By Keith Lacey
Robert Smilanich was so ill that being deprived of oxygen for only a few seconds could have contributed to his death.
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The key focus of a coronerÂ?s inquest into SmilanichÂ?s death, which kicked off Monday at the Sudbury courthouse, is just how much being cut off from oxygen, even if only for a brief period, contributed to his death.
The inquest heard Smilanich had been diagnosed with terminal cancer of the larynx when he was transferred to the Laurentian site of the Sudbury Regional Hospital in late October 2000.
Smilanich was near death the evening Jan. 26, 2001, when the Laurentian site was undergoing an "oxygen shutdown" as part of a hospital construction project.
The inquest heard a valve which brought oxygen to Smilanich and two other patients in a chronic care ward was accidentally turned off and Smilanich died within minutes of his oxygen being cut off.
The inquest also heard Smilanich's health had deteriorated badly during his three-month hospital stay in Sudbury. It was the opinion of doctors and hospital staff he had only days, or perhaps just hours, to live when his oxygen was accidentally cut off around midnight.
"His death was imminent," said Mildred Wunderlich, the senior nurse in Smilanich's wing the night he died. "It was likely he would not survive the weekend."
Smilanich could walk around, communicate in writing and wasn't suffering constant pain when he arrived in October, but was bed-ridden, couldn't communicate and was on heavy medication and in constant pain on January 26, said Wunderlich.
Wunderlich said the nursing staff were advised in a memo that there would be an oxygen shutdown that night, but she believed "there would be no interruption" of oxygen to three patients who needed it, including Smilanich.
The plan was to use a backup system to continue providing oxygen to patients and portable oxygen containers were brought in just in case anything went wrong during the shutdown, she said.
She had checked in on Smilanich at 10 pm and before her shift ended at 11:30 pm and there werenÂ?t any problems with his breathing or oxygen delivery, she said. Smilanich was having difficultly breathing, but only because he was so sick. He did need help cleaning a tracheostomy tube and she cleaned it before she left for the night, she added.
Before leaving she left a taped recording for the nurses coming on shift informing them that all the patients seemed fine, said Wunderlich.
She was shocked when she got a call the next morning from a hospital administrator informing her Smilanch had died, she said.
Renee Girard, a registered nurse who witnessed Smilanich's last few breaths, said he was gasping for air when she went into his room just after midnight.
The three patients who needed oxygen had been cut off when she first checked on them just after midnight and she immediately called a respiratory therapist to assist, she said.
Within seconds, oxygen was flowing again to all three patients, however, Smilanich didn't recover and was pronounced dead within minutes.
Respiratory therapist Gerry Grimard testified a committee had been created to detail what procedures would be followed during any oxygen shut down at the hospital. Nurses, doctors, building control officials, construction leaders and all other involved staff attended the regular weekly meetings for six weeks before January 26, said Grimard.
The oxygen shut down was scheduled to begin at 11 pm and it was his understanding "it would have no effect at all in the wing" where Smilanich's room was, he said.
There's an alarm system in place if oxygen is accidentally cut off, he said.
A hospital staff member took him downstairs into the hospital basement and showed him how a pipe that provided oxygen to the wing had been turned off, said Grimard.
"I said something like 'Oh my god, how could you miss that'," and the staffer was visibly upset, said Grimard.
Paul Sauriol, another respiratory therapist on shift that night, testified he received a page from a nurse about a problem with a patient "about the same time" he was informed the main oxygen supply had been turned back on around 12:13 am.
The inquest, before a three-man, two-woman jury, is expected to last all week and into early next week. Dr. Shelagh McRae is the presiding coroner.
