On February 20, 2024, Maurice* was a resident at the Les Jardins du Haut Saint-Laurent residential and long-term care center, in Saint-Augustin-de-Desmaures.
The 87-year-old man is considered a user “at risk of falling”. Her wheelchair and the chair in her room are equipped with an alert system to prevent falls, and her bed is monitored by a wall-mounted infrared alert system.
When armed, these devices cause a buzzer to sound [alarme] systematically as soon as the user gets up from one of these places.
Around 7:11 p.m., Maurice’s wall-mounted infrared system alarm went off. The 87-year-old man wants to go to the bathroom.
Two attendants appear to help the user put on his pajamas and accompany him to the bathroom, but the latter “categorically refuses and is aggressive,” explains coroner Dave Kimpton.
At 7:15 p.m., the beneficiary attendants had to leave the room because another user’s alarm was triggered. They then leave the room and close the door, without putting Maurice back in his bed and without reactivating the alert system.
Chute
At 7:38 p.m., the beneficiary attendants heard a “uproar” coming from Maurice’s room. The latter was found on the floor, near the bathroom.
He is conscious, but says he has pain in his buttocks and leg. No bleeding is noted. Maurice explains to the attendants that he lost his balance while trying to go to the bathroom.
A few minutes later, Maurice is transferred to the hospital. After assessment, the emergency physician explains to loved ones that the senior has two choices: receive surgery in the emergency room or opt for comfort care.
“Considering the gentleman’s age and his general state of health, the relatives, accompanied by the treating team, opted for comfort care,” explains the coroner.
Palliative sedation began on February 26, 2024 in the afternoon and Maurice’s death was noted the following night.
23 minutes
When Mr. Dave Kimpton looked into this death, there remained “several unanswered questions regarding the circumstances surrounding the fall, the response time of the attendants as well as the proper functioning of the alert system.”
The coroner therefore requested assistance from the Quebec City Police Service (SPVQ). An investigation report was produced.
“I cannot establish with certainty the exact time spent on the floor of his room following his fall in the evening. However, I can affirm that he was left alone in his room for approximately 23 minutes when, in my opinion, he was in a precarious situation. [soit assis seul au bout de son lit].»
— Me Dave Kimpton, coroner
The coroner questions the fact that the two beneficiary attendants left Maurice alone in his room.
“When the gentleman refused help and another beneficiary activated his alert system, one of the two attendants should perhaps have stayed with him and signaled to the nursing resource on duty so that she could come as reinforcement,” says the coroner.
Two recommendations
“For better protection of human life”, Me Dave Kimpton recommends that the CHSLD Les Jardins du Haut-Saint-Laurent:
- Review the quality of care provided in Mauritius on February 20, 2024 and, if necessary, put in place appropriate measures to improve the quality of care for users in such circumstances.
- Remind all stakeholders working with clients of the accommodation center of all the regulations, policies and procedures of the CIUSSS de la Capitale-Nationale relating to cases of refusal of treatment by a user.
*Fictitious first name
