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Special Report, Part two: Five-year-old Sam Shalley died suddenly in the Woodstock ER after being wrongly diagnosed with croup

Posted: April 28, 2017

(March 29, 2017)

By: Heather Rivers, Woodstock Sentinel-Review

One of the last memories Melanie Carter has of her youngest grandson Sam Shalley is that of an excited five-year-old who was handed his very first Woodstock library card.

Carter, who Sam affectionately called Gam, will never forget that day and giant smile on her grandson’s face.

“He took it out of his wallet,” said Carter, her eyes filling with tears. “He was so proud he was going to use it for the first time.”

Sam’s mother Megan Shalley said the five-year-old, who died in Woodstock Hospital’s ER on Jan. 14, 2013, had a special quality that is not often seen in someone so young.

“Something in him always saw everything. He would stop to watch snowflakes. He would never rush, even if you wanted him to,” she said.

Despite his young age, Sam, or Samo as he was nicknamed, was well travelled — having been born into a family who had caught the travel bug.

Baptized in Scotland, he travelled to Morocco and Spain on family vacations, and visited the Children’s Museum in Ottawa.

“He’s been on a hundred adventures,” Shalley said. “He’s lived a happier and fuller life than some people will live in 90 years.”

An avid soccer player, Sam had planned to join CAST, a local theatre group his sister Ruairidh belonged to.

But four years after his death, his mother and grandmother are still searching for the answers as to how a healthy child could go downhill and slip away so suddenly.

For years the duo say they have felt largely ignored by hospital officials, and can’t contemplate how the healthy five-year-old could have been misdiagnosed with croup after three visits to the ER.

After leaving the hospital ER in the early morning hours of Jan. 13, Carter and Shalley treated Sam for croup at his Light Street home.

A nurse in the ER had advised them he had croup and Shalley was confident she could treat him at home.

But her five-year-old continued to worsen, and when they arrived at the hospital ER at around 5 p.m. Sam was gasping for air.

Examined by an ER doctor, a throat X-ray was ordered but the doctor found nothing wrong and there was no hint that Sam had pneumonia and not croup.

“He went to Woodstock Hospital with pneumonia, he should have been treated for it,” Shalley said.

No blood tests were taken, but hospital reports said Sam received Ventolin, a drug designed to increase airflow to the lungs.

He was also prescribed dexamethasone, a steroid medication used to treat inflammatory conditions including croup, before being discharged.

Shalley, who was familiar with the drug because of incidents with her other children, asked the ER workers if they were required to stay for six hours after being given the drug.

While standard procedures vary from hospital to hospital, Shalley had been required to stay for six hours at a London Hospital when one of her children required the same steroid.

“I asked and was told we didn’t have to stay,” Shalley said.

Ironically a hospital report from that visit listed the reason for their visit in capital letter as “HE’S NOT BREATHING.”

The report went on to describe Sam’s mother Megan as anxious and was “making the child worse.”

— — —

Natalie Mehra, executive director of the Ontario Health Coalition, said those words on the hospital charts could potentially have changed the way Sam’s health-care providers viewed him during the following visits to the ER unfolded.

“Because of the…. charting and the subjective assumptions about the mother being hysterical, it would have coloured the situation to how other professionals viewed the situation,” Mehra said. “I think it’s very dangerous to do that.”

With events unfolding so fast, within 48 hours, and Sam’s health deteriorating so quickly, Mehra described the situation as a tragedy.

“One might have hoped for some more aggressive interventions,” she said. “In this case I think it was very tragic indeed that the assumption was made that the mother was wrong.”

Mehra also pointed out that back in 2013 hospital budgets had been cut so severely it couldn’t help but affect the ER.

“Emergency departments are extraordinarily busy and understaffed and ER nurses have to work far too quickly,” she said. “It’s systematic and unfair and unsafe.”

Mehra said the evidence is overwhelming that when cuts take place mistakes go up dramatically.

“There is a pressure on the staff to move people out as fast as possible,” she said. “The staff is put into a position where they are not erring on the side of caution.”

Mehra is also surprised the family never received an apology from the hospital until four years after his death.

“The apology law allows hospitals to apologize without it being held against them in court,” she said. “It sounds like this family has had an horrific experience and that shouldn’t be.”

According the 2016 report Under Pressure: Emergency Department Performance in Ontario, released by Health Quality Ontario, people are seeing doctors more quickly when they arrive at ERs but their overall visits are shorter.

The report says ERs are under a great deal of pressure, and can become very strained by a bad flu season or closures in other hospitals.

Overcrowding, it points out, can lead to poor quality of care, increased distress, illness and mortality among patients, as well as increased medical errors by overworked staff.

“Patients may spend hours and sometimes even days lying on stretchers in emergency examination rooms or hallways,” said Dr. Joshua Tepper, president and CEO of Health Quality Ontario.

— — —

Were the pressures today’s ERs now face part of Sam’s story?

What we know is by the morning of Monday, January 14, 2013 Sam’s condition had worsened so much they headed back to the Woodstock ER where his family was assured he would get better.

Part three of this series examines the two hospital visits on the following day, and the tragedy that was looming.

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