Double mastectomy leads to 'calamity of errors,' review of home care

Lynn Burkitt asked for a double mastectomy, hoping to rid herself of worry after a scary bout with breast cancer.

But what the 52-year-old from Medicine Hat, Alta., got instead was a series of surgeries and mishaps that left her with a gaping, infected abscess in her chest. Two rolls of packing gauze were left rotting inside her, undetected by home care staff.

"You could've put your fist inside my chest," Burkitt said of the initial abscess. "They have made such a mess of my chest that I look like a freak."

The open wound is now the size of a poker chip, slowly healing but still debilitating the Alberta woman.

"If I had known what was going to happen, I would never have done [the double mastectomy]," she says now.

• Hear Lynn Burkitt talk about the medical mistake that happened during her mastectomy:

Burkitt's case caused Alberta Health Services to review procedures at Medicine Hat Regional Hospital and institute new rules for communicating more clearly with home care.

It has also shed a new light on the burgeoning world of home care services. A recent study published last month by in the BMJ Quality & Safety journal estimated that one in every 10 patients in home care experiences an adverse event and that more than half of these events are preventable.

The number of patients recovering in their own homes instead of hospitals is exponentially rising as hospitals try to reduce overcrowding and expensive lengthy hospital stays. Last year, an estimated 1.4 million Canadians received home care, a 55 per cent rise from three years earlier.

'Felt like it was on fire'

Burkitt's woes began in 2010 when she underwent radiation therapy on her right breast following a diagnosis of ductal carcinoma in situ (DCIS), a common type of non-invasive cancer.

Less than two years later, in January 2012, her right breast became swollen and hot to the touch. Doctor after doctor examined it and suggested a myriad of possible causes from shingles to a return of cancer.

When Burkitt had a mammogram, there was no sign of cancer but still the pain persisted. With a strong family history of cancer, she said the fear weighed heavily on her.

"I just said, 'You know what, give me a double mastectomy because this way I don't ever have to worry about cancer coming back'."

On June 6, 2012, Burkitt underwent the operation at Medicine Hat Regional Hospital. Within days, she felt ill.

Burkitt underwent a second surgery to drain an infection. After that, she felt much better and recalls calling her doctor a hero. But in the coming weeks, more troubling issues began.

"My breast was very red, very swollen," she says. "The smell was just horrific. It's hard to even describe. It just smelled rotten."

"It was extremely painful. I could hardly move. I've never felt so terrible in my life. … My whole right side just felt like it was on fire."

Home care nurses took care of Burkitt every day, but "it was getting worse and worse," she says.

Hospital reviewed patient safety

She made multiple trips to the emergency room and doctors prescribed antibiotics, but it wasn't until she underwent a third surgery that the culprit was found.

"When I came to, I found out the second surgeon had left two rolls of packing tape inside of me that rotted and they had to pull it all out," said Burkitt. "So I ended up with a big hole in my chest, which has not healed."

While it’s normal procedure for a surgeon to leave packing gauze in an open wound, that packing must be changed on a regular basis.

Medical experts suggest that home care nurses should have seen the gauze sticking out of the abscess and replaced it daily as the wound slowly healed from the inside out.

But Burkitt says home care staff didn't see the gauze deep inside the wound because the surgeon stitched the sides of the wound together, obscuring it from view. Also, she says there was no documentation passed along to alert caregivers of the packing gauze.

In a letter dated Jan. 10, 2013, Alberta Health Services apologized for Burkitt's experience with the packing gauze and vowed to review its processes to prevent such a situation from happening again.

Burkitt said she asked the hospital months ago to detail what changes had been made, but never heard back.

Alberta Health Services told CBC News that it conducted a patient safety review at Medicine Hat Regional Hospital into continuity of care and communication among caregivers.

"A number of steps have been taken to ensure patient safety in similar circumstances," the written statement said.

'Calamity of errors'

The health authority says that among the changes being made at the hospital is a new "visual alert" on patient charts to alert caregivers to special needs. It is also educating employees on the need to document instructions when patients transfer between parts of the system.

Nadine Henningsen, executive director of the Canadian Home Care Association, said Burkitt's case sounds like a "calamity of errors."

"It seems that if anything could go wrong, it did go wrong," she said.

Home care brings the added benefit of helping patients avoid potentially dangerous hospital-acquired infections and recouping in their own surroundings.

But with acute-care patients discharged earlier and earlier, workers in the home-care sector are dealing not only with more patients but also with more serious wounds. The combination has left many areas open to improvement.

Henningsen notes that, as in Burkitt's case, "communication is usually one of the biggest challenges that break down when you're transferring from one setting to another."

In fact, one of the biggest issues identified in the Safety At Home: A Pan-Canadian Home Care Study was lack of coordination across health-care sectors and failures in communication.

As for Burkitt, she says that lack of communication had a devastating effect for her.

Her relationship with her partner suffered, she's been unable to work for the past year and daily dressings prevent her from leaving town to visit family members.

Also, she can't wear a prosthesis or bra because of the hole. As she says, "It robbed me of over a year of my life."