WARNING: This story contains graphic photography and disturbing details
Kelly O’Leary can’t shake the feeling that the excruciating pain of her father’s death could have been prevented.
Ken O’Leary, 87, of Burlington, Ont., died last February of wounds to the base of his spine after a stay at Joseph Brant Hospital. His daughter describes him as “the size of an avocado.”
“It haunts me,” Kelly said. “It haunts our whole family.” Because we could have done something, but [the hospital] he didn’t tell us.”
Ken was one of more than 4,000 people a year who develop decubitus ulcers — also called decubitus ulcers — while in hospital, according to the Canadian Institute for Health Information (CIHI).
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They occur when prolonged pressure on a body part cuts off blood flow to the skin for more than two to three hours, injuring the skin and underlying tissue. Open wounds, which can lead to serious infection and even death, are best prevented by regular repositioning of patients, a job that usually falls to the often overworked medical staff.
Experts say the number of reported canker sores is far below the actual number because many hospitals do not track and report them accurately. They also fear the number of cases will rise as Canada’s population ages and more people become less mobile — even though anyone of any age can get canker sores from spring.
“Even a young, healthy adult who has been in a motor vehicle accident, ICU patients, our spinal cord population, anyone with diabetes,” said Kimberly LeBlanc, a registered nurse and expert who sits on a Canadian advisory panel on pressure injuries.
“We need to put more emphasis on prevention.”
A hospital spokesman declined an interview but told Go Public in an email that Ken’s case had been reviewed.
The review underlined the importance of clear communication with families, but also said staff were confident he had received “appropriate treatment and care” and no changes to policy or procedures were needed.
Ken was admitted to hospital in September 2021, after exhibiting aggressive behavior associated with dementia. He and his family thought it would be a short stay.
“He was pretty fit,” Kelly said. “And he thought he was still pretty cool. He’d wear his cap backwards and muscle shirts. And at 87, he was pretty good.”
But Ken quickly deteriorated. Medical records show he was often heavily sedated and too sleepy to move much. Within weeks, he was bedridden.
But, unknown to the family, a sore had begun to form at the base of Ken’s spine. His medical record mentions it as October 24, 2021, but no one told his family until almost a month later.
By then the wound was so bad that it went to the bone. He also developed one on his left heel.
“It’s heartbreaking for us because he was complaining about his back hurting,” Kelly said. Pain medications become less effective as the ulcers grow, especially if they reach the size of Kenova.
Hospital spokeswoman Maria Babbage wrote that staff met with his family members “many times on an ongoing basis” and were given “accurate and complete information” about Ken’s condition. Babbage’s email does not say whether the staff specifically mentioned the sores since the spring.
Kelly disputes that claim, saying she and other family members met with Ken’s entire care team three weeks after staff first noticed his bed sore.
“Not once was his… wound mentioned,” she said. “We had to go ask things to try to get information.”
Kelly says she and her mother visited Ken twice a day – enough time to tell her about his wounds.
“Has anyone said to us, ‘Your dad is at risk of pressure sores … can you help us move him when you’re inside?’ “But nobody said anything,” Kelly said.
‘We’re tied up, we need help’
Nurses often don’t have time to regularly reposition patients, LeBlanc says.
“This crisis is not new,” she said. “Nurses have been sounding the alarm for years, saying, ‘We’re tied up here, we need help.’ And now, unfortunately, things are really coming to a head and we’re starting to really see the consequences of that.”
LeBlanc says the nurse-to-patient ratio used to be about 1 to 5, but increasingly, she says, it’s more like 1 to 10.
“It’s really hard to prioritize skin when you have to take people in and out of surgery, you have to administer complex medications, you have to do complex procedures on them,” she said. “The skin just pushes to the side.”
LeBlanc calls for improved nursing education, as only a few universities in Canada currently include mandatory skin care courses in their undergraduate programs.
Recent figures from the CIHI show that the number of hospital-acquired pressure injuries has risen steadily over the past four years, from 3,109 in the year ending 31 March 2018 to 4,440 by 31 March 2022 — an increase of around 43 per cent .
In the past year, the number increased by 20 percent, the largest increase in recent years; possibly due to a shortage of nurses exacerbated by the pandemic.
Wounds Canada, a charity focused on education and prevention, estimates that up to 70 percent of all pressure ulcers are preventable.
It also said treatment costs between $44,000 per patient and $90,000 for more severe cases, adding that the latter (called “stage 3” or “stage 4” pressure ulcers) are considered “never events” – meaning they can lead to blood and bones. infection and should never happen.
This isn’t the first time a patient at Joseph Brant Hospital has had a disturbingly large canker sore.
Bob Wilson, 77, was admitted in November 2018 after falling down the stairs and suffering a brain injury. A wound developed on his backeating away at his flesh until it created a gaping hole the size of a football.
“He basically rotted alive,” said his daughter, Linda Moss.
No one informed Wilson’s family about the festering wound until it reached his bones. He died in June 2019.
The coroner’s report said the wound led to a severe bone infection that he was unable to fight because it had become resistant to antibiotics.
The hospital promised to implement a a series of changes — recommended after Wilson’s death — how to treat ulcers from the spring.
Wilson’s family reached an out-of-court settlement with the hospital in June, which prevents Moss from revealing the details.
“It’s vindication for our father,” she says. “What happened to him was wrong.
Moss has since joined the board of Wounds Canada and leads conversations with health professionals and educators about how pressure injuries can be avoided.
She says she is committed to protecting other families from the same devastating experience.
Guilt, anger, sadness
Gabriella Cruz says she had no idea her 76-year-old mother, Martha, was also suffering from massive wounds at the base of her spine, a month after she was admitted to Credit Valley Hospital — part of Trillium Health Partners — in Mississauga, Ont., last February.
Although medical records describe it as “stage four” (the most serious level), Cruz says she only found out about the wound in April. Then the wound was so deep that the ligaments were exposed.
“I never knew I could have tears this thick,” Cruz said. “I’m like, ‘What the hell is this? Why haven’t I been informed about what’s going on?’
The hospital declined an interview request. Spokesman Amit Shilton said he could not answer questions about the case, due to patient confidentiality. But an email sent to Cruz from the hospital’s director of patient care said Martha had a deep tissue injury when she was admitted — citing photos taken upon her arrival.
“The full extent of tissue damage and the severity of the wound cannot be assessed until the wound is fully opened and the base of the wound is visible,” Sandy Days wrote.
Deiss also says staff notified the family – a claim Martha’s grown children strongly deny.
Meanwhile, Ken O’Leary’s family has since received an apology from Joseph Brandt Hospital – but not for allowing the pressure sore to grow to the size of an avocado.
“It was an apology for dropping the ball and miscommunication,” Kelly said. But that, she says, doesn’t help her family deal with the trauma of watching their father suffer such an agonizing death.
“There is guilt, there is anger and sadness,” she said. “And now, of course, sadness.”
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