A review by the Manitoba College of Physicians and Surgeons has found “system issues” after a woman complained about the care her 70-year-old mother received at Concordia Hospital in 2005.

Tracey Weber says her mother was diagnosed with a urinary tract infection and prescribed antibiotics when she arrived at the hospital’s emergency department in extreme pain in the early hours of March 26, 2005. The family explained that she had a history of kidney stones and was under the care of a urologist.

The infection was expected to improve within 24 hours, but things got worse.

“All of a sudden her blood pressure alarms started going off and we couldn’t find nurses. We had to keep going up and down the hallway,” Weber told CBC Manitoba’s television investigative unit.

She said nurses told her to be patient, but by the evening, a doctor had diagnosed septic shock and a blood infection. Weber’s mother’s organs were shutting down. That’s when the doctor’s orders changed.

Weber said she was told, “If your mom has a husband, go get him. Your mom’s dying.”

Her mother had a kidney stone blockage. She was transferred to Victoria Hospital for emergency surgery. She spent a week on life support and survived.

Weber complained to Concordia Hospital about the treatment her mother received, but was told there was no problem with the care. She then turned to the College of Physicians and Surgeons.

Its review found “system issues” at Concordia Hospital, such as delayed medication administration and poor physician-to-physician contact.

Concordia reacted by creating a new policy on physician communication.

The college also found problems with the care provided by a doctor, including failure to follow up with the patient and adequately treat symptoms.

Weber’s mother’s regular urologist sent the College of Physicians and Surgeons a letter saying under the circumstances that night, he “would have admitted her for appropriate urological management.”

CBC’s investigative unit contacted Concordia Hospital to ask why their review didn’t find these problems. Concordia Hospital officials turned down an interview, but stated, “We’ve acknowledged that there could have been better communications and better management of pain in her case. Those issues have been addressed with staff.”

Weber said Concordia Hospital and the Winnipeg Regional Health Authority should have done a better job addressing her concerns.

“The system doesn’t want to talk about mistakes. The doctors don’t want to talk about them. So where does the family turn when mistakes happen? There’s got to be a different process,” she said.

Weber on 9/27/2008