Province rejects recommendations after patient's death

The province has released its fatality report on an Edmonton woman who died in hospital after being given an overdose of a powerful antipsychotic drug.

The document details numerous mistakes made by doctors and other care professionals leading up to the death of 61-year-old Carol Pifko, a dementia patient. But the fatality inquiry judge issued no recommendations.

Pifko died in 2009 because of a reaction to the antipsychotic drug Zyprexa – a medication Health Canada said was not safe for dementia patients.

The official cause of death given at the time of her death was a rare neurological disorder caused by a reaction to the drug.

However, on five occasions, staff at Capital Care Norwood gave Pifka 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 she became agitated and began to hallucinate.

Pifko died several days later.

At an inquiry into Pifko’s death, her daughter Jodi made nine recommendations to provincial court judge Elizabeth Johnson on how to prevent the situation from happening again.

One of of her recommendations stated that long-term care staff inform patients and their families of the risks associated with Zyprexa.

However, 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," she said in her report.

Another Pifko daughter, Kimberly Bordignon, said the ruling was difficult for the family to hear.

"It just feels like your family member is just disregarded,” she said. “It doesn't seem like anyone's protecting your family member."

Health Minister Fred Horne said that Alberta Health Services would continue to investigate the circumstances surrounding Pifko's death. But he added he would likely not meet with the family.

"While I certainly feel deeply for them and their situation, my responsibility is to find out, 'What can we learn as a health system from this, and how do we reorganize things to make sure it doesn't happen again?' So that's where my eyes will be.”

AHS says they don't have a firm timeline for when that investigation will be completed - largely due to the fact that the judge did not issue any recommendations.