When an ambulance took David Lippert to the hospital in March 2023, the 68-year-old Kitchener, Ont., executive hoped to find out why he felt weak and couldn’t walk.
About 24 hours later, hospital staff found him unresponsive in the emergency room and he had vomited blood in the emergency room while on the admission list. Medical records show he went into cardiac arrest. He was subsequently declared dead.
His widow, Lisbeth Lippert, hopes an investigation into the incident can lead to improvements in the state of emergency care for others.
“I just wanted him to be in a place where I thought he was safe,” he told CTV. “It’s just his worst nightmare to die in the ER.”
Lisbeth says the emergency room was chaos when she stayed with her husband on the first day. She was placed near the nurses’ station, where she says she overheard them receiving calls from other staff claiming to be sick. It was clear, she said, that they were understaffed and overwhelmed with patients waiting for care and lining the emergency room hallways.
“They were running like crazy. I don’t know how you could keep that as your career for long,” Lisbeth said, adding that she saw the nurses doing the best they could.
She said her husband was examined immediately and doctors ruled out a heart attack or stroke. However, they discovered that she had severe anemia, with a hemoglobin level of 40. They suspected it was a gastrointestinal hemorrhage.
David was on blood thinners and had other medical problems.
Lisbeth says she had a blood transfusion and she wanted to go home. She 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, March 14, Lisbeth, who had gone home to sleep, says she was called and told that David was having an “event” in the ER.
Lisbeth Lippert tells CTV News she wants an investigation to shed light on her husband’s death while in the hospital in 2023. (Avis Favaro/CTV News)
It took almost a year to obtain her husband’s complete hospital records, but notes show he was found on his emergency stretcher after vomiting blood and going into cardiac arrest. Medical teams dialed a code blue and performed four rounds of CPR. They took him to the ICU, but found him unconscious. He also suffered seizures and signs of brain damage due to prolonged lack of oxygen.
That’s when, he said, gastroenterology specialists ran tests and confirmed that he had had internal bleeding.
According to medical records, David agreed to be admitted around 12 in the morning. There were no updates to his file until he was found that morning.
“Where were the gastrointestinal doctors? Did they call them?” —Lisbeth asked.
CTV News has reached out to the hospital for comment. While officials said they cannot comment on the details of the case, they did provide a statement.
“We offer our condolences to the family and encourage them to contact our Patient Relations team directly,” said Brandon Douglas, vice president of clinical services at St. Mary’s General Hospital.
Two emergency room doctors who were allowed to see medical notes told CTV News that the case raises questions about staffing and overcrowding as possible contributing factors to why his cardiac arrest was not detected earlier or prevented.
“In a functioning health care system, someone with a gastrointestinal bleed and a hemoglobin of 40 is admitted immediately… we have the example of a man who should not have been in the emergency room for at least 22 hours before being arrested,” Dr. Blair said. Bigham told CTV News. Bigham is also an assistant professor at the Dalla Lana School of Public Health at the University of Toronto.
“It increases the risk of people dying,” said Dr. Michael Howlett, an Oshawa emergency physician and president of the Canadian Association of Emergency Physicians, referring generally to longer wait times in the emergency room.
Howlett says he supports Lisbeth’s call for an investigation.
“It is a person who has a prolonged stay in the emergency department who has a hidden, serious, life-threatening health problem, who suffers significant times and delays… It is a system in crisis,” he said.
A photo of David Lippert, who died in Kitchener, Ontario. Emergencies in March 2023. (Avis Favaro / CTV News)
Lethbridge, Alta. Dawn Peta, an ER nurse and president of the National Association of Emergency Nurses, says that despite efforts to improve ER waits, “the situation is dire.”
“A lot of nurses are talking about how they’re short-staffed and it’s getting harder and a lot of them are leaving the emergency department,” she said.
Ontario’s Office of the Chief Coroner says it has not yet been asked to investigate the Lippert case. “There has been no investigation in the past two years into emergency deaths (in Ontario) that warrants a review,” wrote Stephanie Rae, spokesperson for the Ministry of the Attorney General.
To address concerns about wait times and staffing in emergency rooms, the Canadian Association of Emergency Physicians will hold a two-day national forum in Toronto on April 30 and May 1.
Provincial health leaders were invited to attend and discuss ways to relieve pressure on the country’s emergency units.
Other emergency room deaths were recently reported in manitoba and Quebec amid overcrowding and staff shortages.