ONTARIO
SUPERIOR COURT OF JUSTICE
COURT FILE NO.: 29/12
DATE: 2014-02-20
BETWEEN:
DANIELLE EDITH BOYD, ELAINE LUCIE FRETZ, RICHARD JAMES BOYD, and KAIDEN RICHARD BOYD by his Litigation Guardian, Elaine Lucie Fretz
André Michael and Jill McCartney, for the Plaintiffs
Plaintiffs
- and -
DR. RICHARD BRUCE EDINGTON
Andrea Plumb, Carolyn Brandow and Sarah Martens, for the Defendant
Defendant
HEARD: March 11-12, September 9-13, 17-19, 30, October 1-4, 7-9, 22 and 23, 2013
REASONS FOR JUDGMENT
(The text of the original judgment was corrected on March 10, 2014, as described in the Appendix).
SPROAT J.
TABLE OF CONTENTS
I. OVERVIEW
II. STANDARD OF CARE
A. THE LAW
B. DID DR. EDINGTON BREACH THE STANDARD OF CARE?
(a) Dr. Edington’s Evidence
(b) The Expert Witnesses
(i) Plaintiffs’ Experts
(ii) Defence Experts
(c) Plaintiffs’ Expert Evidence
(d) Defence Expert Evidence
(e) Analysis and Conclusion
III. CAUSATION
A. THE LAW
B. OVERVIEW
(a) Terminology and Anatomy
(b) The Expert Witnesses
(i) Plaintiffs’ Experts
(ii) Defence Experts
C. WOULD LHSC HAVE ACCEPTED IMMEDIATE TRANSFER OF MS. BOYD?
D. WAS THE STROKE THE RESULT OF A BLOOD CLOT OR ARTERY DISSECTION?
(a) Introduction
(b) The Indicia – Clot or Dissection
(i) Blood Clot Is Most Often The Cause Of Stroke
(ii) Circumstances Conducive To Blood Clotting
(iii) Does Any Of The Imaging Show A Blood Clot?
(iv) Is The Blockage At The Area Of Dissection Or Beyond It?
(v) Could A Dissection Extend Beyond PICA Yet Not Block PICA?
(vi) No Additional Areas of Infarction Identified
(vii) Step Like Progression Of Signs And Symptoms
(c) Analysis and Conclusion
E. DID LOWERING BP AND DELAY IN ADMINISTERING HEPARIN CAUSE THE STROKE?
(a) Introduction
(b) Lowering of BP by Dr. Edington
(c) LHSC BP Orders
(d) Plaintiffs’ Expert Evidence
(i) Lowering BP
(ii) Delay in Administering Heparin
(iii) Typical Outcomes for VAD Patients – Efficacy of Treatment
(e) Defence Expert Evidence
(i) Lowering BP
(ii) Delay in Administering Heparin
(iii) Typical Outcomes for VAD Patients – Efficacy of Treatment
(f) Analysis and Conclusion
F. DAMAGES
G. CONCLUSION
INTRODUCTION
I. OVERVIEW
[1] On December 27, 2008, Danielle Boyd, (“Ms. Boyd”) age 24, went bowling. She was taking medication for high blood pressure (“BP”) and had recently been suffering from severe headaches. She was feeling sick and a friend drove her from the bowling alley to Hanover Hospital just after 22:00. On arrival, her symptoms included left-sided numbness, unsteadiness on her feet, speech garbled at times, involuntary eye movement and headache. Her BP was elevated. Ms. Boyd was at Hanover Hospital from the evening of December 27 to the morning of December 28, and I will not repeat references to the date and year.
[2] Dr. Edington saw Ms. Boyd immediately. He considered possible diagnoses of “HTN” (meaning hypertensive crisis), “migraine equivalent” and alcohol use. He kept her in hospital for observation and administered medication to lower her BP.
[3] The attending nurse recorded at 02:30 that Ms. Boyd was unable to move her left arm at all, was drowsy and complained of being very dizzy with movement. The nurse advised Dr. Edington of the change in Ms. Boyd’s condition. Dr. Edington was resting at that time and he did not reassess her.
[4] Dr. Edington did reassess Ms. Boyd at 05:30. By 06:45, Ms. Boyd’s signs had worsened and her left leg was now less mobile. At 07:00, Dr. Edington contacted the neurology department at London Heath Services Centre (“LHSC”) and arrangements were made to transfer her.
[5] Ms. Boyd arrived at LHSC at 09:40 on December 28. By 12:30, imaging revealed that she had a dissection of her right vertebral artery (“RVA”). The dissection extended from near the top of her spinal cord into her cranium. A “dissection” means that the arterial layers have separated and blood enters or bleeding occurs between the layers. The artery wall expands and it can narrow or block the artery. Dissections often result in blood clots which can block arteries. At 13:13, Ms. Boyd was administered heparin, an anticoagulant used to try to prevent the formation of blood clots.
[6] Ms. Boyd’s condition was stable until approximately midnight on December 29. At that time, her condition deteriorated abruptly. She suffered a stroke, which killed the tissue in her upper spinal cord and lower brain stem. When I refer in these reasons to Ms. Boyd’s “stroke”, I am referring to this major stroke.
[7] Ms. Boyd submits that:
(a) Dr. Edington was negligent in failing to recognize the signs of stroke, and in failing to contact LHSC and arrange for her transfer eight hours earlier;
(b) Dr. Edington’s lowering of her BP exacerbated what were minor transient symptoms, and created conditions conducive to blood clot formation;
(c) the immediate cause of the stroke was a blockage caused by a blood clot; and
(d) but for the lowering of her BP, and the approximate eight hour delay in administering heparin, she would not have suffered a debilitating stroke.
[8] Dr. Edington submits that:
(a) he met the standard of care by treating Ms. Boyd for high BP and observing her overnight;
(b) in any event, an extension of the dissection of the artery wall caused the blockage and not a blood clot. (It is agreed that heparin is not effective to treat a dissection and that lowering BP would not cause a dissection to extend. As such, if the stroke was caused by the dissection, this action must be dismissed);
(c) even assuming the stroke was caused by a blood clot, the reduction in Ms. Boyd’s BP in Hanover did not cause or contribute to the formation of blood clots; and
(d) even assuming the stroke was caused by a blood clot, the weight of scientific opinion is that heparin is not recommended for treating vertebral artery dissection (“VAD”) and should not be administered. As such, any delay in administering non-recommended treatment cannot cause damage.
(Full judgment text continues exactly as provided above.)
APPENDIX
Corrections made:
March 10, 2014:
Paragraph [84]: The word “not” has been added so that the last sentence of the paragraph reads, “The evidence of Dr. Antoniadis was also in conflict with Dr. Teal, who was unequivocal in his opinion that Dr. Edington did breach the standard of care by not reassessing Ms. Boyd, and calling LHSC, when she deteriorated at 02:45.”
Paragraph [112]: The spelling of the word “neuroradiologists” has been corrected.
Paragraph 124: In the second sentence, the word “is”, which followed the word “it”, has been deleted.
COURT FILE NO.: 29/12
DATE: 2014-02-20
ONTARIO
SUPERIOR COURT OF JUSTICE
BETWEEN:
DANIELLE EDITH BOYD, ELAINE LUCIE FRETZ, RICHARD JAMES BOYD, and KAIDEN RICHARD BOYD by his Litigation Guardian, Elaine Lucie Fretz
Plaintiffs
- and -
DR. RICHARD BRUCE EDINGTON
Defendant
REASONS FOR JUDGMENT
Sproat J.
Released: February 20, 2014