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Thursday, May 10, 2007

Tragic Death Restores Some Faith

We are hard pressed these days to identify a single one of our public institutions that has not let us down or betrayed our trust in one way or another. The RCMP and the Air India Inquiry, their pension fiasco and the Maher Arar case are all disappointing examples. The churches and our government betrayal of our values over treatment of children and families in Residential Schools and you can go back to the tainted blood scandal and the Sponsorship Scandal just to name a few high profile cases.

Cover ups, legal manoeuvrings, political manipulations, withholding evidence, abuse of power and authority along with many other tricks and techniques result in breaches and abuses of our trust and undermines public confidence in our institutions.

Then in a very recent and sad personal tragedy we get a ray of hope. The recent death Denise Melanson, an Alberta woman who was mistakenly given an excess of chemotherapy drugs is just such an example. Again we unfortunately see the institutional culture that initially misses the mark on earning our trust because a policy for public protection and service was not followed. Investigations into the death show that the family did not get notice of the error for five days and senior management was not advised of the error for 18 days. All this was in spite of a policy requiring immediate notice is to be given in each instance. This has become the typical kind of "response" we have come to expect from too many of our institutions these days.

Then we have the hope that results from the responsible reaction of the people and professionals involved who showed quality character and leadership. They have given us personal examples of how things should be handled, and can be handled, when good people step up and deal with bad situations properly.

Let me outline some facts to show what I mean. There was a swift, confidential and satisfactory settlement of liability and an assessment of damages that was done with out legal manoeuvring or posturing. That is a tribute to the Melanson family and their lawyer Rosanna Saccomani. Accolades go to the hospital, the Cross Cancer Institute too for how they handled this aspect of the consequences of the error as well.

Then we have Denise Melanson’s personal courage and character in how she responded to this terrible situation. She is reported to have had no ill will towards the nurses who administered the mistaken dosage that caused her death. Her family also took steps to reassure people of the care, compassion and treatment she received at The Cross. Sadness and sorrow and the suffering of a great personal loss did not distort their perspective and judgement either.

Then we have the example of quality leadership from Dr. Tony Fields, Vice President of the Alberta Cancer Board. Field’s approach was to be open, transparent, forthright and responsive to the mistake. The quality of his leadership was also shown by taking full responsibility up front and swiftly instead of the usual secrecy, delay and denial reactions we see so often in such circumstances.

Investigations have revealed some changes in procedures need to be made and they are being undertaken. We found that this kind of tragedy is not an isolated incident. Dr. Fields is reported have said “One of the hardest things to hear was that this mistake had been made elsewhere and resulted in deaths elsewhere. We were not able to learn from the mistakes of other, but we’ll ensure others can learn from ours.”

Tony and Rosanna likely did not know each other before this incident. For the record, I am proud to say Tony and Rosanna are both friends of mine. I would not be surprised if they became friends of each other as they worked through their professional roles and responsibilities both trying to do the right thing in these difficult circumstances.

I want thank them for giving us all a shining example of how such devastating, difficult and sad circumstances ought to be dealt with. We have an institution like The Cross Cancer Clinic, and people like Denise and her family, and professionals like Tony and Rosanna who each responded appropriately to this tragedy in their own way. The result was better service of the public interest and better outcomes for the greater good. That is all too rare a result these days.