In her report dated June 2, coroner Pascale Boulay reports that the patient lost his life following a fall from his hospital bed at Gatineau Hospital, although a doctor had prescribed that he or under constant supervision.
When he was admitted to the hospital on September 18, a few days before his death, the 56-year-old patient’s medical file already indicated hepatic encephalopathy, one of the obvious signs of which was confusion and disorientation.
The nursing care plan states that he is subject to falls, the coroner’s report states. On September 22, his file argues that he must then be subject to constant surveillance.
He fell for the first time on September 23, in the evening, hitting his head. He himself notifies the hospital staff of his fall. Later that night, he was found unconscious on the floor after falling from his bed a second time. He was declared brain dead, then died from a brain hemorrhage caused by the head trauma linked to the fall.
“What concerns me in this matter is the fact that twice [le patient] suffered a fall with a cranial impact, one of which proved fatal when he was admitted for a clinical condition for which he presents signs of major confusion and disorientation and for this reason the doctor prescribed a constant surveillance,” questions the coroner, maintaining that there is no indication that the prescribed constant surveillance had been withdrawn. She specifies that it was an accidental death.
“Two falls with cranial impact in a hospitalization context, one of which proved fatal, raise serious questions about the application by hospital staff on the floor of constant monitoring practices when this is prescribed by a doctor .”
— Coroner Pascale Boulay
The coroner maintains that she communicated with the CISSSO, which affirmed that it had carried out an evaluation and an improvement plan.
Coroner Boulay recommends that the CISSSO ensure that clear directives are transmitted to hospital staff when a patient must be subject to constant monitoring and that evaluation and follow-up notes are entered in the patient’s file by employees who exercise supervision. She also recommends documenting the patient’s file when a constant monitoring order is withdrawn.
