Saturday, November 14, 2015

The Coroner's Report

This Wednesday, November 11, after nearly 23 months, the investigation into Anya's death was closed. I should note that I received the report only nine days after filing an official complaint about the delay, so there's probably a lesson here about the necessity of complaining to get things done.

Here's the body of the text (click to make this bigger)

A summary: Anya died of severe perinatal asphyxia (lack of oxygen). The pregnancy was adequately followed, given the information that was available at the time. While Anya's size and weight was normal, a couple of things suggested a delay in where the pregnancy should have been: her bone density was not what would have been expected, and the size of the placenta was small, which presented placental insufficiency (a side note: this may have been due to clotting, from an undiagnosed issue - see Kayleigh's post here).

The endotrachael intubation (placing a tube to help deliver oxygen) presented difficulties. The sole recommendation is for the birth centre to ensure that revival skills are maintained, particularly for intubation.

Well, here it is. It's over now. There's nothing else pending, nothing else to expect. Where do we go from here?

Some of the same old questions keep coming back, after reading this. Principal among those: what if we had been in the hospital?

But other questions are, at least, answered. There doesn't appear to be anything we could have done to have known that anything was wrong. I am satisfied that we made the best possible decisions with the information that we had.

The report gives us a smidge of closure. We know now that Anya was born at 6:58 AM, and died at 7:54 AM. She had all of 56 minutes of life in this world.

There are a few questions that I feel I should still strive to find answers to, but I am not sure that I have the heart to do the necessary followup to force answers:

  1. What possible reason can there be for a two page report to take 23 months to complete? 
  2. Why was Anya's autopsy conducted in Montreal rather than in Ottawa at CHEO? 
  3. Why was I not offered the option of staying with Anya in the ambulance and at the hospital?

The ball's in my court.

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