On the path from shock to grief, Rebecca Bonnell visited her obstetrician for a routine appointment about a month after her newborn son’s death in December 2014.

She and her husband, Patrick, believed Kieran, their 8-day-old infant, had died of an E. coli infection that could not have been prevented.

“How could staff at Mackenzie Health in Richmond Hill miss the E. coli diagnosis?” she asked her doctor.

“They knew he had E. coli,” Rebecca remembered her doctor telling her.

“No they didn’t,” Rebecca said, “not until the end … when it was too late.”

“No. They knew (five days before his death). The blood test result is right here.”

She gave Rebecca a copy of Kieran’s chart.

“It was like someone shot me in the chest,” Rebecca recalled. “I couldn’t believe it. … It was so painful finding out he could have lived.”

The next day, Rebecca drove to the hospital to get Kieran’s medical records, then parked her car in the lot of a nearby mall and anxiously opened the envelope. “I sat there in the car for two hours, in shock.”

In a $900,000 civil suit filed in court, the couple allege they independently discovered the reason their child had died: A blood test result was apparently never seen by doctors at the time Kieran was struggling for life.

After confronting the hospital, the couple were told Mackenzie Health officials had also identified the problem in an internal audit a few weeks prior and were about to call the couple, according to the statement of claim.

The hospital issued a rare written apology to the couple acknowledging the mistake.

Allegations in the couple’s statement of claim have not been proven in court and no statement of defence has yet been filed by Mackenzie Health.

Hospital officials declined an interview, citing the case before the courts. But in a written statement, a hospital spokeswoman, Melina Cormier, said: “Mackenzie Health is committed to continuous open, honest, and transparent communication with patients and their families relating to all incidents. … When an incident occurs, the hospital analyzes the incident and a plan is developed with systemic steps to avoid or reduce the risk of further incidents. This plan is also shared with the patient and/or family.”

The hospital’s response was too little, too late, Rebecca said.

“If they had just showed us they were making policy changes and make a sincere statement that, ‘We messed up and we’re fixing it,’ it would have made a big difference,” Rebecca said. “If a hospital is open with a family and welcomes them in and helps them get answers, people are way less likely to sue. We know mistakes happen. We’re not dumb. And we’re willing to forgive. But if they offered openness, it would have meant so much to us and our grieving.”

The Bonnells’ story is surprisingly common in Canada.

“Adverse events,” in the parlance of physicians and hospital administrators, affect tens of thousands of Canadian families every year.

A seminal study in 2004 concluded that 7.5 per cent of all Canadian hospital admissions end in adverse events — 185,000 cases a year, of which nearly 70,000 are potentially preventable.

In many cases, patients and families never know an error was a factor, in part because of a professional code of silence.

“The question for the public is when and if Mackenzie Health would have approached the Bonnells with this laboratory result and offered a proactive apology rather than a reactive apology,” said the couple’s lawyer, Mark Johnston. “Their hand was forced to make this apology by virtue of the lab results pointed out to them by the Bonnells. They had no other alternative.”

‘He got it from my body’

Kieran was born Dec. 7, 2014, welcomed to the world by instantly love-struck parents. Rebecca and Patrick took Kieran home to a room that had been carefully prepared with blankets and stuffed toys, star lights, a new crib and freshly painted walls.

He wouldn’t be there long.

During those first days, Kieran lost weight and began to act strangely — panting, clutching and clenching his jaw.

The couple returned to Mackenzie Health, where Kieran was diagnosed with jaundice. Doctors ordered several blood tests, the statement of claim reads.

One determined that the source of his breathlessness and “seizure-like behaviour” was E. coli. That information could have saved his life if doctors had acted on it, the couple say.

Loading... Loading... Loading... Loading... Loading... Loading...

That test result — conveyed over the phone by a laboratory technologist at Sunnybrook Microbiology Lab to a nurse at Mackenzie Health at 2:50 p.m. on Dec. 10 — was never seen by physicians, the Bonnells allege in their lawsuit.

“If someone did read it, there is no record of this or any indication that anyone acted upon the information,” the statement of claim reads.

The next day, at 1:27 p.m., a confirmation result was formally reported in an “Outpatient Summary Report,” according to Kieran’s health records and the couple’s statement of claim.

Still, doctors at the hospital puzzled over the baby’s illness without treating the infection that would kill him, the suit alleges.

On Dec. 13, as Kieran grew increasingly ill, he was transferred to the London Health Sciences Centre. New tests were conducted there, “confirmed E. coli infection causing septicemia and meningitis that effectively destroyed all useful brain function,” the statement of claim reads.

“I thought, ‘Oh my God, he got E. coli from the formula,’ ” Rebecca recalled. “They said no, when he was born, he got it from my body. … He got it from me.”

Preparing for a child’s death

“We knew there would be brain damage,” Patrick said. “We hoped he would be well enough to stay with us. Then they put out the facts that there’s no chance that he could be happy or laugh or play. There was a heart beat. He could feel pain. But nothing else.”

Rebecca asked the doctor if her newborn son was in a vegetative state.

“Yes,” came the answer.

“We knew we wouldn’t make him suffer like that,” she said.

Palliative care was all that was left to be offered.

Crushed, the couple agreed to withdraw life support about 11 a.m. on Dec. 15.

As Kieran’s life slipped away, the parents took turns holding him.

“He would gasp for air and cry at the same time,” Rebecca said. “His body was trying to live. But his brain was so damaged. It was horrible. We held him while he gasped for seven hours.”

The family was together as Kieran took his last breath, a trickle of blood dripping from his nose.

“I just watched my baby die in my arms,” Rebecca said. “You’re just in shock. Time freezes.”

They avoided returning home for a few days, choosing to stay with friends to avoid the emptiness of their Richmond Hill home with its carefully appointed room for Kieran and the present overflowing beneath a Christmas tree for their child’s first holiday.

Instead, there was a funeral to plan. It was held on Dec. 20.

Tucked inside the child’s small casket was a photo of the couple standing together against a brilliant fall panorama of colours, his blanket and pacifier and a cheery blue stuffed rabbit that accompanied him during his short life.

A shocking discovery

In a letter to the couple dated May 22, 2015, Altaf Stationwala, the hospital’s president and CEO, wrote of “how sorry we are for this error and for the loss of your son Kieran.”

An investigation had found “the system for critical results reporting for discharged patients from the Emergency Department was found to be faulty and resulted in the result not being escalated,” the letter reads.

The nurse who received the result “is aware of the incident,” the letter reads. “She has no recollection of receiving this specific call nor was she aware that day, that it was a result of (a) newborn. She is devastated by the news and has volunteered to be part of the process improvement … to develop a better system.”

The letter also confirms the hospital’s emergency department has introduced a log book for “abnormal laboratory phone calls” and taken steps to review the “current process of laboratory calls and identify opportunities for improvement.”

It is a coming clean that the Bonnells call disingenuous.

Two months earlier, hospital officials had promised clear answers to their questions.

“Then they went dead silent,” Rebecca said. “Every single day, all day I waited, wondering what the answers would be. And then I call and they treat me like an annoyance. It was cruel.”

Patrick and Rebecca know a lawsuit won’t bring back their child — a court could never heal their grief.

But they seek transparency about what went wrong and an assurance that the hospital has taken measures to ensure others don’t suffer as they — and especially Kieran — did.

“I’m more interested in action than talk. Talk doesn’t do anything to stop this from happening again.”

More than a year after his death, the couple visit Kieran’s gravesite every Sunday.

They planted flower bulbs in spring. They have picnicked next to it. They bring toys and place them lovingly.

“We do things for him, we talk to him. We know he can’t hear us. But it’s a way of being parents to him,” said Rebecca, who gave birth to the couple’s second child on Monday — a healthy, leap year little girl named Lorelei Christine.

Read more about: