Ed. Note: Mrs. Toth attended the Fatality Enquiry into the morphine-related death of Candace Taschuk. The following is her report on the testimony at the enquiry.
Mrs. Toth, chairman of Campaign Life Canada, subsequently sent a letter to the Attorney General of Alberta on September 1st, asking that criminal charges be laid against Dr. Gal.
Mrs. Debbie Taschuk was transferred from the rural hospital in Two Hills Alberta to Edmonton’s University Hospital on October 6, 1982. She was not haemorrhaging and fetal monitors showed no fetal distress; baby was 37 weeks old. Ultrasound normal. Patient began to hemorrhage at 2 a.m. on October 8. Resident doctor in Obstetrics was assisting at another caesarean delivery and so did not see Mrs. Taschuk until after 3 a.m. Nurses did not call Mrs. Taschuk’s own doctor. An emergency caesarean was ordered at 3:30 a.m. but apparently no Operating Room was available. A caesarean was done at 4:30 a.m. and baby Girl Taschuk showed little signs of life, (fetal heart monitor showed 40 beats/min.)
The pathologist who examined the placenta noted that there was a recent acute cord injury which occluded the umbilical artery and one vein. Baby was blue/grey when born.
The neonathologist immediately administered air into the infant’s lungs. The heart stopped beating for 7 or 8 minutes. Doctor Marc Beaudry was ready to stop when the baby’s heart began beating. The baby’s condition was the stabilized with bicarbonate, packed cells and intravenous fluids and she was placed on a respirator.
An electroencephalogram at 8 a.m. confirmed that there was sever cerebral dysfunction and that there was no reaction of the baby to pain because of severe damage to the brain stem. After consultation with the parents of the baby, paediatrician Dr. Thomas Ward decided to remove her from the respirator.
She was not expected to survive very long, but orders were given that she be kept warm and as comfortable as possible. Drugs were discontinued. Although there were no seizures, respiration was irregular. The parents were encouraged to spend as much time as possible with their baby. It was explained to them that the prognosis was poor and that the damage could not be undone.
Baby Taschuk was turned over to the care of Dr. Gal at 3:30 p.m. Oct. 8. Nurses’ notes show that the baby was twitching and “wailing”. At 7:15 p.m. Demerol and chloral hydrate were administered but no improvement was noted. Nurse Barbara Howell asked Dr. Gal to give the baby something to stop the seizures. At 9 p.m. he prescribed 15 mgs. of morphine. Nurse Howell knew it to be an excessive dose so she asked Assistant Charge Nurse Betty Schulze to recheck the order with Dr. Gal.
Miss Schulz returned, brought the 15 mg. vial of morphine to Nurse Howell, confirmed Dr. Gal’s order with Miss Howell and supervised the administration of the drug at 9:10 p.m. Because of the large volume, it was necessary to inject half in each of the baby’s thighs. The baby died 40 minutes later. Although Nurse Howell admitted that she knew it was an overdose, she said she wanted to “release the baby from suffering”. After this incident, there was no discussion about it with Nurse Betty Schulz or with Dr. Gal.
Dr. Gal signed the death certificate. Diagnosis: “Birth asphyxia”. Pathologist Dr. Johnson did the autopsy. He did not recall seeing entry on the chart showing 15 mgs. of morphine being given. If he had he would have ordered tissue samples taken for toxicology studies. He felt that the job of hospital pathologist was generally to confirm diagnosis on death certificate. This he did in all honesty.
On Feb. 23/83 charts of all prenatal deaths were being checked by Dr. Ann Cornet, Chairman of the Prenatal Mortality Committee which was to meet on March 1st. She noticed the entry on the doctor’s order sheet and she called Dr. Gal to confirm. Although he claimed he “did not remember”, Dr. Cornet was satisfied that the morphine ordered had been given. She immediately reported it to her superiors and to the Hospital Administration. Dr, Read, Vice-Pres. of Medical Staff contacted the medical examiner’s office and the registrar of the College of Physicians and Surgeons.
Medical Examiner Dr. Jennifer Rice determined from the chart that the morphine overdose which was administered to the baby caused her to die sooner than she would have if it had not been given. She testified that the infant’s condition had somewhat stabilized and according to charted information, the baby was not in the process of dying although she was not expected to survive more than a few days. Dr. Rice amended the Death Certificate to read MORPHINE INTOXICATION instead of “birth asphyxia”.
Dr. Gal did not return from Israel to testify. His lawyer, Ron Berger maintains that the baby’s circulation was so poor that none of the morphine had time to be absorbed before the baby died. Since no tissue or blood samples were taken, it is impossible to prove that morphine was the cause death.
Judge Carl Rolfe brought down his decision on August 24/83. He ruled that it was not possible to determine the cause of death without tissue samples. Since the baby’s body was cremated and the heart and liver samples from the autopsy had so denatured by formaldehyde, no positive cause of death could be established.
In light of this ruling, the Attorney General of Alberta, Hon. Neil Webber stated in a ITV interview on Aug. 29th that hi department would not be laying criminal charges against Dr. Gal. However, the registrar of the College of Physicians and Surgeons feels charges should be laid and a college council is to meet in mid September to discuss Dr Gal’s case. The two nurses, Howell and Schulze remain on enforced leave of absence with pay until the Alberta Association of Registered Nurses of Alberta has reviewed that case.
Ron Berger, Dr. Gal’s lawyer has suggested that a civil suit may be launched against certain individuals who have made false accusations against his client. How many, or who these individuals are has not been mentioned.
