place to observe that I found Doctor Cowal’s evidence of considerable assistance. Dr. Cowal’s evidence was careful, objective and balanced.
184Dr. Chandran made an observation which is useful in terms of the timing of the decision to return Ms. Mangal to the operating room. Some context for the observation is necessary.
185Dr. Chandran testified that, when she arrived at Ms. Mangal’s bedside, there was a great deal of activity; “a lot of people standing there”. She was told that Ms. Mangal was having some bleeding.
186Dr. Chandran testified that she examined Ms. Mangal. She saw blood coming from her abdomen and she put on a glove and examined her vaginally. She removed blood clots from Ms. Mangal’s vagina. Dr. Girvitz arrived. Dr. Chandran told Dr. Girvitz that Ms. Mangal was bleeding. She told Dr. Girvitz that she thought they had to operate to determine where the blood was coming from. Dr. Girvitz agreed that they should immediately return to the operating room. Dr. Chandran asked about the availability of blood and was told that Dr. Bohay had ordered blood and blood products.
187Dr. Chandran spoke to Ms. Mangal and told her that they would have to take her back to the operating room. She told Ms. Mangal that one of her stitches might have given way and, if that was the case, they would stitch it back again. She also told Ms. Mangal that, if they could not find the loose stitch, they would remove her uterus. Ms. Mangal consented to the surgery. Dr. Chandran testified that Ms. Mangal intended to have the uterus removed in any event due to the large fibroid.
188Dr. Chandran asked the nurses to find Dr. Bohay and tell him not to start any other surgeries because they had an emergency. She also told the nurses to tell Dr. Bohay to make sure that they had an operating room available. It is this latter comment that is of interest. Specifically, Dr. Chandran said she told the nurses to call Dr. Bohay and tell him “to call the operating room, make sure that we have an operating room available so that we can take her right away and stop wasting time”. Clearly, Dr. Chandran thought that time was being wasted.
189I am satisfied that the decision to return Ms. Mangal to the operating room should have been made around 1:30 p.m., as Dr. Dilday stated in his evidence. At 1:13 p.m., Dr. Bohay gave Nurse Smout a number of orders. In my view, Dr. Bohay should have prioritized contacting Doctor Chandran and Dr. Girvitz because one of them had to decide to return to the operating room. Alternatively, Dr. Bohay could have personally contacted one or the other of them.
190It is quite obvious from Dr. Chandran’s evidence that there was a lack of direction concerning Ms. Mangal’s care when she arrived at 1:52 p.m. I am satisfied that Dr. Chandran responded promptly when she was advised of Ms. Mangal’s condition. I am satisfied that it was reasonable for Dr. Chandran to confer with Dr. Girvitz before deciding to return to the operating room. I am satisfied that she and Dr. Girvitz conferred promptly and quickly decided to return Ms. Mangal to the operating room.
191The failure to communicate with Dr. Chandran and Dr. Girvitz resulted in a delay in returning Ms. Mangal to the operating room. This delay constituted a breach by Dr. Bohay of the standard of care expected of a reasonable and prudent anaesthesiologist.
192Nurse Smout spent the time between 1:13 p.m. and 1:43 p.m. carrying out Dr. Bohay’s orders and, in the course of so doing, she carried out the order to contact Dr. Chandran. The orders were not prioritized. Ms. Mangal’s blood pressure was an emergency with which she was dealing by setting up a second intravenous and drawing blood for the complete blood count test and coagulation studies which Dr. Bohay had ordered. I am not satisfied under those circumstances that her failure to contact Dr. Chandran prior to 1:43 p.m. constituted a breach of the standard of care expected of a reasonable and prudent registered nurse.
193Obviously, the next question is whether the delay in contacting Dr. Chandran contributed to Ms. Mangal’s death.
194Dr. Cassar-Demajo was asked a specific question in this regard. He offered the opinion that, assuming fluids were administered, as he thought they should have been, and assuming her coagulation parameters were corrected, as he thought they should have been, then “the sooner one stops the bleeding the better is going to be the outcome”. I am satisfied that what Dr. Cassar- Demajo meant was that, in order to avoid Ms. Mangal’s death, the administration of the Pentaspan, other fluids and coagulation factors had to take place in accordance with his assessment of Ms. Mangal and, in addition, the decision to operate had to be made at 1:30 p.m.
195Assessing whether it is more likely than not that failing to decide to operate at 1:30 p.m. contributed to Ms. Mangal’s death leads to consideration of the cause of death.
Cause of death
196The plaintiff bears the burden of showing that, but for the negligent act, the injury would not have occurred (see: Resurfice Corp. v. Hanke, 2007 SCC 7, [2007] S.C.J. No. 7, at para. 21). In medical malpractice cases alleging delayed treatment, the plaintiff is required to prove that adequate treatment more likely than not would have avoided the outcome which, in fact, occurred (see: Cotterelle v. Gerard (2003), 67 O.R. (3d) 737 (C. A.), at para. 25).
197Applying these principles to the conclusions I have reached means that the delayed treatment is the delayed decision to operate; the outcome to be avoided is Ms. Mangal’s death.
198The question becomes whether the delay in deciding to operate contributed to Ms. Mangal’s death.
199There are certain physical realities described in the evidence which cannot be avoided when considering this question.
200Dr. Noble explained some very basic principles. His evidence in this regard was not contentious. Blood containing oxygen is pumped by the left side of the heart (left is the patient’s left) to the various organs of the body. Oxygen is distributed to the various organs as the blood passes through them. When the blood arrives at the right side of the heart, oxygen has been depleted. Blood then passes through the lungs where it receives oxygen and then returns to the left side of the heart and the process repeats itself.
201Dr. Girvitz’s observations during the second surgery are significant when this basic principle is kept in mind.
202Dr. Girvitz testified that, during the second surgery, Ms. Mangal’s heart stopped beating properly and that this resulted in temporarily successful efforts to get it back into a normal rhythm. While these efforts were being made, Dr. Girvitz testified that he had to step back from the operating table. At this point, he noticed blood coming through sponges which had been used to pack the upper part of Ms. Mangal’s abdomen. He asked a vascular surgeon, who had volunteered to help with the surgery, to try to stop the bleeding in Ms. Mangal’s upper abdomen. As the vascular surgeon was attempting to do this, Dr. Girvitz assumed the role of an assistant. While assisting, Dr. Girvitz made observations of the large vein (Cava) which carries blood back to the right side of the heart. Dr. Girvitz testified that Ms. Mangle’s Cava was “this huge, huge pipe of a blood vessel, of a vein”. Dr. Girvitz described Ms. Mangle’s Cava as “grossly distended and backed up”. Dr. Girvitz said that, at that point, he realized that Ms. Mangal was suffering a failure of the right side of her heart. Dr. Girvitz testified that he realized when he saw this that there was nothing he or any other surgeon could do to save Ms. Mangal. If the right side of heart cannot pump blood into the lungs, then the blood backs up in the vein in which it is contained. The pressure in the vein increases as the supply of blood increases due to the blockage until, finally, the vein bursts. As this is happening, the left side of the heart does not receive sufficient blood and the patient’s blood pressure drops until it becomes so low that the heart stops beating.
203Dr. Girvitz observations were not challenged. Dr. Girvitz recorded in a note made immediately after the surgery that Ms. Mangal experienced “very high venous pressures”. The vascular surgeon who volunteered to assist in the surgery recorded in his note prepared immediately after the operation that the Cava was “under fairly high pressure despite the patient being hypotensive”. The surgeon recorded that, as a result, he tried to clamp the vein. The vascular surgeon also recorded that there was a “further eruption of bleeding from the vein because of the high pressure”. A general surgeon, who also volunteered and assisted in the surgery, recorded that the Cava was “quite distended and profusely bleeding”.
204Doctor Noble advanced the proposition that Ms. Mangal had high venous pressure and low blood pressure, which, in his view, was consistent with an obstruction in her lungs. The obstruction, in Doctor Noble’s view, prevented blood from going through the lungs and resulted in an increase in venous pressure.
205Doctor Noble concluded that it was likely that the obstruction was caused by amniotic fluid. He found this consistent with Amniotic Fluid Embolism being the cause of death. Dr. Dildy explained that amniotic fluid and its contents, which are fetal materials, can sometimes be released into maternal circulation during labour. In other words, Dr. Noble was suggesting that amniotic fluid became lodged in Ms. Mangal’s lungs and caused the blockage which prevented blood from the right side of her heart reaching the left side of her heart. Dr. Noble further concluded that the amniotic fluid blockage led to Disseminated Intravascular Coagulation (DIC) and, therefore, continuous blood loss which could not be stopped.
206Dr. Dildy maintains the Registry for Amniotic Fluid Embolism in the United States. He has co-authored articles with Dr. S.L. Clark, who was generally accepted as a leading authority on Amniotic Fluid Embolism. However, I think the same could be said of Dr. Dildy. Dr. Dildy discounted Amniotic Fluid Embolism in Ms. Mangal’s case due to the delayed onset of symptoms and because, in his view, there were other causes of Ms. Mangal’s death presented by the facts of the case.
207Dr. Dildy testified that Ms. Mangal’s case would not be accepted into the Amniotic Fluid Embolism Registry in the United States. Dr. Dildy also testified Ms. Mangal’s case would also not be accepted into the Amniotic Fluid Embolism Registry in the United Kingdom.
208It was apparent from cross-examination that these criteria, namely, high venous pressure and low blood pressure, were not listed by Dr. S.L. Clark as criteria for Amniotic Fluid Embolism.
209I decline to attach any weight to this aspect of Doctor Noble’s evidence. Accordingly, I am not prepared to find that amniotic fluid caused the blockage observed by Dr. Girvitz and the other surgeons. I do accept, however, that there was a blockage in Ms. Mangal’s lungs which prevented blood from flowing to the left side of her heart.
210Dr. Dildy testified that Ms. Mangal died of cardiac arrest from shock due to haemorrhage. The haemorrhage came, in Dr. Dildy’s opinion, from one of two sources; a soft uterus that was underappreciated by medical staff; or intra-abdominal bleeding that occurred at the site of the caesarean section surgery or behind the thin membrane that overlies all our organs. Dr. Dildy indicated that the soft uterus could also have been the trigger for the clotting disorder.
211Dr. Girvitz was unable to locate the source of the bleeding during the second surgery. He testified that he did not observe very much blood coming out of the primary site of the caesarean section.
212I do not accept Dr. Dildy’s conclusion that the bleeding occurred at the site of the caesarean section surgery. I find that conclusion to be inconsistent with the physical observations made by Dr. Girvitz.
213It was Dr. Schulman’s opinion that Ms. Mangal died of postpartum hemorrhage.
214Dr. Dildy offered the opinion that Ms. Mangal died of cardiac arrest due to haemorrhage.
215Dr. Michael Shkrum, the coroner who investigated Ms. Mangal’s sudden death, thought that the cause of death was “complications and postpartum haemorrhage and hysterectomy”. Dr. Shkrum rejected Dr. Noble’s conclusion that the cause of death was Amniotic Fluid Embolism because microscopic sections of Ms. Mangal’s lungs did not contain amniotic contents. Dr. Toby Rose, the Deputy Chief Forensic Pathologist at the Ontario Forensic Pathology Service, gave similar evidence. Other evidence, including the evidence of Dr. Dildy, established that the presence of fetal tissues in the lungs is not determinative in a diagnosis of amniotic fluid embolism. The testimony of the two coroners was directed to their disagreement with Dr. Noble’s conclusion concerning the cause of death. Their conclusions concerning postpartum haemorrhage did not assist with the cause of the blockage, the effects of which were observed by Dr. Girvitz and the other surgeons.
216Dr. Girvitz testified that the uterus was soft and boggy. He said that it had no tone. Dr. Girvitz described this as a change from what he had observed during his 12:35 p.m. assessment. Dr. Girvitz testified that, once he removed the uterus, there was less and less blood. He testified that, for a short time, the bleeding appeared to be under better control.
217I have no difficulty concluding that Ms. Mangal’s uterus at the time of the afternoon surgery was soft. I am satisfied that this represented change from Dr. Girvitz’s 12:35 p.m. assessment. I accept Dr. Dildy’s opinion that the softness of Ms. Mangal’s uterus was, therefore, underappreciated.
218I do not accept these opinions concerning the cause of death because the opinions, having regard to the totality of the evidence, do not explain the blockage which was observed by Dr. Girvitz and the other surgeons while they were operating on Ms. Mangal.
219When I consider the evidence, I am satisfied that Ms. Mangal died because her heart stopped beating. Her heart stopped beating because there was insufficient blood available to circulate within her body. I am satisfied that there was insufficient blood available to circulate within her body because there was a blockage which impaired the flow of blood from the right side of her heart to the left side of her heart. In my view, this conclusion explains the observations made, not only by Dr. Girvitz but by two other doctors, who voluntarily participated in the emergency surgery to try to stop Ms. Mangal’s bleeding and who made actual observations of Ms. Mangal.
220If amniotic fluid did not cause the blockage, then the question becomes whether the blockage was a blood clot formed as a result of Ms. Mangal having the clotting disorder DIC and whether it is more likely than not that failing to decide to operate at 1:30 p.m. contributed to the blockage.
221As indicated earlier, the clotting disorder known as DIC results in the body attempting to clot blood inside blood vessels. Small clots are formed and transported with the patient’s blood until they are caught in different organs. The lack of oxygen produces symptoms such as decreased consciousness, bluish skin coloration and decreasing organ function. Clots form everywhere and eventually the body runs out of clotting factors and uncontrolled bleeding at the surgery site and elsewhere occurs. Dr. Schulman testified that, when you bleed severely in postpartum haemorrhage, it can develop into DIC. Accordingly, the question becomes whether it is more likely than not that the excessive clotting could have been prevented if the decision to operate had been made at 1:30 p.m.?
222Dr. Girvitz ordered a complete blood count test. The blood sample was drawn at 12:55 p.m. An analysis of that sample discloses that, at 12:55 p.m., Ms. Mangal was not in DIC because Ms. Mangal’s haemoglobin and platelets count had proportionately declined from their pre-operative levels and the evidence established that this was inconsistent with DIC. Further, the 12:55 p.m. complete blood count test result proves that Ms. Mangal’s platelet count was 154, which is at the lower end of the normal range. The evidence established that, if Ms. Mangal was in DIC, her platelets would be consumed first.
223Accordingly, I am satisfied that Ms. Mangal was not in DIC at 12:55 p.m.
224Doctor Schulman testified that the 1:30 p.m. coagulation test result reveals the beginning of a clotting disorder. Doctor Schulman called it “non-overt” DIC or “brewing” DIC.
225Watery blood was observed oozing from the incision site at 2:07 p.m. The evidence established that watery blood in these circumstances is an overt clinical sign of DIC. Accordingly, I am satisfied that Ms. Mangal was in DIC at 2:07 p.m.
226The evidence establishes that the decision to operate was made at approximately 2:00 p.m. and that the surgery actually began at 3:10 p.m. There was no suggestion that the delay of one hour and ten minutes from the decision to operate to the commencement of the actual surgery was unreasonable. Accordingly, I draw the inference that, if the decision to operate was made at 1:30 p.m., the surgery would have commenced at approximately 2:40 p.m. As indicated earlier, the evidence establishes that Ms. Mangal was in DIC at 2:07 p.m.
227Therefore, if the decision to return to surgery had been made at 1:30 p.m., Ms. Mangal would still have fully developed the clotting disorder known as DIC. In other words, the excessive clotting would have already occurred by the time the surgery actually started.
228I also think it is important to observe that I am also satisfied that if, hypothetically, Dr. Girvitz had decided to return Ms. Mangal to surgery at the conclusion of his 12:35 p.m. assessment (12:50 p.m.), Ms. Mangal would not have been operated on until approximately 2:00 p.m., at which time it is more likely than not that she was fully in DIC. In other words, it is more likely than not that the excessive clotting would have already occurred by the time the surgery actually started.
229Accordingly, I am not satisfied that it is more likely than not that the blockage which prevented blood from flowing from the right side of Ms. Mangal’s heart to the left side of her heart could have been avoided if the decision to return to surgery had been made at 1:30 p.m.
230Accordingly, I am not satisfied that, it is more likely than not, that the failure to decide to operate on Ms. Mangal at 1:30 p.m. contributed to the blockage which prevented blood from flowing to the left side of Ms. Mangal’s heart and caused her death.
231I am not satisfied that Ms. Mangal would have survived the second surgery had the decision to operate been made at 1:30 p.m.
The administration of blood and blood products during the second surgery
232Dr. Schulman was critical of the administration of blood and blood products during the second surgery. He testified that plasma has to be administered early and not after the patient has received eight or ten units of blood.
233The second surgery should not be reported as a simple sterile set of sentences.
234Dr. Chandran and Dr. Girvitz agreed that Dr. Girvitz would conduct the surgery. The object of the surgery was to locate the source of the bleeding and stop the bleeding.
235Dr. Bohay testified that, when the surgery began, he had four intravenouses in place to provide fluids. Dr. Bohay testified that, before the second surgery began, two other anaesthetists came to the main operating room and offered to help. Thus, there were three anaesthetists present during the surgery. Dr. Bohay indicated that the two anaesthetists assisting him were each at an intravenous and tasked with ensuring that blood and blood products were administered as they became available.
236Dr. Bohay testified that extra nurses attended to take orders for and get blood and blood products from the lab.
237The first cut of the second surgery began at 3:10 p.m. Dr. Girvitz could not locate the source of the bleeding and so he removed Ms. Mangal’s uterus. Dr. Chandran had discussed this possibility with Ms. Mangal at around 2:00 p.m. and had obtained her consent. Ms. Mangal informed Dr. Chandran that she intended to have the uterus removed in any event because of the presence of the fibroid. Ms. Mangal was clearly alert at this time because she asked Nurse Smout not to inform her mother of the surgery because Ms. Mangal’s sister had died while giving birth.
238Dr. Girvitz testified that, when he removed the uterus, he saw less and less bleeding. However, Ms. Mangal’s heart rhythm suddenly became unstable; that is, her heart stopped beating in an appropriate rhythm. This occurred at 3:55 p.m. This was a crisis. Dr. Schulman testified that Ms. Mangal’s chances of survival at this point were below 50%. It was his opinion that it was more likely than not that Ms. Mangal would die. Ms. Mangal was, at that point, according to Dr. Girvitz, “a step away from dying”. Drugs were administered; Ms. Mangal was defibrillated; her heart began beating properly. Within a short period of time after this, Ms. Mangal began bleeding generally. Dr. Girvitz stated that “it was generalized bleeding from pretty much everywhere”.
239Ms. Mangal was pronounced dead at 5:53 p.m.
240Dr. Dildy’s written report, dated April 12, 2010, summarizes the administration of blood and blood products contained in the hospital records. The hospital records were admitted as proof of the facts contained in them. Dr. Dildy’s report was received as an aide memoir and, while it is not evidence, it is helpful in reading the hospital records. In addition, Dr. Dildy gave evidence concerning the administration of blood and blood products.
241Caution must be exercised with respect to Dr. Dildy’s evidence in this regard through no fault of his. A complete blood count test, performed on a blood sample from Ms. Mangal which was received by the lab at 4:24 p.m. (the 4:24 p.m. complete blood count test), revealed a severe coagulation disorder; specifically, a severe depletion of Ms. Mangal’s platelets. Counsel for the defendant, William Osler Health Centre, erroneously informed the plaintiffs that the 4:24 p.m. complete blood count test result came from a blood sample drawn at 2:00 p.m. This error was repeated in an answer to an undertaking. In his report of April 12, 2010, Dr. Dildy is critical of the fact that platelets, a coagulation product, were not administered until 3:20 p.m., despite the fact that they were severely diminished at 2:00 p.m. Counsel for the William Osler Health Centre did not correct this error until after Dr. Dildy had prepared his reports. It appears that the correction was never brought to Dr. Dildy’s attention. Quite naturally, during cross-examination, Dr. Dildy agreed that he would be prepared to modify his criticism in this regard due to his reliance on the erroneous information.
242As well, Dr. Dildy’s experience with the availability of coagulation blood products in 2004 in Texas was different than it would have been if he were practicing at the William Osler Health Centre in 2004. Specifically, the hospitals in Houston, Texas, where Dr. Dildy had privileges in 2004, maintained supplies of plasma and cryoprecipitate, each of which is a coagulation product, which were not frozen. This meant that those products could be administered almost immediately. The William Osler Health Centre, in 2004, had only frozen plasma and cryoprecipitate which, therefore, had to be thawed before they could be administered.
243I am satisfied, on the evidence, that it took at least forty-five minutes for the lab at the William Osler Health Centre to make plasma or cryoprecipitate available after it received an order. I do not think Dr. Dildy considered this possibility when formulating his criticism of the delivery of coagulation products.
244Dr. Schulman, who practices in Canada, thought that thawed cryoprecipitate would be available at the William Osler Health Centre.
245No issue was taken throughout the trial with the fact that the plasma and cryoprecipitate available at the William Osler Health Centre in 2004 were frozen. Some critical reference was made by counsel for the plaintiffs for the first time in his reply submissions, which I have disregarded.
246I intend no criticism of Dr. Dildy or Dr. Schulman in this regard. However, one must be cautious with their criticisms about the administration of coagulation products.
247Dr. Dildy pointed out that the 4:24 p.m. complete blood count test indicated a haemoglobin count of 74. He compared this with Ms. Mangal’s haemoglobin count from the 12:55 p.m. test which was 76. Dr. Dildy pointed out that, between 2:00 p.m. and 4:15 p.m., Ms. Mangal received fifteen units of blood. Dr. Dildy concluded from the fact that Ms. Mangal’s haemoglobin count was essentially unchanged that the amount of blood she received by transfusion was equal to the amount of blood lost through haemorrhage. I accept this aspect of his evidence.
248Ms. Mangal received a unit of blood at 2:05 p.m.; she received a second unit at 2:20 p.m.; at 2:40 p.m., Ms. Mangal received four units of red blood cells; she received another unit of red blood cells at 2:50 p.m. Ms. Mangal had received seven units of packed red blood cells before the actual surgery began.
249Between 3:25 p.m. and 3:50 p.m., Ms. Mangal received an additional seven units of packed red blood cells.
250At 3:40 p.m., Ms. Mangal began receiving a transfusion of four units of plasma, although there is some confusion in this regard. Dr. Schulman testified that Ms. Mangal received two units of plasma: one unit of plasma at 3:40 p.m. and another unit at 3:54 p.m. Dr. Dildy testified that Ms. Mangal received two units of plasma at 3:40 p.m. and two units at 3:50 p.m. In his written report which was received as an aide memoir only, Dr. Dildy states “at around 15:40 transfusion of the first of 4 units of fresh frozen plasma was started”. The complete hospital record was received as Exhibit 1, tab 1. At page 53, of tab 1, it is recorded that Ms. Mangal received 2500 mL of fresh frozen plasma (recorded as “FFP 2500 mL”).
251I do not accept Dr. Schulman’s evidence concerning the units of plasma administered to Ms. Mangal. Having regard to Dr. Dildy’s evidence and the documentary exhibit, I am satisfied that four units of plasma were administered to Ms. Mangal at the time her heart stopped beating rhythmically. It was not contentious that one unit of plasma should be transfused for every four units of blood transfused.
252Ms. Mangal also received a platelet transfusion at 3:20 p.m. and at 4:15 p.m.
253At 5:05 p.m., Ms. Mangal received a unit of cryoprecipitate.
254At 3:55 p.m., when Ms. Mangal’s heart stopped beating rhythmically and the chances that she would survive were less than 50%, Ms. Mangal had received fifteen units of blood, four units of plasma and a platelet transfusion.
255When the decision was made, at 2:05 p.m. or thereabouts, to take Ms. Mangal back to the operating room, it was apparent that coagulation products were required in addition to red blood. Dr. Bohay ordered coagulation products at 2:23 p.m.
256Allowing a few moments for the order to be conveyed to the lab, allowing a few moments for the delivery of the thawed plasma or cryoprecipitate from the lab and allowing approximately forty-five minutes in 2004 for the lab at the William Osler Health Centre to thaw the plasma, I am satisfied that plasma or cryoprecipitate could not have been administered until approximately 3:20 p.m. Dr. Schulman testified that the first plasma was first administered at 3:20 p.m. However, I think his evidence in this regard is in error and that the first plasma was administered at 3:40 p.m.
257The timing of the administration of plasma has an additional significance. As indicated earlier, for reasons that are not apparent, the 1:30 p.m. test results were not ’phoned to Dr. Bohay until 3:34 p.m. Dr. Schulman criticized the late reporting, despite the fact that Dr. Bohay, for other reasons (watery blood), ordered coagulation products at 2:23 p.m. In the course of giving his evidence, Dr. Schulman testified that, at 3:34 p.m., had there been a proper administration of plasma Ms. Mangal had a 70 to 90% chance of survival. If I were to accept this as true, then I have to also consider that the first of four units of plasma was administered at 3:40 p.m., i.e., some six minutes after 3:34 p.m.
258The evidence established that coagulation products could not have been indiscriminately administered whether they were needed or not because the transfusion process has certain inherent risks.
259It is true that Ms. Mangal received seven units of blood prior to the commencement of the second surgery without receiving one and three-quarter units of plasma. I do not wish to imply that the evidence suggested that plasma could be administered by quarter units. I am simply referencing the fact that one unit of plasma should be administered for every four units of blood. No one suggested that these units of red blood cells should have been withheld.
260The inference I draw is that blood products were administered as they arrived from the lab. I also draw the inference that, at the time when Ms. Mangal’s heart stopped beating rhythmically at 3:55 p.m. and the chances of her survival fell below 50%, blood and coagulation products had been administered in the appropriate proportion. I reject Doctor Schulman’s opinion that blood and blood products were not administered in the appropriate proportion.
Conclusion
261I am not satisfied that the evidence establishes that Nurse Jackson failed to notify an obstetrician no later than 12:00 p.m. concerning her observations of Ms. Mangal and that her failure to do so was a breach of the standard of care expected of a reasonable and prudent registered nurse of similar skill and experience.
262I am not satisfied that Dr. Bohay’s failure to order a larger dose of Pentaspan at 12:30 p.m. was conduct which fell below the standard of care expected of a reasonable and prudent anaesthesiologist with his experience.
263I am not satisfied that Dr. Bohay’s failure to order coagulation studies at 11:45 a.m. fell below the standard of care expected of a reasonable and prudent anaesthesiologist with his level of experience. I am also satisfied that, had Dr. Bohay ordered coagulation studies at 11:45 a.m., the results of those studies would not have disclosed a clotting disorder.
264I am satisfied that Nurse Jackson and Nurse Smout failed to chart properly. However, I am not satisfied that the failures to chart described in the evidence impaired the determination by Dr. Chandran, Dr. Bohay or Dr. Girvitz of how to treat Ms. Mangal.
265I am not satisfied that Dr. Bohay’s failure to order fluids, blood tests and a transfusion at 11:45 a.m. or at 12:30 p.m. fell below the standard of care expected of a reasonable and prudent anaesthesiologist with his level of experience.
266I am not satisfied that Dr. Girvitz’s failure to order coagulation studies when he completed his assessment of Ms. Mangal prior to 1:00 p.m. constituted a breach of the standard of care expected of a reasonable and prudent obstetrician with his level of experience.
267I am not satisfied that Dr. Girvitz’s failure to order a blood transfusion when he completed his assessment of Ms. Mangal prior to 1:00 p.m. constituted a breach of the standard of care expected of a reasonable and prudent obstetrician with his level of experience.
268I am satisfied that, had Dr. Girvitz known that Ms. Mangal’s haemoglobin was 76 and her platelet count was 154,000 when he was examining her prior to 1:00 p.m., he would not have made any different written orders than the ones he left with Nurse Smout.
269I am satisfied that the nursing staff implemented Dr. Girvitz’s order for a complete blood count test (the 12:55 p.m. test) promptly, that the laboratory at the William Osler Health Centre performed the 12:55 p.m. test promptly and reported the results of that test promptly to the Post-Anaesthetic Care Unit.
270I am satisfied that Dr. Bohay’s failure to promptly notify Dr. Chandran or Dr. Girvitz of Ms. Mangal’s condition at 1:13 p.m. was a breach of the standard of care expected of a reasonable and prudent anaesthesiologist with his level of experience. This breach resulted in the decision to operate being made later than 1:30 p.m. I am not satisfied that it is more likely than not that this delay contributed to Ms. Mangal’s death.
271I am satisfied that blood and blood products were administered to Ms. Mangal prior to and during the second surgery as they became available. I am satisfied that blood and coagulation products were administered in the appropriate proportion prior to 3:55 p.m. when Ms. Mangal’s heart stopped beating rhythmically and her chances of survival as a result were below 50%. In terms of the timing of the administration of the coagulation blood products, I am satisfied that Ms. Mangal should have received one and three-quarter units of plasma between 2:04 p.m. and 3:20 p.m. I am not satisfied, on the evidence, that had this quantity of plasma been administered to Ms. Mangal, it is more likely than not that she would have survived hersecond surgery.
272The plaintiffs’ action is dismissed.
Costs
273The plaintiffs’ case failed for the reasons I have set out, but the plaintiffs did establish some conduct which was below the appropriate standard of care and, accordingly, there will be no order concerning costs.
MARROCCO J.
Released: 20130422
COURT FILE NO.: 05-CV-284025PD2
DATE: 20130422
ONTARIO
SUPERIOR COURT OF JUSTICE
BETWEEN:
SUDESH MANGAL, VINCENT RAVI MANGAL, by his Litigation Guardian, SUDESH MANGAL and SARINA MANGAL, by her Litigation Guardian,
SUDESH MANGAL
Plaintiffs
– and –
WILLIAM OSLER HEALTH CENTRE, BRAMPTON MEMORIAL HOSPITAL CAMPUS, DR. INDIRA CHANDRAN, DR. SHELDON GIRVITZ, DR. JORDAN BOHAY, DR. KEITH LOUIS, DR. AZHAR MALIK, DR. A. SINGH, DR. I. GOLD, DR. D. PRICE, DR. A. MACDONALD, DR. D. DU BOIS, DR. J. DOE #1, DR. J. DOE #2, NURSE CARON HALL, NURSE AMY ROMYN, NURSE TARA BENFORD, NURSE CONNIE BRAIN, NURSE MARY BELL, NURSE K. GRAVAC, NURSE T. ELLIS, NURSE ANN BOTTING, NURSE IRIS PERRY, NURSE V. GUTWEIN, NURSE J. DOE #1 and NURSE J. DOE #2
Defendants
JUDGMENT
MARROCCO J.
Released: 20130422
