Sherbrooke man, 73, 'probably' died from attack by fellow patient, coroner finds

A Quebec coroner is calling for a review of how a public long-term care institution (CHSLD) deals with aggressive patients who suffer from dementia or other cognitive disorders.

Coroner Richard Drapeau's recommendations come after the death of a patient last fall that was "probably" provoked by the punch he received from a fellow resident at the Argyll Pavilion, a CHSLD in Sherbrooke.

Serge-André Guérin, 73, died on Oct. 3, 2017. A patient living in the same wing as he did entered his room at around 10:15 p.m.

An orderly who walked in minutes later saw the patient strike Guérin in the face.

Guérin, who was sitting on his bed, went into cardiac arrest and was pronounced dead just 15 minutes later.

The pathologist who carried out the autopsy concluded that "the altercation may have increased the physiological demand on an already weak heart," Drapeau wrote in his report.

History of violence

The coroner found that Guérin's assailant had numerous past episodes of violence and had tried to hit an orderly hours before attacking Guérin.

In a previous episode, he had struck another patient, breaking the person's tooth. 

​The coroner's investigation revealed that despite this history of violence, the assailant was living in a wing reserved for patients who show signs of problematic behaviour, but behaviour that has "little or no consequences" for others.

Drapeau also noted that the incident with the staff member was not reported to the medical team that night. He recommends that the CHSLD keep more accurate records of their patients.

The coroner is also recommending the Argyll Pavilion review its methods of determining the best living arrangements for patients who show signs of aggression. 

Patients' rights lawyer Jean-Pierre Ménard said while he considers the recommendations appropriate, he said the Argyll Pavilion should have already had all of the protocols called for by the coroner in place.

"The situation has confirmed a serious lack of basic precautions in that case," said Ménard, who is not representing Guérin's family in this case. He said he hopes the report will raise awareness.

"There was a major lack of organization, assessment and follow-up in this case, and we hope it will be enough to bring change," he said.

Hospitals brings in extra staff, cameras

Sylvie Moreault, a director at the CIUSSS de l'Estrie which manages the Argyll Pavilion, said the regional health agency welcomes the coroner's recommendations.

Moreault said many of the measures have already been put in place following the internal investigation that was launched after Guérin's death.

She said an additional orderly has been added to the night shift, and there is one more nurse on duty during the day to evaluate patients and assess whether they need more surveillance.

"If the behaviour has changed between the morning and the evening, we have to re-evaluate the patient right away," said Moreault.

Moreault said the CIUSSS has also encouraged its staff to share patient information more efficiently.

Extra cameras have been added to allow nurses to have better oversight of activity on their floor from their work station.

Despite all these changes, Moreault said it's still possible an incident like this one could happen again.

"Zero risk doesn't exist," she said. 

Moreault said Quebec's aging population means long-term care facilities across the province will have to increase efforts to deal with a growing number of patients suffering from dementia.

"We are all confronted with the evolution of this clientele which can have unpredictable behaviour," Moreault said.

Criminal charges against the assailant were thrown out because of his mental state.

Resident left in bed for 36 hours

The coroner's report comes just months after Quebec's ombudsman launched a separate investigation at the Argyll pavilion in November 2017, after families filed complaints alleging residents were sometimes left in their bed for long periods.

The ombudsman contacted the family of one female patient after Radio-Canada reported the woman had been left in her bed for 36 hours.

At the time, the CIUSSS admitted this had been a problem because of staffing issues they were trying to resolve. The CIUSSS then issued a directive to staff, limiting the time a resident could stay in bed to 24 hours.

The ombudsman's report on that investigation hasn't yet been released.