Coroner Francine Danais clearly states this in one of her recent reports: the care units of private seniors’ residences (RPA) “now serve as waiting areas” for long-term care centres (CHSLDs). She denounces the fact that the attendants who work there are not required to take notes, which can leave a lot of questions unanswered.
This is the case for the relatives of Gaston Roy, who died at the Hull Hospital on the night of September 27 to 28, 2023. A few hours earlier, the 78-year-old man had been discovered unconscious in his room at the RPA Vilia Gatineau (now Chartwell du Plateau).
Gaston Roy with his three children. The septuagenarian’s condition deteriorated so quickly that his son Dominique, who lives in New York, was unable to reach the Outaouais before his last breath. (Courtesy)
The coroner wrote that after a hospitalization during the summer, Mr. Roy was able to return to his RPA “with intensive monitoring.” The Integrated Health and Social Services Center of Outaouais (CISSSO) ensured that there was an attendant from a private agency at his bedside 24 hours a day, while waiting for a place to be found for him in a CHSLD.
“It really relieved me,” recalls one of her daughters, Isabelle Grenier-Duchesne. […] It took a weight off my shoulders, I felt safe.”
Gaston Roy lived at the RPA Vilia Gatineau, which is now called Chartwell du Plateau. (Simon Séguin-Bertrand/Le Droit)
Despite this constant surveillance, Gaston Roy’s children do not really know what happened in the hours leading up to his death. Neither does the coroner. What is certain is that he succumbed to trauma that caused blood to pool in his brain.
“We didn’t understand how a brain hemorrhage could happen when we had no reports of a fall,” laments his other daughter, Pascale Roy.
What happened to the man with dementia and Parkinson’s? It’s far from clear. The attendant’s notes are “of no help,” the coroner says. She also says it’s “deplorable” that attendants aren’t required to take notes, even though “they’re being given more and more tasks.”
“But what was the orderly doing? Did he have the knowledge and skills to realize that something abnormal was happening? […] The question is whether the attendant had the knowledge to make the observation or distinguish between sleep and unconsciousness.”
— Excerpt from the report of coroner Francine Danais
The day Gaston Roy was taken to the hospital, the attendant asked a nursing assistant from the RPA to come and examine him because he was bleeding from the ear. But “she didn’t show up,” says Me Danais. This element “really frustrated” the deceased’s relatives. “Maybe the attendant wasn’t competent, but he asked for help and he didn’t get it,” says Ms. Grenier-Duchesne.
Gaston Roy still recognized his relatives, including his only grandchild, Francis. (Courtesy)
Paramedics were finally called. When they arrived, the older boy was unconscious. “The nursing assistant could certainly have made this observation earlier,” said Me Danais.
“The status quo is becoming intolerable”
It was “impossible” for the coroner to know when Gaston Roy lost consciousness. “We will never really know what happened,” lament the deceased’s daughters.
Without being able to say whether a more prompt visit from the nursing assistant would have prevented Gaston Roy’s death, Me Danais believes that “more rapid appropriate care would have increased his chances of survival.”
While recalling that other coroners have recommended changes in the training of care workers, Me Danais insists that “the status quo is becoming intolerable” and that it “must change.” She recommends that the public network require note-taking for care workers in RPAs and private agencies.
Such an obligation is “a minimum” in the eyes of Mr. Roy’s children, who had also been told that their father was “too heavy” a case for his private residence.
Another recommendation from the coroner is to the Ministry of Education to add a component on note-taking to the training of attendants. She also recommends that the Ordre des infirmières et infirmiers infirmiers infirmiers auxiliaires du Québec review this file.
Cogir Immobilier, which was the manager of the RPA when Gaston Roy lived there, reacted by speaking of a “very unfortunate accident.” “Any recommendation aimed at improving the training of beneficiary attendants […] can only be welcomed by our company, indicated the group’s communications director, Brigitte Pouliot. […] We recently took the initiative to develop and implement training and a procedure on taking notes in the file for our beneficiary attendants.”
When Dolores Kearney was transported from the RPA Résidences de la Gappe in Gatineau to the Hull Hospital on July 27, 2023, she had been complaining of pain for four days.
Coroner Francine Danais says paramedics contacted one of her children after noticing “internal rotation of the right leg […] and a hematoma on the knee.” They were then told that for four days, the lady suffering from Alzheimer’s had been crying a lot and saying: “Help, Mom.”
Diane Dolan with a photo of her late mother, Dolores Kearney. (Simon Séguin-Bertrand/Le Droit Archives)
“She wasn’t normal, she was screaming, she was scared, she was shaking,” remembers her daughter, Diane Dolan, who took turns at her bedside with her sister and brother. […] I don’t understand what happened.”
At the hospital, a hip fracture was diagnosed and the 88-year-old woman, who had been waiting for a place in a CHSLD for two years, underwent surgery.
During her hospitalization, her cognitive abilities “greatly” declined. She took her last breath on October 22.
“It’s not fun to die in that state,” laments Diane Dolan. “It’s true that her condition wasn’t going to improve and she might not live ten years, but she didn’t have to die in pain either.”
Dolorès Kearney lived in phase 1 of the Résidences de la Gappe, in the Gatineau sector. (Simon Séguin-Bertrand/Le Droit)
Dolores Kearney was supposed to be assisted by a private agency attendant 11 hours a day. On the day she was injured, no attendant from the agency was able to show up in the evening. The family, who were supposed to be notified, were not.
The coroner tried in vain to find out what happened. There was very little written in the file. However, a note dated July 25 mentions an “incident” with an RPA attendant, adding that she is “suffering a lot.”
“What incident is this? When did it happen? […] When questioned on this subject, the general management of the RPA denied that an event had occurred.
— Excerpt from the report of coroner Francine Danais
All that was found was a report of a “near fall” late in the evening on July 23. “Ms. Kearney allegedly took small steps backwards when getting up and the attendant grabbed her and put her on the ground before she was picked up and put back in bed,” the coroner reported, adding that “no physical examination” was performed at the time.
“This is dangerously close to negligence”
For the coroner, even in the presence of a disorder such as Alzheimer’s, “we cannot ignore the tears, the refusal to be touched and the call for help without investigating the Source, trying to understand and above all without consoling and providing care.”
Diane Dolan filed a complaint following the death of her mother. (Simon Séguin-Bertrand/Le Droit Archives)
“This borders dangerously on negligence and is unacceptable,” she wrote.
For Diane Dolan, her mother’s fall should have raised “a red flag” so that her condition could be monitored more closely.
Me Danais emphasizes that “once again”, she “comes up against the lack of relevant and reliable information” from an RPA to explain what “ultimately caused the death of a vulnerable person, unable to communicate”.
“Organizational Abuse”
In a report of which Les Coops de l’information obtained a copy, the assistant complaints commissioner of the CISSSO confirms that Ms. Kearney’s profile “was much too heavy” for an RPA. She says she is “very concerned” by what the octogenarian experienced.
She points out that paramedics did not have many details about what happened. They described a fall story that was “very nebulous without much information and a lot of assumptions.”
Who was present during the incident? The assistant commissioner was unable to determine, because the testimonies “were conflicting.” After analyzing the file, she concluded that the 88-year-old woman “was the victim of organizational abuse through negligence.”
The CISSSO says it takes “this observation very seriously” and assures that it has implemented “a plan for continuous quality improvement”.
The company responsible for Résidences de la Gappe – All Seniors Care – did not respond to our request for a response.
RPA attendants “not prioritized”
Mr. Danais writes that it is “essential” that the training of attendants “be standardized and include a ‘notes and record keeping’ component.”
The Ministry of Health indicated to the coroner that efforts are primarily aimed at public establishments such as CHSLDs and hospitals and that RPA attendants “are not being prioritized.”
The coroner judges that with “the increase in deaths in RPA” in which attendants “are directly or indirectly involved”, the Office des professions du Québec should consider “other forms of supervision” of their work.
The CISSSO points out that the regulation on the certification of RPAs does not provide for “any element” on the recording of notes by attendants. The organization emphasizes that it is the Ministries of Health and Education that can “act directly to propose improvements to training as well as to the expectations of the role of a beneficiary attendant.”
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