Coroner won't reopen case of woman found on Montreal ER floor

The Quebec coroner's office will not be reopening the case of 86-year-old Candida Macarine, whose lifeless body was found on the floor of a room at the ER of the Lakeshore General Hospital last year. 

Macarine's family have lobbied for more transparency and accountability in the aftermath of their matriarch's death. After a coroner's investigation yielded a sparse, three-page report, family members and the Center for Research-Action on Race Relations (CRARR) called on Chief Coroner Pascale Descary to revisit Macarine's case. 

But in a letter sent to CRARR's president Fo Niemi earlier this month, Francine Dubé, who handles complaints to the coroner's office, said the bureau was declining the family's request. 

"The coroner's office is of the opinion that Coroner [Amélie] Lavigne acted with rigour and integrity in this investigation. After careful analysis of the file, there is no need to reopen it," Dubé wrote. 

Gilda Macarine, the fourth of Macarine's 11 children, said the letter felt like "a smack in the face, as if we are just nothing; we don't have value at all."

She said she believed her mother wasn't treated with the care she deserved, in part because she was an immigrant and had trouble understanding staff at the hospital as her hearing aid wasn't in place — not because she couldn't speak English as staff may have thought. 

"The coroner's office failed us," Gilda Macarine said in an interview Wednesday. 

The first coroner charged with investigating Macarine's file stepped aside in May 2021 after the family suggested she was in a conflict of interest. They discovered on LinkedIn that Karine Spénard had been the head of legal affairs for the CIUSSS de l'Ouest-de-l'Île-de-Montréal, the health agency that oversees the Lakeshore, before joining the coroner's office in 2017. 

Lavigne took on the investigation in her place, but Gilda Macarine says the resulting report was disappointing and further made her and her siblings question the office's credibility. 

Niemi noted Dubé's letter made no mention of the results of a venous blood gas test the family obtained and submitted to the coroner's office, which they said further called into question the lack of care Macarine received. 

Gilda Macarine, who herself works as a nurse's assistant in a long-term care home, said her family is looking into further legal recourse at their disposal.

'Lack of dignity'

In early November, CBC News obtained a 317-page report into conditions at Lakeshore. 

The report was drafted by an independent mediator between the nurses' union and the local health authority and mentioned Macarine's case as an example of the "extremely worrying situation" in the hospital's emergency room. 

The report's author, Marie Boucher, visited the ER and described it as a "ticking time bomb" that left her worried for staff and patients, for whom she observed a "lack of dignity."

According to the report, Lakeshore had one of the highest occupancy rates in the region this past summer, regularly exceeding capacity.

When Candida Macarine died of an apparent heart attack on Feb. 26, 2021, she was in an isolation room that wasn't visible to staff at the nursing station and an alarm indicating her distress was not heard by health-care workers. 

Lavigne's one recommendation was to improve the surveillance of patient cardiac monitors. 

"There is documentation of systemic, systematic, repeated failures at Lakeshore in ER care, in medical care. Why the coroners ignored the evidence? I don't know," Niemi said.

The report by Boucher described the death of another patient identified as "D" in April 2022, more than a year later, whose cardiac monitor was supposed to be closely monitored.

A nurse told Boucher: "Nobody checked on D. The last time she was seen alive was at 20:55 by an RT. She was found dead at 22:00."

"She did not get what she needed because there was not enough staff. Two nurses cannot properly monitor four very sick patients in three different room (and) the layout of the three code rooms is poor," the nurse was quoted as saying in the report.