An investigation into the end-of-life care of Andrée Simard, widow of former Quebec premier Robert Bourassa, found evidence of poor communication and organization at St-Mary's Hospital -- but no sign of "ethical lapses" by staff.

In January 2023, Michelle Bourassa published a statement alleging the medical team charged with her mother's care refused to give her adequate pain relief, causing deep distress in the days leading up to her death.

Hospital staff reportedly told the family sedation only happens in palliative care and that Simard couldn't be transferred there because she had COVID-19.

The family said it was only after an attending physician found out who Simard was that her sedation levels were significantly increased.

The accusations prompted a probe by the Collège des médecins (CMQ), the organization that monitors medical practice in Quebec.

The CMQ concluded that multiple factors contributed to a "difficult situation" for Simard and her family.

"The change of the attending physician, the lack of clarity regarding the substitute decision-maker, the non-alignment of the family's expectations (comfort care vs. palliative sedation), the effective but insufficient communication with the family during weekend care, a staff ill-equipped to respond to the family's expectations and Mme. Simard's needs, all of these elements combined to make the situation difficult," the report, reviewed by CTV News, states.

Nevertheless, the CMQ did not find evidence of medical malpractice.

"In this case, the investigation at St. Mary's Hospital Center did not reveal any ethical lapses on the part of the medical team, but rather several contributing factors, including problems in communication between the family and the care teams and in the organization of care and services."

The report highlights a need for "competency and adequacy" in end-of-life care when it occurs outside the palliative care unit, the CMQ said.

The organization made several recommendations to the hospital, including further staff training, a review of operations on the floor where Simard ultimately died, adding a "pivot nurse" to better coordinate individual care, and updating clinical documents.

In a statement to CTV News, The CIUSSS de l'Ouest-de-l’Île-de-Montréal, which oversees St-Mary's Hospital, said it sympathized with the family.

“We will take note of the report and analyze its recommendations with the utmost care. Measures have already been put in place, such as additional training for staff and the enhancement of our psychosocial support services offered to loved ones,” read the statement.

Simard died in November of 2022.

In January, after the allegations about her final days came to light, Quebec Health Minister Christian Dube called Robert Bourassa's family to apologize for the suffering she experienced.

With files from CTV's Rob Lurie.