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Missing Medical Records: Evidence points to Cardston Alberta Doctor's involvement with Ezekiel Stephan during his stay at Lethbridge Hospital

6/18/2019

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Missing Records

Court of Queen's Bench heard Monday that almost all records of a visit by 18 month old Ezekiel Stephan to the Chinook Regional Hospital were missing.  

On March 14th, 2012, 18 month old Ezekiel Stephan entered the Chinook Regional Hospital with a medical team from Cardston Alberta.  What was supposed to be a routine stop over on their way to Alberta Children's Hospital quickly became every parents nightmare.  
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David and Collet Stephan left their 18 month old baby boy in the hands of medical professionals at a rural hospital in Cardston Alberta.  Their son had suffered a sudden respiratory arrest and had been rushed to meet an ambulance before entering the care of medical staff.  Ezekiel was stabilized at the hospital and was prepped for transport to the Alberta Children's Hospital.  His parents were told to meet him there.  
On Monday June 18, 2019 in the Court of Queen's bench Dr. Shauna Burkholder directed the Court to evidence of a Severe Cardiac Event in the Lethbridge Hospital that took place during the period where records are missing. 

​She pointed out it was the result of a mistake by Dr. Alexander Cunningham where he has began to ween 18 month old Ezekiel Stephan off a medication he was relying on to live.
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Dr. Sandy Cunningham
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Doctor's notes showing that there was an attempt to wean 18 month old Ezekiel off Epinephrine while he was critically ill and during transport from the Cardston Hospital to the Calgary Children's Hospital.
PictureDr. Shauna Burkholder
The time where almost all records are missing for about 1.5 hours, was during Ezekiel's stop over in the Lethbridge Regional Hospital.  Dr. Shauna Burkholder testified that the staff were too busy assisting Ezekiel to keep records at this time. 

Medical records showed that there were at least; 3 doctors, 3 nurses, 3 EMS, 1 respiratory therapist, and the night staff of a regional hospital present during this time.  Almost all records from 00:25 to 01:40 on March 14 2012 are currently missing.  Dr. Shauna Burkholder was on the phone directing his care during this time.

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First week in review: Chaos, shocking revelations and perjury at its worse.

6/15/2019

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Ok, so this is a tough post.  It was tough to watch and its going to be even harder to express what I saw as I sat in the court room.  Eye opening for sure. 

At times I have thought there is no humanity! But then I see the absolutely heart wrenching efforts of a father standing at the front of a room against all odds, doing everything he can to shelter and protect his wife and other 4 children.  And I melt.  

The finger pointing has started.  There is a lot of it.  It seems that every medical professional involved remembers things about what the others have done wrong but when a question comes up about their conduct they either can't remember or are suddenly unqualified to speak to the event.  

I'm going to break it down for you:
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Source: Lethbridge Herald. David Stephan interviewed outside the Court House in Lethbridge Alberta
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Day one
No Symptoms; more questions than answers.

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Day one of the trial was not a surprise. 

Registered Nurse and friend of Ezekiel's mother, Terrie Shaw testified that she visited and checked Ezekiel's vitals. 

Collet Stephan had complained that he was more tired than usual and appeared to be achy with muscle stiffness.

Terrie testified that there was nothing she could see of concern and that if Collet wanted to know more then to take Ezekiel into a doctor.   They looked up viral meningitis as a possible reason for the muscle stiffness but Ezekiel did not have the symptoms to match that either.

Answers and clues: Quite literally, nothing lined up

Ken Cherinowski, paramedic testified:
  • the EMS had not secured the endotracheal (breathing)  tube. 
  • That they were driving while holding it by hand. 
  • That a mass of air had entered Ezekiel's stomach as a result of too much pressure on the bag valve mask or possibly and endotracheal tube being placed in the esophagus rather than the trachea.  
  • The bag valve mask and laryngeal mask would not seal or get "Chest rise" because they had been destocked and they did not have pediatric airway supplies.
  • The PCRs were left "open" for days after the incident and not finalized.  This was for "accuracy" so they could add stuff later.
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X-Ray showing a mass of air in Ezekiel's stomach that was forcing his left lung, heart and trachea to the right.

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Dr Lloyd Clark testified:
  • ​That his medical report was wrong.
  • That Dr. Cunningham's medical report was wrong.
  • That his recorded conversations were wrong.
  • That the Cardiopulmonary Report was wrong.
  • That his testimony from the last trial was wrong.
  • That his memory was not accurate and the medical records were important.
  • That all the documents showing he was involved in an intubation in the back of the ambulance were incorrect and that the intubation did not happen.
  • That the Ambulance achieved an airway before arrival, this in spite of a recorded conversation being played that had him discussing the ambulance issue as 12 minutes of travel without getting air into 18 month old Ezekiel Stephan.

A concern was raised over Dr. Clarkes previous notoriety which he earned in 2018 when he made some hard remarks to a group of homeless Natives in the small Southern Town of Cardston Alberta.  News of his actions made national headlines.   
  • ​Dr. Lloyd Clark testified that it was because of the Stephan's case that he had misbehaved during this time.
  • He then accused a member of the Stephan Family of calling him a murderer and perjurer on social media.  
  • He then testified that after hearing that the case was going back to court that he felt the need to seek legal representation.  (His Bennet Jones Lawyer accompanied him to court where he indicated that he would likely be representing Dr. Clarke in the civil litigation to follow the trial)
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Facebook post referred to by Dr. Lloyd Taylor Clarke.

Dr. Clark then continued on with his testimony.  When asked to identify an X-ray he had ordered and interpreted he testified:
  • he was unqualified to give testimony on the film.  
The justice promptly straightened him out. 

The Xray seen to the right shows a zoom in on the trachea.  You can see on the film that the trachea, lungs and heart are all offset to the childs right side.  

This could create catastrophic "intubation difficulties".
You can aslo see a dark spot in his trachea about the same size as the intubation tube.  In the autopsy photos a deep gouge was found directly below this spot.  

The medical Examiner would later testify that Ezekiel did not have an infection in his lung.  It formed only on the outside of the lung.  It is believed that the intubation tube placed in the back of the ambulance in the ambulance bay punctured Ezekiels Plural Cavity and created the infection.
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X-Ray taken of Ezekiel Stephan shortly after arrival to the Cardston Hospital.

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Dr. Clarke was asked if he knew anything about a tracheal tear.  He responded that it was the first time he had heard of it.  

He was then shown the contents of the social media post he had complained about.  The contents were exclusively limited to discussion surrounding a tracheal puncture.  

At this point he claimed he was not qualified to speak to the difference between a tracheal tear and a tracheal puncture.  

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text from the trial transcript where Dr. Lloyd Clarke testified on his first day that he was involved in the intubation in the back of the ambulance. He later recantted the testimony saying that he had forgotten what happened that day and now had a better memmory of it.

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$20,000.00 Reward for New Information on events that took place in the Lethbridge Hospital

6/9/2019

21 Comments

 

Thank you !

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Thank you to the individuals who have provided information thus far. Many people from AHS have come forward and have either provided information or told us to stop digging.  Either way its been telling and has assisted us in determining who and what we need to focus on in the coming weeks of trial.   

There is a current claim that Medical staff were too busy to document during this time.

​Medical expert Shawna Burkholder testified of a severe cardiac issue while Ezekiel was in the Lethbridge Regional Hospital.  She indicated this was a result of a Doctor from Cardston reducing Ezekiel's medication.   The records surrounding this time are undiscoverable!  We need your help!
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Paternal Grand Father of Ezekiel Stephan is offering a $20,000 Reward to the people who provide new information about what happened to Ezekiel Stephan at the Lethbridge Hospital.

$20,000.00 Reward

Missing medical records have left large gaps in Ezekiel Stephan's care.  Missing blood culture reports, un-finalized PCRs, missing charts and logs are all issues currently being dealt with during the Stephan trial. 

Most concerning are is the fact that there is a large gap in records while a severe cardiac arrest was taking place, and evidence of a lethal overdose has been found.
You or someone you know knows something about this case. Please contact us gordonrockinvestigations@protonmail.com ​ 
​This Family needs your help.

Missing Medical Records from the Chinook Regional Hospital

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Transfer records show that Ezekiel Arrived at the Lethbridge Hospital at 00:25 on the 14th of March 1012
​Court heard this week that Logs, charts and recorded phone calls from the Cardston Alberta Hospital all showed promise of a full or near full recovery for Ezekiel Stephan. 

Ezekiel Stephan was transferred from the Cardston Alberta Hospital to the Lethbridge Alberta hospital.  During transport, records show that he improved continually.
Here is where it gets sketchy.  Medical logs, charts and records are almost entirely missing from 00:25 to 01:40.

During this time notes from other doctors at the Alberta Children's Hospital record numerous procedures and a now uncharted Cardiac Arrest.   No charts, logs or records have ever been provided for over 55 minutes of this time frame.  We do not know the identities of who witnessed the events at the Lethbridge Hospital and Alberta Health Services is claiming they have turned over all of the files that are now in their possession.
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Transfer records show that Ezekiel left the Lethbridge Alberta Hospital at 01:40 on the 14th of March 2012
The record below shows knowledge of an uncharted Cardiac Arrest that took place at about 00:50 in the morning.  Right in the middle of the time where records are missing.

Cardiac Arrest Took Place In Hospital  : no charts, logs or records available

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Alberta Children's Hospital PICU record showing that medical staff were aware of a Cardiac Arrest that took place during the time that missing records would have charted.
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ED chart showing that Ezekiel was admitted to the Lethbridge Hospital at 00:29 on March 14 2012.
Records provided from this time frame have the attending physician stating "I was not involved..." Leaving the Stephan family wondering what he wasn't involved with.  The ER Doctor who lives next to Ezekiel's grandfather now claims to have no memory of the events that took place that night.

No one has been willing to talk and the Medical Doctors who were involved have all now lawyered up with the legal firm Bennett- Jones.  

​

Ezekiel Stephan did not have Meningitis.

Newly acquired medical records show that Ezekiel did not have Meningitis.  This new information paints a grim picture of events that took place in the Lethbridge Regional Hospital.
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Dr. Shauna Burkholder's notes showing that after rewarming Ezekiel he began to breath on his own. Then an uncharted dose of Rocuronium was given before he entered a severe cardiac arrest that was uncharted.
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Dr. Aoife O'Carroll was noted in a conversation indicating 0 objective evidence of an infection and that the CT scan ruled out meningitis.

What you need to know

Medical records we do have Identify a number of individuals who were present or in contact during the events that took place on March 14, 2012 at the Lethbridge Regional Hospital ( now Chinook Regional Hospital).
  • Dr. Sandy (Alexander) Cunningham - Currently practicing in Cardston Alberta
  • Paramedic Lou Labrash - Currently listed as residing in Nanton Alberta and working in Calgary Alberta
  • Dr. Jack Regehr - Zone medical director for Alberta South (Lethbridge Alberta) and currently living in Magrath Alberta
  • Dr. Shauna Burkholder - Pediatric  Intensivist at Alberta Children's Hospital
  • Dr. Naminder Sandhu - Currently working at Alberta Children's Hospital.
  • RN Rob Briltz - Currently working at Alberta Children's Hospital
  • RRT Nathan Shewchuck - Currently working at Alberta Children's Hospital
A number of other nurses and medical practitioners would have been on hand during this emergency and would have a personal knowledge of the facts. 
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Stephans get "Rooked" by Alberta's Top Justice.

6/1/2019

3 Comments

 
Friday May 31, 2019 saw three hearings in the Lethbridge Court of Queen's Bench involving the parents of Ezekiel Stephan.

My head is still reeling from what I witnessed.  I can only describe it as confusion, misrepresentations, strategic maneuvering and a complete lack of professionalism on all accounts.  

Here's the breakdown of what took place:
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If all else fails, employ "Judicial Misconduct"

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  1. Associate Chief Justice for the Province of Alberta John Rooke enters and announces that they will be dealing with 3 applications.
  2. Crown stands up confused and indicates that they are only aware of two applications.
  3. David Stephan stands up and confirms their were only two applications filed with the Court.
  4. Justice Rooke blames David Stephan for not providing a copy of his recusal application to the Crown and says we are moving ahead.  He says that the Application was filed.  Clerk can't find the application.
  5. Court Adjourns for a 10 minutes for David to prepare.
  6. Court is back in and David explains that he does not have any of the materials needed to and offers to play this as an explanation.

      7.   After being exposed for intentionally creating the issue in his Court, Justice Rooke lost his temper and declared, he is aware of the recording and they may not play it.  It's not illegal but was improper...
       8.   Justice Rooke rules that the Stephans must now ask permission before speaking with Court officials.
       9.   Justice Rooke directs the Recusal application to run without notice or materials required to run the application.  
     10.   Justice Rooke does not allow the Stephans to read the application.
     11.   With nothing being entered onto the record, justice Rooke dismisses the Recusal application.

"Rooked" with no hope of success

Having strategically dismantled the Stephan's ability to force his recusal, Justice Rooke now had nothing to prevent him from moving ahead as the Justice over the other two applications.

During the application to allow an adjournment for Ezekiel's mother's lawyer to attend, her lawyer stood to assist her.  He was told to sit down and was not allowed to participate further in any of the hearings.  

Justice John Rooke then dismissed the application for adjournment required for Ezekiel's mother to have counsel attend.  She sat quietly wiping tears from her face for the remainder of that hearing.  As of right now Collet Stephan will not be allowed to have legal counsel during her trial.

The Stay Application

The stay application was interesting.  It started with David Stephan presenting a note from the Office of the Medical Examiner as an exhibit.  In this note the writer noted that Valerie Wallace from the Crown's office called to ask if the Medical Examiner was aware of some evidence being sought by the Defence counsel. 

She then proceeded to tell the writer that she did not want the evidence sent to her or for the ME's office to acquire it.  She just wanted to know where to find it. 
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The Office of the Chief Medical Examiner in Calgary Alberta Canada
David drew the conclusion that this was an attempt to avoid obtaining evidence which the Crown would be required by law to turn over to the Defence.   It was also evidence that the defence was not able to acquire during the first trial.

No records kept or logged during a severe cardiac arrest?: Application for stay

David Stephan was given about 35 minutes for this application and as a result had to literally tear pages of documents and arguments from his brief.

The evidence presented boiled down to three basic documents and then other documents that also spoke to the same factors.

Logs on arrival to CRH

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Logs showing arrival to the Lethbridge Regional Hospital. Ezekiel had improved throughout transport.

Gap in records

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Logs showing transport from Lethbridge Regional Hospital to Alberta Children's Hospital.

Cardiac Arrest During Gap in Records

Stephan's argument was simple; It's not reasonable to believe that because a child goes into Cardiac Arrest a hospital would then cease to log medications, vital signs, times or other critical information.  The records are being withheld.
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Notes of a Cardiac Arrest during Ezekiel Stephan's stay at the Lethbridge Regional Hospital. Medical charts and other records surrounding this time have not been turned over to the Stephans after 6 years of asking.
Stephan quoted Supreme Court case law stating that in the case of missing third parties records a stay was the only relief.  Justice Rooke dismissed the application with what appeared to be very little consideration for the law or facts presented.  
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