Pediatric intensive care specialist offers explanations for alleged missing AHS documents during Stephan retrial

“Yes,” she said. However, she also noted that while many pieces of medical apparatus automatically record information now, that was not the case in 2012. The trauma team would have made their own manual notes when possible.

“You had one of the best teams I could have asked for,” said the doctor. “A very good team took care of your child.”

“Did you find it odd that…there were never records? No record by phone or medical for 55 minutes?” asked David.

“Well, there is a record of written notes from my team,” answered Burkholder.

“But no formal record?”

“I would consider that a formal record… There is the summary of medical records my team wrote. They can’t be documenting and caring at the same time. I don’t know what to say about that. We often write records later.”

“Do you recall receiving information on Monday, March 14, 2012?”

“I was busy keeping Ezekiel alive, but I did not look at all information sent,” said Burkholder.

Stephan also asked about the length of time the doctor treated his son in Calgary, and when it ended. She explained that care was handed over to Dr. Jonathan Gamble at 8 a.m. on March 14, 2012, but that she did come back to the hospital later. She became tearful answering Stephan’s question.

“I felt very engaged with your son. It was a highly emotional case for all of us. I stopped and asked his nurse about him. I made a correction in one of the resident’s notes,” she explained. “It was more for my own interest. I had been thinking of him a lot.”

Burkholder explained that a resident doctor had mistakenly written the toddler had a myocardial infarction, however he was actually post cardiac arrest.

She told the court that after he was admitted, Ezekiel had not experienced another cardiac arrest, and notes to the contrary written by representatives from Children’s Services referred to by Stephan – were incorrect.

Another issue arose when Stephan presented Burkholder with the results of an O’Connor application (disclosure of 3rd party records); medical records from an AHS system of record called “Netcare.” He questioned why information between midnight March 14, to noon on March 15, or, a period of about 36 hours, was not included in the package they had requested and received.

Burkholder explained that there were other types of records during that time period, including manual notes and another system that doctors used. Justice Terry Clackson then asked Burkholder to leave briefly and explained to Stephan that she could only testify about her experiences using the Netcare system.

“Would it seem abnormal that a 35 to 36-hour portion be missing from Netcare?” asked Stephan once the doctor returned.

“I don’t know, I use it to search for records. That’s it,” explained Burkholder. “I don’t know how or why some things are in Netcare and some things aren’t.”

She also told the court it was not unusual for some records not to be entered into the Netcare system.

Dr. Shauna Burkholder is on the stand in Court of Queen’s Bench in Lethbridge, as the Crown seeks to have her declared an expert witness in pediatric care at Calgary Children’s Hospital. While the testimony can be reported, the defence, including David Stephan and Collet Stephan’s lawyer Jason Demers, must also examine Burkholder about her qualifications. In the meantime, the comments have not yet been entered as evidence.

David and Collet Stephan have been charged with one count each of failing to provide the necessaries of life, after their toddler died of bacterial meningitis in 2012. They were initially convicted, however after subsequent appeals, the Supreme Court of Canada ruled the jury was not properly instructed during the first trial in 2016. A new trial for the couple was ordered in May 2018.

The Crown expects to call Dr. Jennifer D’Mello, an emergency department physician and child abuse consultant next week, prior to wrapping up its case, likely mid-week.

The defense will then begin calling its witnesses. The trial, which was expected to last one month, will now continue for at least 6 weeks.

by Lara Fominoff

Pediatric intensive care specialist offers explanations for alleged missing AHS documents during Stephan retrial

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