Coroner's report into 2017 death at Maison Herron found under-qualified staff and questionable policies
MONTREAL -- A 2019 coroner’s report into the death of a 94-year-old woman who choked to death at Maison Herron in 2017 suggested there were many issues at the seniors’ residence long before the COVID-19 pandemic.
Diana Pinet suffered from Alzheimer’s and a disorder called dysphagia that affects the ability to chew and swallow food. She died at Herron on Nov. 30, 2017 after choking on food that was being fed to her by an attendant.
According to coroner Julie-Kim Godin's coroner's report, several attendants assisted, including three nurses, who found her unconscious, not breathing and with slightly a purple complexion after she failed to swallow food.
CHSLD staff tried to assist the patient, but were unable to. The employees cancelled the ambulance, removed the food remaining in the woman’s mouth, and noted her death around 4:45 p.m., around three hours after her lunch.
Pinet’s “clear risk of suffocation” meant clear guidelines were thus issued to feed her safely and minimize the risk, the report reads. She needed to be well-awake, breathing clear and actively monitored with the attendant making sure she swallowed food before continuing to feed her.
The instructions were posted in her room.
The coroner’s report notes that the CHSLD file on Pinet’s death was “not very detailed,” does not provide a clear chronology of events leading to the woman’s death or “the care provided, the personnel involved and the decisions that were made.”
“An employee involved in the events said that she did not know that such a report should be completed in the event of a death,” reads the report.
An SPVM investigation also found conflicting accounts from witnesses.
The attendant feeding Pinet told the coroner she knew the woman and her feeding routine well, but Pinet wound up with a large quantity of food in her mouth causing her to choke, and the coroner found that staff did not seem to perform a Heimlich manoeuvre or abdominal thrust to try to remove the food.
“The videotapes of the cameras in the dining room do not establish that a clearing of the airways was carried out by the staff,” reads the report.
The coroner writes that staff may not have known how to do such manoeuvres and that some witnesses said they patted Pinet on the back to try to clear her airways.
“Is it possible that the desired level of care has created some confusion among staff regarding the care and manoeuvres to be performed? It's possible,” wrote Godin.
Her report also says that an attendant working at the time did not call 911, as they did not have authorization, a policy the coroner questioned.
The director of the establishment, the report notes, did not respond to a request from the coroner as to why staff wasn’t trained properly or authorized to make an emergency call.
“I also spoke with the Centre universitaire de santé et de services sociaux de l'Ouest-de-l'Île-de-Montréal and the Minister of Health and Social Services, who confirmed that recommendations had been transmitted to the CHSLD, but that they do not seem to have been implemented,” wrote Godin.
The coroner recommended that the “Quebec Order of Nurses examine the professional conduct of their members involved in caring for Ms. Pinet on or about November 30, 2017.”
In addition, the coroner recommended Maison Herron management:
- Assess with a qualified cardiopulmonary resuscitation trainer the certification needs (and recertification) in cardiopulmonary resuscitation and general first aid for nursing staff and attendants at the beneficiaries of their establishment.
- Offer training on cardiopulmonary resuscitation (including airway obstruction manoeuvres) and general first aid to nursing staff and attendants and ensure that the latter successfully complete these training courses.
The coroner recommended that Health and Social Services:
- Ensure that the CHSLD Herron complies with the certification conditions with regard to the health and safety of users.
- Continue their mentoring and support work in order to enhance and bring standards to the care and services provided within the CHSLD Herron.