Transported by taxi, on August 19, 2019, from the Var nursing home where he resided, to a Marseille hospital for the administration of treatment, Jean Ligonnet, 72, had disappeared from the department where he was waiting seated on a chair in front of the nursing room. The searches undertaken by the hospital and by his family remained in vain until the discovery, on September 3, of his body in a room located in the west wing of the sixth floor, disused for five years and whose entrance door floor was well padlocked.
Due to the condition of the body, the victim was identified by a partially legible “Christine” tattoo on the shoulder. The court, explained its president Laure Humeau, exonerated the AP-HM of negligence in welcoming this patient and of a failure to implement the existing protocol for vulnerable people. The nursing home had in fact not alerted the hospital of episodes of running away or of his transfer, in May, to a closed unit. In the department where he came every week, the staff had not noticed any tendency to wander.
On the other hand, the judges consider that “the failure to secure the disused wing and the ineffectiveness of the search are indeed determining causes of the death of Jean Ligonnet since it was his confinement in this place which caused it”. The disused wing was in fact accessible from emergency staircases and the triggering of room alarms had given rise to a search that was far from exhaustive.
Two nights in a row, security agents passed near Mr. Ligonnet, found dead in a room without an exterior handle. While the management of the AP-HM recognizes daily disappearances of patients, according to the court, it would be “necessary to implement permanent and reliable instructions to ensure, in the rare cases where the disappearance is not resolved under 24 or 48 hours, that the entire establishment is indeed the subject of research.
During the hearing, on July 8, the general director of the AP-HM François Crémieux, representing the legal entity, recognized that “there is no more atrocious death, locked in this murky and dirty place” . He added that “it is not possible to return to what happened but it is possible, with words, to express the sympathy (of the institution) towards those close to them.”
Related News :