Carter Bonsdorf, 9, died after his bowel obstruction wasn’t properly treated at Cowichan District Hospital
On Aug. 17, 2019, nine-year-old Carter Bonsdorf was playing in the water at the family cabin on Cowichan Lake with his younger brother Declan, who was swimming for the first time.
It’s a story, they charge, of racism, medical incompetence, failed communication and failure to follow up on a radiologist’s X-ray report noting a possible bowel obstruction.Despite an internal review of Carter’s death by Island Health and a complaint to the College of Physicians and Surgeons of B.C., the family still does not know why Carter’s condition wasn’t caught and treated.
Tanisha lay on the bed with Carter to try and get him to sleep. “But that wasn’t happening,” she said. The doctor ordered an X-ray but after he looked at it, “we were basically shooed out,” she said. He told them Carter had the flu and to take him home to rest and to give him fluids and Tylenol. Carter was rushed in for exploratory surgery. The surgeon discovered he had a congenital deformity in his intestine, a soft spot where the bowel had punctured it.
“They had an internal review but said they were unable to share because of legislation,” said Tanisha. “It was a huge shock when we went to that meeting and they said: ‘We can’t tell you anything.’ So why are we here then? That was the whole point of the meeting, in my point of view, was to go over what they found,” Tanisha said.
Carter’s medical history recorded on the chart and physical examination were “inadequate,” the college found. The doctor’s charting, which they described as “illegible,” was in contravention of the college standard for medical record-keeping. The report was sent back to the college for reconsideration, “with directions to justify its decision or issue a further disposition.”“The doctor said, and I’m trying to be calm, ‘I didn’t know Carter was Indigenous,’ ” said McMenamie. “This is Cowichan, the largest band in B.C. You have a responsibility as a doctor working in that community to know [whether] people you are dealing with are Indigenous or not and to be culturally sensitive.
“Nobody wrote it down. The trouble with the college, they put a lot of weight on the medical notes. Reading between the lines, they must have believed Carter was tolerating fluids.” “Since 2019, many changes have been made to care in emergency departments within Island Health, including emergency medicine chart documentation, diagnostic imaging procedures and ongoing education and appropriate use of Pediatric Early Warning Systems.”
Carter’s story was never about lawsuits, said Gill, but about trying to prevent something similar in future. McMenamie, who assists at the Anglican Parish of Central Saanich, said his grandson’s death has affected his ministry in many ways.
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