A coroner has declared that the death of Louise Simon at the Griffith-McConnell residence in Cote-St-Luc was entirely preventable.

Catherine Rudel-Tessier has also found that the residence, which is slated to close in a few weeks, ignored safety and security recommendations made by the Montreal Health and Social Services Agency.

Simon, 94, suffered from Alzheimer's disease, and her condition had started to noticeably degrade in December.

Her medical file shows she was increasingly confused, and had already tried to leave the residence on her own more than once.

"Nobody addressed that problem. The medical staff didn't change her meds. They didn't look for a reason for that new behaviour," said Rudel-Tessier.

Death was avoidable

On March 3, 2010, a maintenance worker found Simon face-down on the grounds outside the building, wearing only her nightclothes, and with her walker beside her.

Rudel-Tessier ruled her death from hypothermia was accidental, but entirely avoidable.

Simon's son James finds the conclusion of the report difficult to accept.

"It's just an accident waiting to happen," he said.

Residence ignored security advice

In 2008, Montreal's Health and Social Services Agency visited the residence and noted some of the doors were not secure and should be repaired, but according to Rudel-Tessier "the residence didn't make the change."

The night she died, Simon was wearing an electronic bracelet intended to sound an alarm if she tried to leave the building, but Simon still managed to get through an emergency exit that had no alarm.

In addition, the coroner's report indicates the layout of the Alzheimer's wing at the Griffith-McConnell residence makes it very hard to monitor the patients, especially since the number of staff on duty had declined in recent years.

On the night she died, no one had checked on Simon's room for close to three hours.

Griffith-McConnell declined interview

The director-general of the residence declined CTV's request for an interview, but in a statement said: "We have always taken all reasonable means to ensure an adequate balance between our residents' safety as well as their general well being. It was, and still is, our view that residents should enjoy as much freedom of movement and normality of life as is commensurate with their safety. The balance is delicate."

Police investigation triggered

James Simon has now filed a formal complaint with police.

"They were aware that my mother wandered," said Simon. "They were aware that the door exit closest to her wasn't locked, but it was required to be locked. They were aware they they have proper surveillance because of the architecture of the building. They were aware that they were understaffed because they cut that staff because they were running out of money, and they didn't also check on her when they were supposed to."

His complaint has triggered a new investigation.

Meanwhile, the Griffith-McConnell residence announced in April that it would shut down on June 30 due to a high vacancy rate and a monthly deficit of $100,000.

As a result, the coroner is recommending Montreal's Health and Social Services Agency be more active.

"I asked them to be more vigilant to see that what they recommend is done," Rudel-Tessier said.