When an ambulance took David Lippert to the hospital in March of 2023, the 68-year-old Kitchener, Ont., executive was hoping to find out why he was feeling weak and unable to walk.
Some 24 hours later, he was found unresponsive by hospital staff in the ER, having vomited blood in the emergency room, while on a list to be admitted. Medical records show he suffered a cardiac arrest. He was later pronounced dead.
His widow, Lisbeth Lippert, is hoping for an investigation into the incident that could lead to improvements in the state of ER care for others.
"I just wanted him to be in a place where I thought he was safe,†she told CTV. "It’s just his worst nightmare to die in the ER."
Lisbeth says the ER was chaotic when she stayed with her husband on the first day. He was placed near the nurse's station where she says she heard them taking calls from other staff calling in sick. It was clear, she said, that they were understaffed and overwhelmed with patients who were waiting for care and lining the ER hallways.
"They were running around like crazy. I don't know how you would even maintain that as your career for any length of time," Lisbeth said, adding she saw the nurses and orderlies doing their best.
She said her husband was promptly tested and doctors ruled out a heart attack or stroke. However, they did find that he was seriously anemic, with a hemoglobin level of 40. They suspected a gastrointestinal bleed.
David was on a blood thinner and had other medical issues.
Lisbeth says he was given a blood transfusion, and that he wanted to go home. He stayed, and later, agreed to be admitted, according to medical documents. His blood count was still dangerously low.
At 7:30 a.m. the next morning, on March 14, Lisbeth, who had gone home to sleep, says she was called and told David had an "event" in the ER.
Lisbeth Lippert tells CTV News she wants an investigation to shed light on her husband's death while in hospital in 2023. (Avis Favaro / CTV News)
It took her almost a year to get the full hospital files on her husband, but the notes show he was found on his ER gurney having vomited blood and in cardiac arrest. Medical teams called a code blue and gave him four rounds of CPR. He was taken to the ICU, but they found him non-responsive. He also suffered seizures and had signs of brain damage from an extended lack of oxygen.
That’s when, she said, specialists in gastroenterology tested him and confirmed he had been bleeding internally.
According to medical records, David agreed to be admitted at around 12 a.m. There were no updates to his file until he was found that morning.
"Where were the GI doctors? Were they called?" Lisbeth asked.
CTV News reached out to the hospital for comment. While officials there said they can't comment on the specifics of the case, they did provide a statement.
“We offer our condolences to the family and encourage them to reach out directly to our Patient Relations team," said Brandon Douglas, Vice-President of Clinical Services at St. Mary's General Hospital.
Two ER doctors who were permitted to see the medical notes told CTV News the case raises questions about staffing and overcrowding as possible contributing factors to why his cardiac arrest wasn’t caught earlier or prevented.
"In a functioning health care system, someone with a GI bleed and a hemoglobin of 40 is admitted promptly... you have an example of a man who should not have been in the ER for at least 22 hours before arresting," Dr Blair Bigham told CTV News. Bigham is also an assistant professor at the University of Toronto's Dalla Lana School of Public Health.
“It increases the risk of people dying," said Dr. Michael Howlett, an emergency doctor in Oshawa and the president of the Canadian Association of Emergency Physicians, referring generally to longer wait times in the ER.
Howlett says he supports Lisbeth's call for an investigation.
"It's a person who has a prolonged stay in the emergency department that has a hidden, serious, life-threatening health problem that undergoes significant time and delays... It’s a system in crisis," he said.
A picture of David Lippert, who died in a Kitchener, Ont. ER in March, 2023. (Avis Favaro / CTV News)
Lethbridge, Alta. ER nurse and president of the National Emergency Nurses Association Dawn Peta says that, despite efforts to improve ER waits, "the situation is dire."
"A lot of the nurses are talking about how they're working short staffed and it's getting harder and harder and a lot of them are leaving the actual emergency department," she said.
The Office of the Chief Coroner for Ontario says it has not yet been asked to look into the Lippert case. There "haven't been any inquests in the past two years on ER deaths (in Ontario) that warrant a review," wrote Stephanie Rae, a spokesperson for the Ministry of the Solicitor General.
To address the concerns about ER wait times and staffing, The Canadian Association of Emergency Physicians is holding a two-day national forum in Toronto on April 30 and May 1.
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Other deaths in the ER were recently reported in and amid overcrowding and staffing shortages.
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