ER doc flagged Wettlaufer victim death as possible medication error, inquiry hears

An emergency room doctor thought a coroner should investigate an elderly woman's death because she thought it was likely caused by a medication error, the Wettlaufer inquiry heard Wednesday.

Dr. Elizabeth Urbantke said she was concerned when Maureen Pickering, 79, was admitted to Woodstock General Hospital with severe hypoglycemia, or low blood sugar, in March 2014.   

When she discharged Pickering, she told a nurse at the Caressant Care nursing home in Woodstock, Ont., where the elderly woman lived, that when the woman died, a coroner should be called to investigate. 

Pickering was one of eight people Wettlaufer killed between 2007 and 2016, when she confessed to murdering nursing home patients with insulin overdoses after checking herself into a psychiatric facility. She was convicted of murdering eight of her patients and attempting to murder another six.

Pickering died five days after being released from hospital, but Uranantke's red flag about her condition was ignored by Dr. William George, the local coroner who testified Wednesday. He said he didn't think the death was suspicious.

The public inquiry into the safety and security of residents in the long-term care homes system is being held at the Elgin County courthouse in St. Thomas. When the inquiry was called, officials said they hoped to determine how Wettlaufer was able to get away with her crimes without detection. 

'Unresponsive and in poor condition'

Urbantke testified Thursday that when Pickering left Caressant Care in an ambulance, her blood sugar level was 0.4. A regular level is between four and six. The blood sugar was corrected with several injections of liquid glucose.

Urbantke said she didn't consider that the a nurse might be intentionally injecting patients with massive amounts of insulin to kill or harm them. 

"I believe I was thinking more along the lines of a medication error," Urbantke told the inquiry. 

When she arrived at the hospital, Pickering was in bad shape. 

"She remained unresponsive and was in poor condition so we turned to comfort measures, or a palliative care approach," Urbantke testified. 

When Pickering was transferred back to palliative care at Carressant Care after several hours in the emergency room, Urbantke called the nursing home. 

It was nurse Wettlaufer who took the call, noting that Urbantke told her, "It might be a good idea to call the coroner on this one."

When Pickering died five days later, another nurse, Karen Routledge, called the provincial dispatch line for coroners because of Urbantke's suggestion. Urbantke couldn't take the case because she had treated Pickering in hospital, so it was transferred to George. 

No notes, no memory

On Wednesday, George testified he declined to investigate a death or do an autopsy because the woman was elderly and medical records indicated she had had a stroke. 

He considered a medication error as the cause of the low blood sugar, but thought it was a “solitary event” that had happened five days prior to the woman’s death. He concluded Pickering’s death was “foreseeable and expected.” 

Dr. William George, a local coroner, looked into the deaths of two of Elizabeth Wettlaufer's victims in Woodstock, Ont. He testified he did not think he made any mistakes.

On Thursday, Urbantke testified the severely low blood sugar would not have swayed her away from investigating the death. 

But George has no memory of actually speaking to Urbantke or Routledge about Pickering. Despite regulations that require him to keep his notes about deaths, whether he investigated them or not, for 10 years, George threw his out after weeks. 

Urbantke, a coroner since 2004, testified she takes handwritten notes when she's called about a death and has kept all of her notes since she became a coroner. 

George was also called about the death of James Silcox, 84, at Caressant Care in 2007. Silcox was Wettlaufer's first murder victim. 

Even though Wettlaufer herself had flagged the death as "sudden and unexpected," a designation that should trigger a coroner's investigation, George declined to investigate or do an autopsy. Instead, he ruled Silcox died as a result of a fall. 

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