Nick Bordignon was still deep in grief over the death of his infant daughter last October when an envelope from the Provincial Health Services Authority (PHSA) turned up in his mailbox.
It was addressed to the infant he and his wife had named Makayla Poppy when she was delivered at B.C. Children’s Hospital four weeks earlier following an ultrasound that showed the child was dead.
Inside was an invoice for the cost of an autopsy and an itemized list of tests conducted by a coroner — a bill the PHSA has since admitted the Bordignons were never supposed to see.
And to make matters worse, the letter seemed to indicate Makayla’s body was still in the morgue — two weeks after the autopsy was performed and nearly a month after she was stillborn.
“I remember just standing there in disbelief … and the initial confusion very quickly turned to rage,” said Bordignon, who works as a police officer.
“I’m no fool, I’ve seen autopsies performed, they are not pretty … it was soul-crushing and just wrong…. It’s just like, okay, so if this is an itemized list, this means the autopsy has been done. Where is she?”
‘Who’s to say it can’t happen again?’
CBC News has learned that the Bordignons’ concerns about both the invoice and the delay in releasing Makayla’s body are now under investigation by B.C.’s Patient Care Quality Review Board — the body tasked with reviewing complaints about health authority policies and procedure.
The story highlights what experts say is a lack of standardized care when it comes to stillbirths, which can result in errors that traumatize already grieving families.
The Bordignons’ are not the first B.C. family to experience delays receiving their baby’s body after a birth or stillbirth — a situation apparently compounded by disagreements over who ultimately bears responsibility for delivering the child to the family.
Dr. Lynn Murphy-Kaulbeck, president of the Society of Obstetricians and Gynaecologists of Canada, says the Bordignons’ experience is indicative of wider problems in the system.
“That horrible story just speaks to a larger issue of not having things in place,” she told CBC.
“The system not acknowledging the gravity of what’s occurred and not having systems in place so that no parent will ever go through that.”
Bordignon says losing Makayla already felt “insurmountable.”
“To have these other things added to it, the invoice, delay of having her return to us, it’s things that harm an already terrible experience,” said Bordignon.
“Even if it’s an error, who’s to say it can’t happen again?”
‘Error in coordination’
In the hours they had with Makayla’s body after she was born on Sept. 25, 2024, Bordignon says he and his wife Laura admired her brunette hair, large feet and “super cute” nose.
They also consented to an autopsy that might help them learn more about what had gone wrong.
“We kind of looked at it as she will be protecting her future siblings with this knowledge,” said Laura Bordignon
The family say they were told Makayla’s body would be transferred to the B.C. Children’s Hospital’s morgue for an autopsy. They believed she would then be promptly transferred the funeral home the Bordignons chose to collect her remains.
“Walking out of the hospital after a birth without a child is soul-crushing,” said Nick.
“We know she’s not coming home the way that we want her to come home, obviously. But it was this notion that when she’d be home, she’d be safe. She’d be with her parents.”
According to the invoice, Makayla’s autopsy was performed on Oct. 7.
In a letter to the family, PHSA apologized and reversed the invoice.
After the Bordignons received the invoice in the mail and called the hospital, the process of getting Makayla’s remains home unfolded quickly. Makayla’s body was released and transferred to the funeral home where it was cremated.
Not the first time
The Bordignons told CBC they just want a clear understanding of what went wrong.
The couple began by filing a letter to Provincial Health Services Authority asking for the invoice to be scrapped and for the hospital to make changes to stop something like this from happening ever again.
In a letter, the PHSA apologized for the invoice and said the charges for the autopsy had been reversed.
But the Bordignons say they weren’t satisfied the hospital’s response would prevent the same thing from happening again and requested a face-to-face meeting with leadership. They’ve been promised a chance to do that in June.
Now the issue has been escalated to the provincial Patient Care Quality Review Board. The board says it is experiencing a “backlog” and anticipates the review might not be complete for several months.
It’s not the first time grieving parents have lost their child’s remains to miscommunication.
In 2022, Émilie Negahban says her child’s body was left unnecessarily in the morgue for eight weeks.
Negahban gave CBC a letter she received from PHSA’s Patient Care Quality Office after she filed a complaint about how long her son had been left in the morgue. The letter promised to standardize the process to reduce the risk of it happening again.
“It’s disheartening to see that another grieving family already went through this. They did the proper steps to try to get that preventative measure,” said Nick Bordignon.
In a statement to the CBC from Ruth Appanah, the executive director of B.C. Women’s and B.C. Children’s hospitals, the organizations offered a sincere apology to the both families and said “we take these matters incredibly seriously.”
The statement says that hospital leaders are taking action and that “we have an obligation to learn from families and do our best to improve.”
‘She’s back home’
As a maternal fetal medicine specialist, Murphy-Kaulbeck wants a more robust system working to prevent stillbirths while supporting families like the Bordignons in their grief.
“If you have a system where you’re looking from the beginning to the end, and it’s dealt with every time the same way with the same respect and the same process, you won’t hear stories like that,” she said.
The U.K. and Australia have adopted national bereavement care guidelines for families after stillbirth. They have also adopted national action plans to decrease the number of stillbirths from happening in the first place.
Even the definition of what counts as a still birth is not standard across nations.
In the U.K. a stillbirth is defined as loss that happens after 24 weeks — which sets the rate at about four deaths per thousand births.
In Canada, where stillbirth is is defined as loss after 20 weeks, the rate is nine deaths per thousand.
Murphy-Kaulbeck has been asked by Ottawa to help develop a national action plan on stillbirth. She cites estimates from the World Health Organization that say 30 to 40 per cent of stillbirths are actually preventable.
“As a country, we aren’t addressing it to the degree that it needs to be addressed,” she said.
The Bordignons picked up Makayla’s ashes from the funeral home on a rainy day in the first week of November.
They chose a small heart-shaped purple urn with a silver butterfly for her. Laura protected it under her jacket. The couple held the box and cried.
“We have her on the mantle now,” said Nick. “She’s back home.”
