Bridget Denny in an undated photo died unexpectedly in a Cape Breton Hospital. Photo courtesy of the family.
The College of Physicians and Surgeons of Nova Scotia says a probe into the death of Eskasoni Elder Bridget Denny in a Cape Breton hospital warrants further investigation, APTN News has learned.
Denny, 65, a residential school survivor, mother of five, grandmother to 15, Mi’kmaw language speaker, and an active member of Eskasoni First Nation, went to the Cape Breton Regional Hospital on Jan. 19, 2021, for pain and complications from her diabetes.
She died the next day and her body was cremated.
Days later, before the funeral, the family found out from another patient that Denny had fallen in the middle of the night.
The family obtained Denny’s medical chart, then filed a complaint with the Nova Scotia College of Physicians and Surgeons of Nova Scotia.
“It makes me sad as a Mi’kmaw woman, for our elders, for my parents the fear to go to a place that is supposed to care for you, that blows my mind, no elder should ever be scared to go to a hospital,” said her daughter-in-law Mary Joe-Franncis.
The incident sparked an investigation under the Protection for Persons in Care Act.
A final report issued on Feb. 25, 2021, concluded:
“The facility failed to provide adequate care based on the lack of documentation…in response to the affected patient’s unwitnessed fall, including failing to document the affected patient’s post-fall vitals and post-fall assessments firsthand, staff inaccurately completed the affected patient’s admission fall risk assessment and hourly checks, and no documented evidence that post-fall neuro vitals and a SIMS report were completed.”
The report also said, “it is beyond the scope of this investigation to determine if this contributed to the affected patient’s death.”
According to the report, “around 2 a.m. another patient was ringing their call bell, while standing in the doorway attempting to get the attention of the staff, saying, ‘someone is on the floor here’ and ‘someone needs help in here.’”
Staff arrived and helped Denny back to bed.
The report continued, “the person implicated documented second-hand information about the fall as patient slid to the floor,” however, “the fall was consistently reported as being unwitnessed, therefore, investigators were unable to determine how the fall occurred and the length of time the affected patient was on the floor.”
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The report said there is no documentation Denny was assessed after she fell, or staff followed the hospital’s fall and injury prevention policy, which includes:
“A head-to-toe assessment, monitoring for injuries especially for an un-witnessed fall … for 48 hours after fall, monitoring involves vital and neuro-vital sign assessments every two hours at a minimum, and documentation of details of the fall in the patient health record chart and the incident reporting system,” according to the report.
According to the report, the nursing flow chart indicated Denny was in bed and did not get up to go to the washroom between 7 p.m. and 6 a.m, which contradicts the progress note and staff reports.
The next morning, Denny was unresponsive and could not be revived.
The report said, “had the physicians known about the fall, the file would have been reported to the medical examiner, and the family would have chosen to proceed with an autopsy.”
With files from Angel Moore
