Coroner cites long wait time, improper reassessment in report on Quebec senior who died in the ER

A Quebec coroner has ruled that a senior's death at a Chateauguay hospital ER was due to long wait times and poor organization.

A coroner has cited long emergency room wait times and a lack of proper evaluation by hospital staff in a new report about a Quebec senior who died in the ER after waiting 12 hours to see a doctor.

Coroner Jean Brochu concluded in his report into the death of Yvon Brossoit that the “organizational context, the organization of resources, and the functioning of the emergency department” at Chatteauguay’s Anna-Laberge Hospital had an impact on the evolution of the 80-year-old’s condition in the ER.

Brossoit was one of two patients who died within 24 hours of each after waiting for care in the ER at the hospital on Montreal’s South Shore in November 2023.

The man from Sainte-Catherine, an off-island suburb of Montreal, showed up to the ER on Nov. 30, 2023, after experiencing severe abdominal cramps and fainting on a couch.

He arrived at the ER at 12:41 p.m. that day, but the triage process didn’t start until 1:08 p.m. When his vitals and blood work were assessed, he was put on a priority code 3, meaning his condition was not life-threatening and he should be reassessed every 30 minutes, and returned to the waiting room in a wheelchair, where he waited for hours with other patients.

Shortly after 6 p.m., a family member who was accompanying him in the waiting room told the nurses that he was having abdominal pain. “Mr. Brossoit had not yet been reevaluated,” but a nurse gave him pain pills, took his temperature and checked his blood pressure, the coroner stated.

Then, at 11:45 p.m., he suffered cardiorespiratory arrest in front of his relative. After ER staff successfully performed resuscitation maneuvers on him, an ultrasound revealed that he had a “ruptured abdominal aortic aneurysm.”

Staff decided to transfer him to the Centre hospitalier de l’Université de Montréal (CHUM), but his condition quickly deteriorated. He was pronounced dead at 12:48 a.m., about 12 hours and seven minutes after showing up at the ER.

Hospital’s ER was at 191 per cent capacity

According to the coroner’s report, Brossoit was unaware that he had an abdominal aortic aneurysm, which can remain asymptomatic as it develops. If an aneurysm is 5.5 centimetres in diameter, surgery is recommended.

Brossoit’s abdominal aneurysm was 6 centimetres after it ruptured.

On the day he showed up at Anna Laberge Hospital, the ER was at 191 per cent capacity as there were 61 patients on stretchers in an ER that only has 32 stretchers.

“Twenty patients had been waiting to see a doctor for more than 48 hours,” the report stated.

Public data shows that hospitals in that region regularly exceed their ER capacity and can sometimes reach 200 per cent capacity.

Coroner Brochu also noted that at the time of Brossoit’s death, ambulances had been diverted from the Suroît Hospital in Salaberry-de-Valleyfield to Anna Laberge Hospital “due to equipment failure,” causing a surge in patients there needing urgent care.

An investigation carried out after the senior’s death revealed that the re-evaluation interval of every 30 minutes was not respected and that, had a diagnosis been done sooner, he could have been transferred to the CHUM much earlier.

The report also revealed that certain criteria for referring patients to the ER were not in place during his visit, which would have directed him to a stretcher area with a heart monitor, rather than being returned to the waiting room.

The coroner made several recommendations that are either already being implemented or are in the process of being implemented, including “evaluate possible renovations in the hospital to add stretchers, considering the consistently high occupancy rate” and “reduce the volume of ambulances in accordance with the number of stretchers in the traffic management permit.”

Recommendations that require further attention include “conduct frequent reassessments, based on priority level, taking into account subjective data provided by users/relatives” and “assign a nurse to users waiting for a stretcher other than the one assigned to triage, using the same ratio (1:5) as for observation, as mentioned in the triage guidelines.”