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“We believe the changes … will make our care safer in the future and improve our disclosure process when errors do occur.”

The hospital said it is sorry for the mistake and “any harm that may have occurred,” but relied on the coroner’s original finding that the death was natural, and failed to see the revised report for months.

Though it’s almost unprecedented for such a case to come to the fore, it highlights the veil that shrouds much of health care’s harmful slip-ups. Studies have estimated that as many as 23,000 Canadians die yearly because of preventable medical error at acute-care hospitals alone, but a National Post review earlier this year found that only a tiny fraction of those cases are ever reported internally, let alone disclosed publicly.

The 85-year-old patient was admitted to Grand River in June 2010 with a suspected bowel obstruction and prescribed 1-2 milligrams of dilaudid every three hours, to be given by “subcutaneous” injection. But the drug was mistakenly administered by IV instead, changing the potency of the treatment.

The man, who is not named in the board’s decision, suffered depressed breathing, contracted pneumonia and died the next day.

Sharma, an emergency physician, and other hospital officials later insisted the mistake had nothing to do with the patient’s passing.

That was the conclusion of the coroner’s investigation, too, until the family passed on information about the timing of blood tests, the appeal board ruling said. The coroner later issued a new statement, saying death probably resulted from “narcotic overdose.” The family, meanwhile, complained to the college.