From the moment Rheanna Laderoute was born, her older sister Kassandra Costabile doted on and protected her. Eight years younger, Ms. Laderoute was deeply empathetic, with a quiet grace and an offbeat sense of humour, Ms. Costabile recalls. And she remembers fondly how Ms. Laderoute could pull off silly sound effects and voices that no one else could – always making her laugh, even when she was upset.
Ms. Laderoute adored her older sister, too. Ms. Costabile once asked her sister why she would sometimes tell their mother about a relationship or school problem, but not her. “You’re the one I’m most fearful of disappointing,” Ms. Laderoute told her.
The sisters in a photo from around 2003-04.Supplied
When Ms. Laderoute realized she was pregnant at 19, she told neither her sister nor her mother. She went to a women’s health clinic in Brampton, Ont. – about an hour’s drive from her home near Newmarket – where she was prescribed Mifegymiso, the abortion pill.
When she was still heavily bleeding and experiencing abdominal pain two weeks afterward, she sought emergency care, as the pill’s brochure instructs patients to do.
On Feb. 14, 2022, she walked into the emergency department at Newmarket’s Southlake Regional Health Centre, a bustling 400-bed hospital located across the street from where she worked as a medical receptionist. Ten days later, she died of an infection, with signs of septic shock – a devastating outcome that appears as if it could have been prevented.
In the week leading up to her death, Ms. Laderoute visited Southlake’s emergency department three times. Her condition continued to worsen, but doctors failed to recognize the seriousness of her symptoms.
During her final visit, medical records show nurses were pleading for her to be transferred to the ICU, but that move wasn’t made soon enough.
Two investigations into her treatment by the College of Physicians and Surgeons of Ontario revealed several red flags were missed, and necessary tests and treatments weren’t provided in a timely manner.
One of the doctors who treated her – Marko Duic – had been cautioned previously by the college for poor documentation and inappropriate care. He’d also been the subject of a 2018 Globe and Mail investigation, which detailed allegations of gender discrimination in his hiring and training practices and improper billing, accusations he has disputed. Although Dr. Duic resigned as the hospital’s chief of emergency within two months of that investigation, he continued to see patients.
Relying on more than 400 pages of Ms. Laderoute’s medical records, which were provided by Ms. Costabile, as well as two decisions of the college, The Globe has reconstructed the medical decisions that preceded Ms. Laderoute’s death – a series of events that raise questions about the professional conduct of two of the physicians responsible for her care, and whether there has been adequate accountability within the health care system.
Ms. Laderoute, right, died of an infection in February, 2022.Tara Walton/The Globe and Mail
‘Constant refusal’ for ICU care
On Ms. Laderoute’s first visit to Southlake, the emergency doctor who saw her ordered an ultrasound, which didn’t show any retained fetal or placental remnants, a potential cause of an infection. This was a good sign, but it didn’t rule out an infection entirely; very rarely, serious infections after abortions can occur when bacteria invade the uterus through the open cervix.
The doctor referred Ms. Laderoute to Southlake’s early pregnancy loss clinic for more testing, and discharged her. (The Globe is only naming the two health providers who were later investigated by the college in relation to Ms. Laderoute’s care.)
The next day, the clinic was unable to reach Ms. Laderoute to set up an appointment, with a staff member writing back to the emergency doctor, “Phone number provided not in service.” No efforts to find alternative contact information are documented in Ms. Laderoute’s health records.
A week later, Ms. Laderoute returned to the Southlake ER, this time by ambulance. Notes from the paramedics and emergency nurses include that Ms. Laderoute told them her lower abdominal pain had “significantly been getting worse.”
The notes also show she complained about symptoms suggesting an infection: “discharge, foul-smelling, using 2-3 pads per day. Nausea.” She ranked her pain as 10 out of 10.
The doctor assigned to Ms. Laderoute on her second visit was Dr. Duic. Shortly after he assessed Ms. Laderoute, a nurse described her in the medical record as holding her abdomen, breathing heavily and crying.
Dr. Duic wrote that Ms. Laderoute had a “peritonitic” abdomen upon examining her. Peritonitis, swelling of the lining around the abdominal organs, is life-threatening. Dr. Duic ordered imaging, bloodwork and a urine sample – tests which the college later determined weren’t sufficient to investigate this condition.
With morphine and Gravol in her system, Ms. Laderoute was feeling well enough to walk. Dr. Duic wrote that Ms. Laderoute might have “cyclic vomiting” owing to her cannabis use. He discharged her six hours after she arrived at the hospital, with a prescription for oral antibiotics for a suspected urinary tract infection, as well as Percocet, a heavy-duty painkiller.
Ms. Laderoute went to Southlake’s emergency department three times.Laura Proctor/The Globe and Mail
About 24 hours after being discharged, Ms. Laderoute arrived at Southlake’s emergency department, once again by ambulance. This was her third visit in the span of a week.
At triage, at around 10:30 p.m. on Feb. 22, 2022, Ms. Laderoute’s heart rate was sky high – 175 beats a minute – and her systolic blood pressure was low, at 99. She told the triage nurse that she had vomited blood. The nurse wrote that Ms. Laderoute was pale and sweating, and that she “looks unwell.”
At 1 in the morning, her systolic blood pressure dropped down to 84, and she was breathing fast. These are all signs of sepsis, a life-threatening condition where the immune system goes into overdrive in response to a widespread infection and attacks the body’s tissues and organs.
Based on guidelines from the Society of Critical Care, patients with probable sepsis should receive broad-spectrum IV antibiotics within an hour. (These are much stronger than the oral medication prescribed by Dr. Duic for a suspected UTI.) Every hour of delay of antibiotics reduces a patient’s chance of survival by more than 7 per cent. Ms. Laderoute didn’t receive IV antibiotics until more than eight hours after her arrival to the hospital.
Ms. Laderoute was treated with fluids, morphine and three different medications to control vomiting. After being assessed by an emergency doctor around 11 p.m., she was not seen by a doctor again until 4:20 a.m., and IV antibiotics (ceftriaxone) weren’t prescribed until a third emergency doctor saw Ms. Laderoute around 7 a.m.
Piperacillin and tazobactam, which the college described as the “appropriate antibiotic for severe sepsis” in relation to Ms. Laderoute’s case, were administered at 2:30 p.m., or 16 hours into the third visit.
There were also delays in specialist consultations. It took an internal medicine doctor seven hours to come down to the ER and assess Ms. Laderoute after the request was sent. When this doctor saw Ms. Laderoute around noon on Feb. 23, he requested specialist consultations, including an urgent gynecologist consultation. While several specialists saw Ms. Laderoute that afternoon, a gynecologist didn’t examine Ms. Laderoute until around 6 p.m.
As the day wore on, on Feb. 23, nurses were getting increasingly worried. They mentioned several times in the medical record that they were waiting on the internal medicine doctor and noted they had followed up with him. They also documented their concerns that Ms. Laderoute needed ICU care to the ICU doctor on call, Dr. Albert Yun-Pai Chang.
“Throughout the day, multiple attempts were made at advocating to [Dr. Chang] re patient deteriorating and also to [internal] medicine MD that patient not appropriate for [emergency department] floor, to no avail,” a nurse wrote in the patient record.
A second nurse wrote that her efforts, along with the first nurse’s, to get Ms. Laderoute admitted in the ICU were met with “constant refusal” from Dr. Chang.
Nurses were struggling to insert IV lines into Ms. Laderoute’s veins, and could only get one IV line to work. They asked Dr. Chang to insert a central line, so they could more rapidly administer antibiotics. A nurse wrote that “multiple times since 11:00 [a.m.]” he’d made this request, and that Dr. Chang responded with “nope,” and “that’s tough.” Dr. Chang assessed Ms. Laderoute around 1 p.m. and 3:30 p.m., but each time determined she didn’t require ICU admission.
Other doctors disagreed with Dr. Chang’s assessment. Shortly after 3:30 p.m., an internal medicine doctor wrote that she talked to “critical care” (led at the time by Dr. Chang) about ICU monitoring; at 4 p.m., she added, “I still think that she does belong to ICU.”
At 4:45 p.m., an emergency doctor mentioned a conversation that he’d had with Dr. Chang. “He did not believe that she currently needs ICU admission. I think this needs to be revisited.”
At around 5:10 p.m., Ms. Laderoute’s heart stopped. Doctors resuscitated her for 22 minutes before her pulse came back. She was then admitted to the ICU, on a ventilator and unresponsive.
Once Ms. Laderoute was in the ICU, her family was informed that she was in the hospital, and were allowed to visit. Her dire condition came as a surprise, as neither Ms. Laderoute nor her boyfriend had called to let them know. Up until that point, owing to COVID restrictions, Ms. Laderoute‘s boyfriend, and any friends aware of the situation, weren’t allowed to visit her in the hospital. As Ms. Costabile points out, this meant she didn’t have a loved one to advocate for her.
Ms. Costabile took her sister’s case to the College of Physicians and Surgeons of Ontario.Tara Walton/The Globe and Mail
In the ICU, health workers pumped Ms. Laderoute’s body full of medicines. In the early hours of the morning on Feb. 24, a gynecologist and general surgeon performed joint surgery. They drained, the records show, “several litres” of pus, but didn’t find the source of infection.
Around 7 a.m., an ICU doctor wrote, “We continue on an uphill battle here. She has multi-organ failure.”
At 7:55 a.m., a social worker wrote, “Mom and sister and her [sister’s] fiancé at bedside. Aware of how sick she is and behaving appropriately for the situation. crying.”
At 8:52 a.m., after two more cardiac arrests, Ms. Laderoute was pronounced dead. Her grandfather drove from Ottawa, joining the family to say goodbye. The social worker reported that her boyfriend “ran out of the ICU crying.”
A hospital staff member handed Ms. Costabile the purse that Ms. Laderoute had brought with her. In it was a gold necklace that Ms. Laderoute had been wearing before a nurse removed it so it wouldn’t get in the way of IV lines. The necklace, gold and engraved with the word “Always,” was a graduation gift from Ms. Costabile.
Ms. Laderoute graduated from high school in 2020. Ms. Costabile had felt terrible that there was no in-person ceremony. So, she threw Ms. Laderoute a combined graduation and 18th birthday in their backyard, and she bought her a custom blue-and-lavender ombre cake adorned with flowers.
Along with the necklace, Ms. Costabile gave Ms. Laderoute a card that read, “I’ll always be proud of you, I’ll always be there for you, I’ll always trust you, and most importantly, I will always love you with all my heart. You were and always will be the greatest surprise of my life.”
Now, it’s Ms. Costabile who wears the necklace.
Tara Walton/The Globe and Mail
‘Nobody had an answer’
The coroner, who performed a postmortem examination in the hours after Ms. Laderoute’s death, found peritonitis and signs of septic shock. While “the source of the infection could not be identified,” the coroner noted that “a bacterial infection was likely.” (Blood and swab tests came back negative, possibly because samples were only taken after IV antibiotics were administered.)
Lynora Saxinger, an infectious disease expert in Alberta, said it’s possible that Ms. Laderoute had a severe bacterial infection stemming from her abortion – but that it could have also been an unrelated gastrointestinal infection. Although the surgery and postmortem examination didn’t show obvious signs of infection in Ms. Laderoute’s uterus, there are case reports of group A strep infections after abortions and births in which the patients’ uteruses appeared normal, Dr. Saxinger explained.
After accessing and poring through her sister’s medical records, Ms. Costabile complained to the College of Physicians and Surgeons of Ontario about Dr. Duic’s and Dr. Chang’s treatment of her sister. The dismissive comments attributed by the nurses to Dr. Chang made her livid, and she didn’t think Dr. Duic should have discharged her sister, given how sick she was.
Last summer, the college decided that Dr. Chang should receive an in-person caution, the regulator’s term for a warning. According to the college, Dr. Chang argued that his decisions were appropriate based on the information available to him at the time, and he stated that he wasn’t aware that only one of the patient’s peripheral IV lines was working.
Ms. Laderoute at her graduation and 18th-birthday party.Supplied
The college disagreed with Dr. Chang’s recollection, noting that documentation shows “that the Respondent was advised that there was only one IV available” and also that he “failed to recognize the concerns of nursing staff and other physicians about the severity of the Patient’s condition as well as the need for a central line.”
The college added that “the Respondent missed many clinical signs/symptoms or ‘red flags’ that the Patient was very sick and was experiencing end organ dysfunction, and thus should have been admitted to the ICU sooner, if not at the Respondent’s first assessment, definitely by the Respondent’s second assessment.”
The college committee was also “concerned that in his response to the complaint, the Respondent showed little insight or reflection about the care he provided to the Patient, suggesting that he would not have done anything differently.”
Recognizing that Dr. Chang “does not have a history with the College,” and is early in his career, the college said that a caution in this case was appropriate provided he pursue “professional education in communication and the role of cognitive biases in clinical decision-making.”
Both Ms. Costabile and Dr. Chang requested a review of the college’s decision by the Health Professions Appeal and Review Board (HPARB). In Ms. Costabile’s case, she doesn’t think it was an adequate punishment.
Dr. Chang’s lawyer, Stephen Ronan, declined to answer a question about Dr. Chang’s request for a review, as well as questions about the events detailed in this story. “As the matter is still before the Board, Dr. Chang cannot comment further at this time,” Mr. Ronan wrote.
Dr. Duic’s punishment was more severe. In February of this year, the Ontario Physicians and Surgeons Discipline Tribunal found that Dr. Duic committed professional misconduct and suspended his licence for three months.
A physician reviewer assigned to the case by the college determined that Dr. Duic should have ordered a CT scan to determine the cause of peritonitis, conducted a pelvic exam, including swabs of the patient’s vaginal fluid, started IV antibiotics and referred the patient to a gynecologist, among other measures. The second physician reviewer said that Dr. Duic should have considered other possibilities, including sepsis.
Jay Sengupta, in his capacity as chair of the college’s discipline panel, reprimanded Dr. Duic over a videoconference hearing, saying his management of Ms. Laderoute’s case “showed a lack of knowledge, skill and judgment.”
Dr. Sengupta also noted that Dr. Duic had a history with the college, “including deficiencies in assessments, incomplete examinations, inappropriate prescribing of opioids and inadequate documentation,” and that previous cautions from the college “provided ample opportunity for you to address these areas of concern.” Dr. Duic did not contest the college’s finding.
In April of this year, Dr. Duic, who is in his 70s, resigned his medical licence. (Had he not done so, he would have been required to practise under clinical supervision for six months, followed by a reassessment.) Dr. Duic did not respond to The Globe’s e-mails asking about his case.
A memorial tribute to Ms. Laderoute in her sister’s home.Tara Walton/The Globe and Mail
Danny Kastner, a Toronto-based lawyer who represents eight female physicians who first complained about Dr. Duic in 2018, says the college should have issued a more severe punishment to Dr. Duic years ago. Mr. Kastner points out that the college cautioned or counselled Dr. Duic four times between 2009 and 2018, without ever sending him to a disciplinary committee.
The college also, in Mr. Kastner’s view, failed to adequately investigate the gender discrimination and improper billing allegations against Dr. Duic, which were reported in The Globe and outlined in a complaint that Mr. Kastner submitted to the college in 2019. “My clients and I are haunted by the realization that a decisive disciplinary response from the college … might have prevented this tragedy,” Mr. Kastner says.
The Globe asked Southlake’s communications department about the concerns raised by Ms. Laderoute’s care, including communication challenges between nurses and Dr. Chang, and why Dr. Duic was permitted to practise, despite gender bias and patient care allegations.
Derek Rowland, chief communications officer, e-mailed a statement, attributed to Southlake, which reads, “The loss of any young life is a tragedy and our hearts go out to Ms. Laderoute’s parents and the entire Laderoute family.”
Southlake added that the hospital can’t speak on the specifics of any patient’s care for privacy reasons, but in cases like this, Southlake’s Office of Quality reviews what happened and makes recommendations, if necessary, to prevent future harm. Mr. Rowland declined to provide any information on whether reviews have been completed regarding Ms. Laderoute’s care, and what, if any, changes resulted.
Months after her sister’s death, Ms. Costabile’s family was invited to Southlake Hospital to discuss the hospital’s response to her death – a common practice when patients, especially young patients, die unexpectedly. While a Southlake administrator told her that internal assessments of the care Ms. Laderoute received would occur, the hospital never shared details of what those assessments found, nor whether any changes were made in light of them, Ms. Costabile says.
At the meeting, Ms. Costabile, her mother and several of the doctors involved in Ms. Laderoute’s care during her final hospital visit were seated around a large table. Dr. Chang was present, but not Dr. Duic. At one point, Dr. Chang said, “We did everything we could,” according to Ms. Costabile. The words, she said, were “like nails on a chalkboard.”
Ms. Costabile recalls shoving the medical record toward him, open to the nurses’ comments, and asking him, “Can you read me what you said to the nurses when they were trying to fight for her to be in the ICU?” He told her he didn’t recall saying those words.
She also remembers asking the physicians why IV antibiotics took so long. “Nobody had an answer.” Ms. Costabile recalled that most of the doctors acted “robotic,” as if they’d been coached to divulge little and keep emotions at bay.
Systemic failings also contributed to Ms. Laderoute’s death, sources interviewed by The Globe said. Health workers and advocates said the delays, communication breakdowns and difficulty accessing an ICU bed are clear signs of an underresourced health system.
Dr. Alan Drummond, an emergency physician in Perth, Ont., declined to speak to the specifics of Ms. Laderoute’s case, but said that understaffing at hospitals means emergency doctors are overwhelmed with sick patients and “you worry every day that you’re going to miss something.”
Michelle Cohen, a current family physician and former emergency physician from Brighton, Ont., and one of the eight female physicians represented by Mr. Kastner, questions whether the predominantly male makeup of Southlake’s emergency physicians was a factor in the care Ms. Laderoute received.
For most of the seven years Dr. Duic was chief of emergency, there were no female physicians working in the department. Today, Southlake has two female emergency physicians out of 17, making it an outlier compared with other departments its size in the province.
In comparison, St. Joseph’s Health Centre in Toronto rapidly scaled up its presence of female physicians after Dr. Duic’s time there ended more than a decade ago. Today, 21 of the hospital’s emergency physicians are women, representing 40 per cent of the total, according to Sabrina Divell, a spokesperson for Unity Health Toronto, a network of hospitals that includes St. Joseph’s.
Dr. Cohen pointed to research showing female physicians are generally more responsive to women’s health issues than male physicians, and that they can positively influence how their male colleagues practise. As an example, a study published in the British Medical Journal in 2021, involving 98 physicians and more than 2,600 patients, found female emergency doctors are 50 per cent more likely than male doctors to request an obstetrician-gynecologist consult in early pregnancy loss cases.
Dr. Cohen, who reviewed Ms. Laderoute’s medical records with Ms. Costabile’s permission, points out that they show none of the emergency doctors who assessed Ms. Laderoute (all of whom are male) performed a pelvic exam, nor requested an in-hospital gynecologist consult – which meant neither of those occurred until she was unconscious in the ICU.
“Southlake has had since 2018 to investigate serious concerns about gender discrimination and I’m not at all reassured by how they’ve dealt with it,” Dr. Cohen says. “I think the onus is on the hospital now to show that they’ve actually addressed long-standing concerns, including the possibility of a women’s health knowledge and skills gap in the emergency department.”
Ms. Costabile with her then-two-week-old daughter in June. Her daughter’s middle name is Rheanna.Tara Walton/The Globe and Mail
Fighting for accountability
At Ms. Costabile’s wedding in the summer of 2023, her best friend walked Ms. Laderoute’s flowing, sage green bridesmaid dress down the aisle, holding it by a wooden hanger, and placed it on an empty chair.
Ms. Laderoute had been the first person Ms. Costabile told about her engagement; she’d squealed with excitement. “Now, I have to face every milestone without her,” says Ms. Costabile, who recently gave birth to her first child, a daughter whose middle name is Rheanna.
Of her mother, stepdad and Ms. Laderoute’s father, she says, “We’ve all dealt with the loss in our own ways and not always in the best ways.”
With her forgiving nature, and her ability to make people crack up even in tense situations, “she was the glue that held our family together,” Ms. Costabile says.
Ms. Costabile hopes that raising awareness of what happened to her sister can prevent others from suffering the way her family has.
“This system failed her. It failed to look deeper into what was causing her pain, failed to act urgently, failed to listen to the nurses who were sounding the alarms,” she says.
“We cannot continue to allow a culture where doctors see themselves as above accountability, and where women are dismissed, disbelieved or ignored.”
Tara Walton/The Globe and Mail