Family says Alberta fatality inquiry system failed them and their mother

When the fatality inquiry began in March 2012 into the horrific death of their mother, Jodi Pifko and her sister Kim Bordignon wanted accountability, but mostly they hoped the inquiry would ensure another family did not have to suffer through the needless death of a loved one.

Three years later, Jodi Pifko is still so emotionally devastated by how the inquiry failed to provide any accountability, or purpose, for her mother Carol Pifko's death, she can't talk about it.

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So it falls to Kim Bordignon to express the family's anger and frustration with a system that not only provided no closure, but actually increased their personal trauma over the preventable death of their mother.

"There isn't a day that goes by that you don't think about it," Bordignon said in a telephone interview from her home in Thunder Bay, Ont.

"My sister has never been the same since this. You hope for closure but we never got any. We never got any."

Carol Pifko, a dementia patient, died in 2009 after being given double the prescribed dose of Zyprexa, a powerful psychiatric drug that Health Canada does not approve for dementia patients because it can kill them.

'Accidental death'

An autopsy ruled Carol Pifko's death was "accidental," due to a rare neurological disorder caused by a reaction to the drug.

The inquiry heard that on five occasions, staff at Capital Care Norwood in Edmonton gave Pifko double the prescribed dose a mistake caused by a mislabelled bag. Pifko was eventually transferred to the Royal Alexandra Hospital, where doctors continued to prescribe her Zyprexa, even after Jodi Pifko told staff she did not want her mother given that drug because she knew it could be deadly.

You have faith in the process, in the system and the system failed us.- KimBordignon

The inquiry uncovered a series of mistakes both at Capital Care Norwood and at the hospital.

Jodi Pifko and Kim Bordignon hired their own lawyer for the inquiry and through him made nine recommendations to Alberta Provincial Court Judge Elizabeth Johnson aimed at ensuring no other dementia patient died from a drug with known serious safety risks.

One of their main recommendations was that long-term care staff inform patients and their families of the risks associated with Zyprexa. Johnson dismissed that recommendation.

"It would seem to fetter a physician in how he or she deals with a patient and exercises his or her professional judgment," Johnson said in her report.

Judge dismisses recommendations

Another main recommendation was that when an error is made in the prescription of a drug, there should be documented evidence that the patient is being monitored and that the patient's vital signs are taken. In the case of a serious error, the daughters recommended a doctor should examine the patient immediately and the patient's family or guardian should be notified.

Johnson noted a nurse produced an observational record but, as the judge herself noted: "It does not appear that (Carol Pifko's) vital signs were taken that day."

Johnson dismissed these recommendations stating: "There is no evidence before the inquiry upon which the inquiry could base the specific directions suggested to nurses and physicians."

During the final hours of Carol Pifko's life, her daughter Jodi watched her writhe in a hospital bed, twitching, her limbs rigid from the onset of the neurological disorder that finally killed her.

"We lost her to a series of mistakes," Kim Bordignon said. "You have faith in the process, in the system and the system failed us.

"And we can't help anyone else, you know, to make changes for them. It is devastating."

Dr. Paula Rochon of Toronto is an expert in the prescription of anti-psychotic drugs to the elderly. Rochon previously told CBC about one-third of all long-term care residents in Canada will be prescribed anti-psychotics. She said those people are twice as likely to be hospitalized, or die, if they have been newly started on anti-psychotic therapy.

Both the hospital and the continuing care centre have denied any wrongdoing and have said they would not have done anything differently in their treatment of Carol Pifko.