The former owner of Chrissie Tomlinson Memorial Hospital, Dr. Steve Tomlinson, told a coroner’s jury Wednesday that a nurse had been terminated following the death of the patient who is the subject of an ongoing inquest.

Dr. Tomlinson was giving evidence at the inquest into the death of Tanya Welcome Joseph, 31, who died at Chrissie Tomlinson Memorial Hospital on Sept. 25, 2010 after undergoing surgery.

Dr. Tomlinson confirmed he was the owner and chief executive officer of the hospital at the time of Mrs. Joseph’s death.

Dr. Tomlinson told the jury that he had been off-island from Sept. 21 to Nov. 2, 2010. When advised of what had happened, he directed his administrator to take statements from everyone concerned and notify the hospital’s malpractice insurer.

When he returned, he conducted his own investigation, looking into the drugs administered to Mrs. Joseph after her surgery, and the hospital staffing at the time.

Records submitted so far showed that Mrs. Joseph had gall bladder surgery, which concluded at 10 minutes after midnight on Sept. 25.

She was in recovery for about 30 minutes before being moved to the ward at 12:40 a.m. At 1 a.m., she received medication for pain. At 2 a.m. she was observed to be asleep and intravenous fluids were replenished.

At 3 a.m. she was observed to be asleep, breathing spontaneously and snoring. At 5:35 a.m., she was found unresponsive.

Dr. Tomlinson said he felt that Mrs. Joseph should have been checked more often.
At the time of the incident, a registered nurse was in charge and there were two nursing assistants on hand.

At the time, there were nine patients and one baby at the hospital.

Dr. Tomlinson said there should have been two registered nurses on duty.

If the charge nurse needs more help, she has the discretion to call in nurses from an on-call roster. “She didn’t, but I am the CEO and I have to take the blame,” he said. “I accept that the nurse failed to do her duty.”

There were 32 nurses on staff, he pointed out, and most of them were registered nurses.

The charge nurse was dismissed as a result of this case, he continued. “She was responsible and I felt she should have made sure the patient was checked more regularly.”

He pointed out that there was also a doctor in the hospital 24 hours a day. The doctor on duty that night was in a room just down the hall from Mrs. Joseph.

He noted that the nurse he dismissed went to the Labour Board and was exonerated.

He said that although he felt from the very beginning that the registered nurse should have checked Mrs. Joseph more frequently, he was not able to tie that together with her death.

“I do not know the cause of death. I do not know if it would have been different if she had been checked more often. There are situations that can occur quickly,” he noted, explaining that there is an adult equivalent of Sudden Infant Death Syndrome.

“There must be a reason anybody dies,” he pointed out, “but medicine is not an exact science and cause of death may remain unexplained.”

The jury has already heard that the surgery itself was not considered the cause of death. Experts have been giving evidence about patient aftercare and the particular drugs administered to Mrs. Joseph.

The inquest, conducted by Queen’s Coroner Angelyn Hernandez, is expected to continue into next week.

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