The report from coroner Bernard Lefrançois was made public last week. The 81-year-old man, whom we will call André*, died last year from burns combined with toxic smoke inhalation.
André lived in the municipality of Colombier, on the North Shore of Quebec. Late in the morning, on November 11, 2023, his neighbors saw smoke coming from his house.
A man enters the house despite the intense smoke to rescue André, who is lying on the ground, unable to get up due to his limitations.
After several trips outside to breathe, the neighbor managed to get André out of the house with the help of other people. The blaze caused heavy damage to the residence.
The 81-year-old man suffered burns over a large part of his body. Resuscitation maneuvers were provided to him before the arrival of paramedics. André was then transported to the Local Community Services Center (CLSC) in Forestville where his death was pronounced by a doctor.
His death was declared accidental by the coroner.
Hospitalisation
First, the coroner points out that the emergency services took time to reach André’s house, as they were arriving from Forestville. The distance to travel to Colombier explains the necessary intervention from neighbors. This aspect is not criticized by the coroner.
Me Lefrançois then analyzed the police reports and the victim’s medical file.
The octogenarian had several health problems, including neurocognitive disorders, diabetes, hypertension and dyspnea. André had memory problems and could have hallucinations.
He also suffered repeated falls due to his mobility problems. He lived in his house in Colombier with his partner of over 50 years. The woman ensured his safety by often helping him up. She sometimes called the paramedics to help her.
André benefited from home help, offered by the CLSC de Forestville. Members of health personnel came to his home to take medication and provide hygiene care, in particular. André’s partner took care of the rest, including preparing food for him.
In the summer of 2023, the spouse expressed her exhaustion to the helping staff. She felt overloaded; André was not always cooperative in receiving care.
On October 21, 2023, less than a month before his death, the 81-year-old man was forcibly transferred to the Baie-Comeau hospital center after disorganization. He remained hospitalized for nine days.
Lack of communication
During the period of hospitalization, André’s partner left the family home to be accommodated elsewhere, no longer able to cope with her partner’s state of health. The move is also suggested by the speakers in the file.
On October 30, André was released from the hospital. “The decision seems to have been made considering that his partner was at home when in reality she was staying elsewhere,” wrote the coroner in his report.
André therefore continues to receive care from the CLSC at home, but now lives alone.
“The victim’s relatives disagreed with the medical staff who discharged him; They considered that André was not able to take care of himself and could be a danger to himself and to others,” underlines the coroner.
The police investigation shows that the fire started in the kitchen, with fried food. According to the witnesses consulted, André had the habit of cooking fried food with a frying pan filled with oil, which he often forgot on the fire.
“I consider that the last leave given to André after a nine-day hospitalization, in the state he was in, and with the prospect of being returned home alone or even with the help of a spouse incapable of doing so. assume, was questionable,” notes Me Lefrançois.
No question of finding a culprit
In the report, we recall that coroners cannot comment on the civil or criminal liability of a person during an investigation. Also, coroners do not have the competence to judge the quality of the actions performed by health professionals.
The objective of the investigations is to formulate recommendations with the aim of avoiding similar deaths and thus saving human lives.
“Was André really able to take care of himself adequately and safely when he returned home? Did he obtain the services required in the circumstances?
Coroner Me Lefrançois indicates that it is important for the CISSS de la Côte-Nord to shed light on these questions, so that other deaths of people with precarious health can be avoided. The choice of keeping André hospitalized or returning him to his home must be analyzed.
The coroner therefore recommends to the CISSS, to which the Baie-Comeau hospital center reports, to review the quality of the care provided to the deceased, in October 2023.
It also encourages the CISSS to put in place measures to improve the quality of care for users and ensure safety.
“We have read the report and a follow-up to the coroner will be made within the required time frame,” notes the CISSS de la Côte-Nord in an email sent to the Soleil.
*Fictitious name
