MONTREAL -- Nursing supervisors faced tough questions about why more wasn’t done to save Joyce Echaquan when she was in distress at the Joliette Hospital last September.

At the coroner’s inquiry Wednesday, no one seemed to be able to answer why the 37-year-old Atikamekw woman wasn’t brought into the ICU sooner and why resuscitation maneuvers weren't started when her vital signs were crashing.

Questions were also raised about why staff gave her Haldol to calm her down and then restrained her on Sept. 28.

So far, every staff member who has testified at the coroner's inquest said that Echaquane should not have been left unsupervised under that medication.

A nursing supervisor said she asked an orderly to stay with Echaquan, but the orderly was the only one on the floor at that time and had 50 patients to deal with.

So she said no and added that Echaquan's daughter, who was at the hospital, would watch her instead.

There was a two-hour gap where the supervisor testified she was told no one could watch over the patient, even though that was the rule.

It was during that two hour gap that Echaquan died.

"She was essentially left there on her own, without any monitoring, and over the course of that period when she was left alone, is when she went into cardiorespiratory arrest, her state completely deteriorated, and no one really noted it,” said Patrick Martin-Menard, a lawyer for the Echaquan family.

“And we have this very damning video taken by her daughter about 50 minutes after Mrs. Echaquan had done the Facebook live, and you essentially see in this video that Mrs. Echaquan seems to be in respiratory distress, and no one seems to be doing anything.”

When the supervisor was asked why she didn't find another solution she didn't have much to say except to blame the lack of staff, as others before her have also testified.

She admitted that hospital rules were also broken by putting Echaquan under the care of a nursing student without supervision.

The last frontline staff members are taking the stand this week before the inquiry hears from experts outside of the hospital.