A coroner has released a report criticizing the St. Mary's Hospital administration the death of a patient last year.
Mark Blandford, 73, died of an aortic aneurysm after he was denied emergency surgery at the hospital.
The 20-page report states that Blandford was already vulnerable upon his arrival to the ER, since he had waited 24 hours before presenting himself at the hospital with abdominal pain.
He had been transferred to the MUHC because vascular surgery had been discontinued at St. Mary's due to budget concerns. Even though a surgeon was available to operate, he was not authorized to do so.
Coroner Dr. Krystyna Pecko does not fault St. Mary's for discontinuing the surgery, but the report points out that ER staff was not informed of the decision, which led to a 40-minute delay in transferring Blandford to an institution that could perform the procedure. Blandford died during surgery at the MUHC.
“It is very surprising that the decision to discontinue aortic surgeries had not been communicated to the emergency responders in a timely manner. This shows a major omission in planning and communication in the hospital," wrote Pecko in her report.
Pecko also blames the hospital for not putting an adequate contingency plan into place, and suggests that the communication within the hospital networks be improved to avoid future consequences.
Health Minister Gaetan Barrette said he is pleased to see the report did not criticize the reorganization of Quebec’s health care.
“It has nothing to do with the budget, it had to do with the communication of the protocol and that's the issue and that wasn't clear,” he said.
Among Pecko’s recommendations: Improving communication within the network of health care professionals.
In response to the report, the West Island CIUSSS health authority in charge of St. Mary’s Hospital said it has already deployed corrective measures and is committed to implementing the coroner’s advice to prevent similar situations in future.
