SARS: The chain of errors

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Star investigation reveals litany of mistakes by officials

Lack of infection control, misdiagnosis helped to kill 44

KEVIN DONOVAN AND TANYA TALAGA (TS)

SARS was able to kill and sicken so many people in Toronto because of a litany of mistakes made by hospital and public health officials, a Star investigation shows. The errors include: misdiagnosis; failure to enforce infection precautions;

routinely sending ill people back into the community; the use of an archaic tracking system; lack of leadership; and refusal by the province to share key information with its own scientific advisory team.

The Star's research is based on interviews with more than 100 people involved in the outbreak, including relatives of 20 of the 44 people who died of SARS, nurses, doctors and researchers on the front lines, and senior officials at all levels of government. The Star also used freedom of information legislation to obtain government documents.

Families of the dead told a similar story. Loved ones got sick, usually because they were in SARS-affected hospitals where precautions (masks, gloves, gowns) were not properly used. They developed fever, coughing, chills, aches and returned to hospital. There, doctors sometimes sent them back into the community, saying they did not have the disease, or sent them to other hospitals without a proper warning. Other relatives, plus health-care workers, became infected.

"The hospitals and public health could have saved us all by keeping isolation precautions in effect," Vadim Bychutsky says.

His mother, uncle and grandmother were all killed by the second wave of SARS that originated at North York General in April and swept through the hospital in May. Hospital and public health officials had failed to identify two new SARS clusters on separate floors at North York.

North York General's chief medical officer, Dr. Keith Rose, says his hospital staff worked heroically to battle SARS.

"Nobody knowingly missed any patients," Rose says. "Our physicians used their best judgment," adds Bonnie Adamson, hospital president.

During the original outbreak, Scarborough Grace hospital misdiagnosed James Dougherty, 77, and sent him to York Central Hospital for urgent dialysis treatment. Doctors did not realize he had SARS.

Dougherty lay in the intensive care unit of York Central for 13 days without any SARS precautions, until March 27, when he was isolated from other patients. This, despite the fact that he had been in Grace emergency on March 7 with the first SARS patient to enter the hospital. Dougherty died on March 29.

At least 15 people were infected at York Central as a result of exposure to Dougherty. His wife, visibly ill with SARS, was transferred out of York Central to a nursing home with another patient. His wife survived, but the other patient died.

At the epicentre of Toronto's outbreak, Scarborough Grace hospital, the disease was misdiagnosed and overlooked.

Originally, in early March, the respiratory ailments of five members of one family were dismissed as tuberculosis, despite a hunch by a Chinese-speaking Grace nurse that it was an emerging virus she had read about emanating from southeast China and Hong Kong.

Among those infected at Grace was Joe Grande. His widow, Rosa, is angry with a system that refused to believe her husband had SARS until it was too late.

"Something has happened to my family that I would not wish on my worst enemy," she says.

Joe and Rosa Grande were infected as part of the original Grace outbreak. They visited a sick friend there but were not told to protect themselves. Later, when Grace was closed, a public health official suggested they go to Markham Stouffville Hospital to be checked. They were turned away and told they did not have SARS, although Joe was feverish and coughing so hard he could barely stand.

Public health promised to send them a kit with masks and thermometers, but it never arrived. Eventually, almost too sick to move, they called ambulances to take them to emergency at Scarborough General.

A spokesperson for the Markham hospital said the disease was difficult to diagnose because there was no accurate test. Senior Grace doctors and officials were unavailable for comment.

As the outbreak developed, Toronto Public Health was overwhelmed with the task of tracking people at risk. Many fell through the cracks of a system that used an archaic paper-based tracking method that was not up to the task.

Toronto's chief medical officer of health, Sheela Basrur, who blames chronic underfunding, describes how difficult it was to keep track of the hundreds of exposed patients and thousands in quarantine: "Someone takes the file. Where is the file? Okay, well you look that way and I will look this way. It's the dumbest thing in the world. I can't believe this is the state of affairs," Basrur says.

"It's amazing to me that we have been able to manage the way we have, given that degree of inadequate support on these central functions with basic technology," Basrur says.

Public health struggled along with triplicate paper files and attempts on the fly to create its own computer tracking system.

The Star's research shows that some people at risk, who should have been warned they had been exposed, were not called. Others were called too often. Two families reported to the Star they were called after SARS had killed their loved ones. In both cases, Toronto Public Health called several times to check the person's temperature (after that person had died).

At North York General, the site of the second outbreak, sick patients were again misdiagnosed and some were sent home. The blame for the misdiagnosis falls on the shoulders of both hospital doctors and top researchers called in from other hospitals.

Nurses and doctors with less seniority repeatedly raised warning flags when patients showed up in April and May with what, by that time, were known to be classic SARS symptoms. But lead doctors at North York appeared to believe what the province and top medical experts were telling them: SARS was over and done with.

Although senior North York officials say the hospital did everything right, they have begun making sweeping changes to the way the hospital does business. More doctors and nurses, some with specific infectious disease expertise, are being hired, and the hospital is working on protocols so any concerns of nurses and other staff get to the right place. "This was a wake-up call," says North York's Rose.

The problems at North York can be traced to two clusters of patients with SARS that were discounted until it was too late. One was a group of three patients on the psychiatric ward, the other was a growing number of patients on the orthopedic ward. In both cases, patients had respiratory problems, fevers and coughing. Some died before SARS was discovered.

Meanwhile, the psychiatric ward patients were checked out by a parade of experts, doctors and nurses from Toronto Public Health, top microbiologists and North York's own expert, Dr. Barbara Mederski.

Due to an ongoing judicial inquiry into the outbreak, Mederski has been told by her hospital not to speak to the press.

At North York, a junior doctor sounded numerous alerts, and nurses were also vocal, particularly when five family members showed up with near-identical SARS symptoms. Despite all this, nobody blew the whistle and told the public until May 23, when it was far too late.

Toronto Public Health's Dr. Bonnie Henry says that while they were alerted to the psychiatric patients, they were not told about patients connected to the orthopedic ward (where the outbreak is believed to have started) until May 23.

`Something has happened to my family that I would not wish on my worst enemy.'

Rosa Grande, widow of Joe Grande

"Everybody is at fault for the second outbreak, all of us got caught," says Mount Sinai's Dr. Donald Low, a microbiologist who helped investigate many suspected SARS cases.

Low personally blames himself for ruling out the psychiatric ward cases, although Toronto Public Health's Basrur says she takes the ultimate blame.

The cases, Low says, did not provide a link to a known SARS case and so did not fit the definition, despite the fact the people were very sick. The cases turned out to be SARS, and one woman became so ill she had to be intubated. The North York outbreak spread and claimed at least 13 lives and sickened 118. (The first outbreak sickened 257 and killed 31.)

Within the provincial government, a lack of leadership caused conflict and confusion throughout the public health system. In effect, nobody was in charge during the SARS crisis. Provincial health officials even refused to share crucial data on victims with the province's own SARS scientific advisory committee.

"We desperately needed a general in this war," says Low, who was involved in investigating many SARS cases but had no authority. Low's comment is seconded by fellow microbiologists, Dr. Andrew Simor of Sunnybrook and Dr. Allison McGeer of Mount Sinai, and by Basrur.

In the SARS outbreak, there were many lieutenants: Colin D'Cunha, provincial medical officer of health; Dr. James Young, public security commissioner; officials at Health Canada, the provincial health ministry and others. Low, the approachable, highly respected disease expert from Mount Sinai, emerged as another lieutenant.

Yet nobody was in charge. "If you ask who was leading this, you wouldn't get an answer. There wasn't a leader and there should have been," Simor says. He and others are using this example to press the federal government to set up a Canadian centre for disease control, similar to the vaunted Centers for Disease Control in Atlanta.

Young says he believes he and D'Cunha provided a great deal of leadership, although improvements could be made to better define who does what in an outbreak such as this.

"I think there was leadership and everybody pulled together and acted as a team," Young says. "We did our best. Lots of people knew I was leading my part and they came to me all day with questions."

D'Cunha was on vacation and unavailable for comment. Acting chief medical officer of health Dr. Karim Kurji said he believes one leader is not necessary. Instead, Kurji lauded everybody involved for "pulling together" to combat the disease. He said several leaders emerged with responsibility for specific areas, and that worked well.

The Star found occasions when leaders were reluctant to take action. For example, Scarborough Grace hospital management were determined to remain open despite pressure to close. Finally, on March 23 (the outbreak began March 7 and was clearly identified by March 15), the hospital was closed following consultations between hospital management and provincial health officials. Keeping the hospital open resulted in more infection for families of patients and for health-care workers.

Trying to determine who had SARS caused a myriad of problems, since there was no test.

Hospitals and public health also did not have a clear idea of the risks.

For example, many of those who were infected, some of whom died, were visitors to emergency wards or other parts of an affected hospital.

What seems so obvious to an observer - that sick people hacking away in a cramped ER would infect others - did not register with hospitals until it was too late.

"It never crossed anybody's mind that visitors would get sick," says Mount Sinai's McGeer, who was infected but recovered.

McGeer has tough words for infection control at hospitals, an "underfunded" public health system and for the design of hospitals themselves.

Hospital emergency rooms are poorly designed for infection control, she says.

"People aren't in private rooms. They are in `bays.' Chances are, your face isn't (more than) four feet away from someone else's," McGeer says. "Patients are being admitted and lying in corridors."

The four-bed hospital rooms seen on some wards may make economic sense, but not public health sense, she says.

Open-air intensive care units are also problematic, she adds. Open-concept units allow medical staff to get to a patient more quickly in an emergency, but McGeer says they make it difficult to control infectious diseases. More expensive glass walls are good for infection control and allow patients to be seen.

During the SARS crisis, hospitals quickly found there were far fewer negative-pressure isolation rooms than patients requiring isolation. Patients were either kept in less than perfect settings or sent home sick. Hospitals like Sunnybrook purchased air devices that could turn a normal room into a negative-pressure room.

As to the sharing of data, doctors and researchers say the provincial health ministry refused to share key data with the provincially appointed SARS scientific advisory council, which was charged with the job of investigating and stopping the outbreak.

Members of the committee, including Simor, say the province did not work "collaboratively" with them. The researchers needed key information on specific patients, symptoms, where they got sick and how they got sick, but found it difficult to obtain.

"We were clamouring for the information and they were not giving it to us. The province basically said `It's our data,'" Simor says.

Public security commissioner Young says he was aware of the problem and stepped in at one point to pressure the health ministry to get the information to the council.

The Star's investigation also encountered examples of hospitals, doctors, nurses and public health officials going beyond the call of duty.

Nurses such as Tecla Lin volunteered to care for fellow nurses in a special SARS unit at West Park Hospital. Lin was infected and died.

Doctors and nurses at various hospitals worked tirelessly in a quarantine situation that forced them to wear cumbersome gloves, masks, eye shields and gowns around the clock.

And at Toronto Public Health, people like Toronto's associate medical officer of health Henry went out of their way to help family members who were in danger of falling through the cracks.

In the case of one sick family that was being overlooked at Scarborough Grace (the father had just died of SARS) Henry and Mount Sinai's McGeer saw that the mother, who was the sickest, was admitted to Sinai, and the daughter closely monitored and then admitted herself. Mother and daughter were reunited at Sinai shortly before the mother died.

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