| Issue | Original PCQO Letter (July 12 2024) | Later FOI / Retraction Evidence | Likely Author or Source of Error |
|---|---|---|---|
| “Two-week” follow-up / no urgency check | Claimed a screener “saw she had a follow-up in two weeks” and didn’t ask if a quicker appointment was needed. | FOI and Aug 29 2024 letter admit this was wrong — Felicity’s meetings were weekly and it was not Felicity who was spoken to. | Input originated from START leadership (Aldo Bonato & Geneva Healey); final wording issued after Risk Management assumed control. |
| “Family went to Adult Mental Health” | Stated that the family approached Adult Mental Health and was not redirected properly. | Fraser Health later confirmed “no record” of any such visit — an admitted error. | Introduced while matter was “left in Doug Clouden’s hands,” according to internal email between Aldo Bonato and Geneva Healey. |
| Continuity-of-care / coverage when clinician away | Implied coverage processes existed for sick or unavailable clinicians. | FH later admitted: “We did not have a specific policy regarding continuity of care” and created a new protocol only after Felicity’s death. | Drafted under oversight of Risk Management (Doug Clouden) during liability-review stage. |
| Who was actually called for the cancellation | Framed that “Felicity called in” to cancel and the screener acted on that information. | FOI / retraction show it was someone else spoken to, not Felicity; Fraser Health apologized for the error. | Input error from START team; later corrected by Indigenous Health lead Katie Alexander after document review. |
| Existence of protocol at the time | Suggested “process improvements” and coverage protocols were already in place before the incident. | FOI emails and the Aug 29 letter show the protocol was only created after Felicity’s death to address the ga |