She wanted to get pregnant: died at 33 in disturbing circumstances at the Royal Victoria Hospital

A young woman who wanted to become pregnant died in disturbing circumstances at the Royal Victoria Hospital after a routine operation, our Bureau of Investigation has found.

The family and husband of Joëlle Audrey Glan are demanding $1.4 million following her sudden death during a simple surgery to remove a fibroid from her uterus.

Beyond money, they especially want answers regarding the series of problems that led to his tragic cardiac arrest on August 6, 2021.

“The doctors told me that she had run out of oxygen, that she was in intensive care. I didn’t understand anything,” says her partner, Yannick Hébert, painfully remembering this sad day.

Investigations by the coroner, the hospital and the College of Physicians were unable to clarify beyond all doubt what had happened.

The patient’s family therefore remained in the dark, until Mr. Hébert received an anonymous letter detailing certain failings that allegedly took place during the operation.

We also know that the anesthesiologist was not in the room at the time of the cardiac arrest and that certain important information was not recorded in the medical file (see other texts).

She wanted a child

The young woman had decided to go under the knife in order to get pregnant. In the preceding months, she and her husband had taken numerous steps in vain.

“She was convinced that this surgery would allow her to have children,” says the man who married her in 2016.

However, she instead left the operating room unconscious. She was kept on life support for around twenty days before the family resigned herself to having her disconnected.

According to the lawsuit, a significant amount of fluid accumulated in the patient’s lungs during the operation. Despite attempts, it was impossible to intubate him. The operating room team performed resuscitation techniques for nearly 45 minutes, leaving her with severe brain damage that led to her death on August 27.

The same day, a doctor approached Lucine Ekomano, M’s mother.^me Glan, and suggested he contact the College of Physicians to find out what happened.

“It’s very difficult to grieve. I see Audrey’s friends who have children. I am very unhappy, because I would have liked her to be a mother too,” confides M^me Ekomano, who resides in France.

Presentiment

She says that her daughter moved to Quebec in 2009 for her studies. When she spoke to him the morning of the surgery, she had a bad feeling.

“She told me: ‘as soon as I go out, I’ll call you’. But she never came out,” she says, suppressing a sob.

In the following days, she got on a plane and moved heaven and earth for answers. A meeting with the operating room staff left her unsatisfied since no one seemed to know what had happened.

“If you had done your job, my daughter would not be in her grave,” she told a nurse.

Anonymous letter

Six months after the death of his wife, Yannick Hébert received an anonymous letter in the mail in which there was talk of professional misconduct and disturbing details about the circumstances of the death.

The letter stated that a significant amount of fluid had leaked into the blood vessels and lungs without stopping the surgery.

“Such a water deficit would be a well-known risk of causing the death of a patient. The rest of the story is a cover-up,” concluded the letter, the provenance of which is still unknown.

Lack of rigor

The College of Physicians deplores a lack of rigor on the part of the various stakeholders in the matter. A situation which did not make it possible to determine whether the doctors involved had committed professional misconduct.

“How can we explain that information as factual as the time of the start of surgery, of anesthesia or even the time at which desaturation appeared differ so much between the information placed in the file by different professionals?” questions the D^r Steven Lapointe in a letter of which our Bureau of Investigation obtained a copy.

The one who is deputy trustee at the College of Physicians indicates in particular that the anesthesiologist was not in the room where the intervention took place. How long did it take him to return to the patient when complications occurred? The D^r Lapointe said he was not able to determine this.

He recommended an inspection visit to the anesthesia and gynecology departments in the operating context.

However, no complaint was filed against the doctors in connection with the events that occurred that day.

“We are in the presence of a systemic problem without being able to establish the specific responsibility of an individual,” indicates the deputy trustee.

The coroner criticizes

The coroner who investigated Joëlle Audrey Glan’s file noted several anomalies in the notes taken by the operating room staff.

The D^r Jean Brochu himself decided to launch an investigation around ten days after the death, when the body was to be repatriated to France for its final rest.

He notes that there was no incident/accident report, that the monitoring of anesthesia during the operation was not precise enough and that there was no note written by the anesthesiologist.

In addition, the report of each participant present in the surgery room, with their decisions and observations, does not appear to have been recorded precisely.

Partly because of this missing information, “we therefore do not know what caused M’s breathing problems and cardiac arrest.^me Glan during surgery,” writes Dr.^r Paperback.

The coroner recommends that the hospital review the quality of the patient’s care and make corrections if necessary. He also asks to ensure that an incident report is completed in this type of situation, as provided for in the Health and Social Services Act.

COVID-19 in cause?

The MUHC believes that Joëlle Audrey Glan died following an extremely rare inflammatory reaction.

“According to the scientific literature, a severe complication of this nature occurs in approximately 3 out of 17,000 cases,” wrote the D^re Claudine Lamarre, from the Professional Services Directorate of the MUHC, in a letter addressed to the family.

According to the hospital, this reaction was amplified by the patient’s weakened lungs following a COVID-19 infection that occurred two months earlier. M^me Glan was then hospitalized at Saint-Eustache Hospital.

According to the lawsuit, an email was then sent to the doctor who was to operate on her to tell him that she had received a blood transfusion.

However, it was judged that she could still be operated on. According to the hospital, the standards of the time were respected since more than six weeks had passed between the two hospitalizations.

Without recognizing any wrongdoing, the D^re Lamarre mentions that several changes took place after this sad death. In particular, staff were trained on the maximum quantity of fluid that can be administered during this type of intervention and reminded of the importance of good documentation.