Inquest into death of 29-year-old man reveals gaps in emergency care at Lions Gate Hospital in North Van

A grieving mother says a report from the College of Physicians and Surgeons of British Columbia about the care her daughter received in the emergency room at Lions Gate Hospital did little to explain why her daughter died.

A grieving mother says a report from the College of Physicians and Surgeons of British Columbia about the care her daughter received in the emergency room at Lions Gate Hospital did little to explain why her daughter died.

Ann Forry’s daughter, Natasha Forry, 29, died in October 2020 after a small infection was not detected by doctors until long after it developed into generalized septic shock which shut down already its internal organs.

Forry visited Lions Gate Hospital four times between October 2 and October 12, 2020, with her condition worsening with each visit. She was never given antibiotics but was sent home with painkillers, until her last visit when she was rushed to the intensive care unit with breathing difficulties.

Natasha died later that day.

A report recently produced by a college investigative committee examined the actions of eight doctors who saw Natasha at Lions Gate Hospital, finding fault with just one of those doctors, an emergency physician who saw Forry during her third visit to the emergency room. The college’s Board of Investigation report found that Forry’s vital signs were not checked and documented after treatment, which could have provided an indication of his worsening condition. A “significant drop” in Forry’s “serum albumin” – which may indicate a serious infection – was also “underestimated” according to the report.

The committee noted that the doctor would be asked to participate in an interview to discuss those concerns “and ways to improve care for future patients.”

But that’s cold comfort for Natasha’s mother, Ann Forry, who said she wasn’t convinced the college report would lead to changes.

“Complete collapse of care”

“There is no justice for me,” she said. “It was a complete breakdown of care for Natasha… Twenty-nine-year-olds don’t die like that.

Forry said the events leading up to her daughter’s death at Lions Gate Hospital should be of concern to everyone on the North Shore.

“It’s not just my problem,” she said.

Forry said she thinks her daughter is in the best possible place when she repeatedly visits Lions Gate. “My mistake was trusting the hospital,” she said. “It cost my daughter her life.”

The Investigating Committee’s 18-page report details the events leading up to Natasha Forry’s death. According to the report, on October 2, 2020, the young woman went to the emergency room with an infected cyst in her pelvic region. Doctors drained the cyst and sent her home.

A week later, however, Forry returned to the emergency room with pain in her abdomen and upper leg. Blood tests and a CT scan showed what doctors considered minor abnormalities. Forry was again sent home with painkillers.

A day later, however, Forry was back in the emergency room, with worsening symptoms of pain, tenderness and nausea. The doctor saw no signs of infection, although the possibility was considered, and no further CT scans were ordered. Forry was given painkillers and again sent home.

She returned 11 hours later with her oxygen saturation levels dropping to 85% and was diagnosed with pneumonia caused by a Staph bacterial infection.

Forry was given antibiotics and moved to intensive care, but her condition quickly worsened and she was put on a ventilator with dialysis, as her kidneys were failing. At that time, “metabolic abnormalities consistent with septic shock were noted.” Doctors rushed Natasha into surgery, but Forry’s heart stopped on the operating table. She was revived but her heart stopped again in intensive care and she could not be revived.

A 29-year-old man died of toxic shock syndrome

An autopsy determined the cause of his death to be toxic shock syndrome due to a generalized Staph infection, including ‘necrotizing pneumonia’ as well as other organ damage – an infection that likely spread from initial infection treated in the emergency room.

It is unclear whether the doctor whose standard of care was criticized in the report will face further formal disciplinary action from the college. The college only makes public certain decisions that result in formal disciplinary measures.

But the mistakes made in her daughter’s assessment should never have happened, Natasha’s mother said.


Natasha Forry died in October 2020 at Lions Gate Hospital in North Vancouver after seeking emergency care four times. | courtesy of Ann Forry

“The public should be alarmed,” she said. “If (the ER doctor) had checked his vital signs, he would have seen something was seriously wrong,” she said.

Forry said she thinks people are too willing to assume doctors don’t make critical mistakes. “That’s not true,” she said.

A spokesperson for Vancouver Coastal Health issued a statement on Forry’s death, saying, “We are devastated by this situation and offer our deepest condolences to Natasha’s family and loved ones as they mourn her loss. This incident was tragic and does not reflect the high level of personalized care that Vancouver Coastal Health strives to provide to all of its patients.

VCH cites change in how repeat ER patients are managed

In response to the incident, VCH conducted a comprehensive review, the statement said, which resulted in recommendations, including “the development of criteria for the management of patients who repeatedly present to the emergency room without an established diagnosis. “.

Meanwhile, Forry said that due to B.C.’s wrongful death laws, she didn’t even have the ability to sue the doctor and hospital. This is because the Family Compensation Act only places value on people who have dependents.

Forry wants the province to change that law, saying it prevents families from seeking legal recourse when loved ones die.

Under current law, the message is “my relationship with her, my only child – the person I thought was going to take care of me when I was old – it doesn’t matter. His future doesn’t matter.

Natasha grew up on the North Shore and loved living here, says her mother. “She would always be in the woods or on the water.”

She had many close friends, Forry said.

For her mom, however, the North Shore is now a place that brings only painful reminders of her daughter’s final days.

“A lot of people are heartbroken,” Forry said. “I miss her a lot.”

-with files by Steven Chau

Natasha Forry2
Natasha Forry died in October 2020 at Lions Gate Hospital in North Vancouver after seeking emergency care four times. | courtesy of Ann Forry

Julio V. Miller