Discretionary inquest granted to examine teen’s death after he sought care at Ontario hospital

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An Ontario coroner has granted a discretionary inquest to examine the circumstances of a teen’s death after he went to a hospital in the province in agonizing pain, waited hours to receive care and later died of sepsis and pneumonia.

The decision was recently shared by a local coroner with the family of 16-year-old Finlay van der Werken.

Finlay was rushed by his mother to Oakville Trafalgar Memorial Hospital in February, 2024, after experiencing excruciating pangs on his right side. Hospital records show he waited more than eight hours to see a doctor. He later suffered cardiac arrest and was transferred to Toronto’s Hospital for Sick Children, where he died.

Earlier this year, The Globe and Mail highlighted the van der Werken’s request for an inquest to examine their son’s death. The story garnered public attention and underscored concerns levelled by medical organizations and numerous health-care providers, who say overcrowded and understaffed emergency rooms across Canada could carry serious and even fatal consequences.

An Ontario teen died after waiting in agony for hours at an ER. Now, his family wants an inquest

Finlay’s mother, Hazel van der Werken, remains haunted by what happened to her eldest child. She cried when she learned of the inquest.

“I got very emotional because it was just this feeling of finally, finally, somebody is stepping up and saying: ‘Yes, we agree. Something went wrong here,’” she said.

However, Ms. van der Werken and her spouse GJ were disappointed to also learn from the coroner that it could be five to seven years for the inquest. They say families should not have to wait years for answers, accountability or change.

“Most people see that our story is a tragedy and it’s terrible,” Ms. van der Werken said. “They see it, that it’s somebody else’s story. And what we’re trying to get everyone to see is, yes, this is our story, but it could be yours next because there’s nothing stopping this from happening again.”

Inquests are not mandatory when children die in hospital but are under different circumstances, such as if someone dies in prison. Discretionary processes can be granted if a coroner determines it to be in the public interest.

Hospital staff provided ‘reasonable’ care to Ontario teen who died after waiting hours in ER, statement of defence claims

Inquest jury findings are not legally binding. Rather, they are designed to prevent future deaths.

Stephanie Rea, a spokeswoman for the Office of the Chief Coroner, said each year, approximately 85 deaths require mandatory inquests and the inquest unit is staffed to manage 55. There are currently 412 inquests in various stages of planning and 40 are discretionary.

“While discretionary inquests provide valuable insights into systemic issues, they have no legislated timeframe and often take longer to plan and schedule,” she said. “Waiting years to address public safety concerns is not ideal.”

The OCC is considering alternative approaches to provide timely recommendations, such as specialized death review committees, Ms. Rea added.

The van der Werkens have also filed appeals to findings from a committee that looked at two of its complaints made about Finlay’s care with the College of Nurses of Ontario. The committee took no action on one of the family’s complaints, and issued written advice to a member on the second.

The family said the committee found one of the health-care workers recognized Finlay had lower oxygen saturation, but appeared to lack knowledge, skill and judgment. The committee also concluded that this posed “a high risk of patient harm.”

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Separately, the van der Werkens filed a lawsuit against the Halton Healthcare Services Corp., a network of hospitals that includes Oakville Trafalgar Memorial, and medical staff, alleging Finlay’s pain, suffering, emotional distress and death were caused solely by negligence.

The allegations have not been tested in court.

A statement of defence filed in September by the health services corporation and several nurses denied the allegations of negligence. It said at all times, hospital defendants provided “reasonable hospital and nursing care” to Finlay.

The van der Werkens are urging Canadians to support a campaign they launched called “Finlay’s Voice,” to spur ER reform. They want legislation to stipulate, among other things, legal limits for wait times for pediatric patients (they have not specified how long that should be).

GJ van der Werken also noted improved sepsis detection called “Rory’s Regulations” passed in New York State more than a decade ago after the 2012 death of 12-year-old Rory Staunton. The regulations mandated hospitals to have protocols and report metrics. Other states, including Illinois, Ohio, and Wisconsin, also passed similar laws.

“We don’t see why that couldn’t happen here in Ontario or in Canada.”