Coroner outlines series of mistakes that led to Gilles Duceppe's mother being found dead in snow

Hélène Rowley Hotte Duceppe, who died of hypothermia outside the emergency exit of her seniors' residence last January, was stuck outdoors in plain view of a security camera that no one bothered to check for six hours, a coroner has concluded.

The report, published Tuesday, describes that and a number of other mistakes made by staff at the residence where the 93-year-old woman lived. Rowley Hotte Duceppe's son, Gilles Duceppe, is the former head of the Bloc Québécois.

It felt like -35 with the windchill, according to the report, with strong winds and blowing snow, when Duceppe's mother slipped out just before 5 a.m. last Jan. 20, in response to an alarm that went off in her building complex.

Her access card would not allow her back inside via the emergency exit.

An alarm went off as a result of her using the emergency door, but an employee turned it off 20 minutes later without checking to see if someone was outside, Coroner Géhane Kamel said at a news conference at which the report was presented. 

• Gilles Duceppe's mother, 93, found dead of hypothermia outside Montreal seniors' residence

Family considering legal action

The Duceppe family is now considering legal action against the residence, according to their lawyer, Marc-Antoine Cloutier. Cloutier said the residence, Lux Gouverneur in Montreal's east end, has never apologized for what happened.

Kamel wrote in the report that Rowley Hotte Duceppe lived at the residence for about a year. The coroner said she had been nervous about moving in, but her family was supportive and present.

She was rarely alone because one of her two daughters stayed with her five nights a week. Rowley Hotte Duceppe had a "visceral" fear of fires, a daughter told the coroner.

The general alarm had gone off at 4:55 a.m., the coroner said. She concluded that Rowley Hotte Duceppe died just minutes before her body was found by an employee at 11:04 a.m.

The unit the woman lived in had been equipped with a motion detector, but that alarm failed to go off when she went outside, according to the report.

Preventable death

Kamel concluded that Rowley Hotte Duceppe's death could have been prevented, recommending a series of measures that the residence where she lived should take to avoid similar situations in the future. 

She said an intercom and doorbells should be installed at each of the residence's six emergency exits, as well as an indicator panel which would connect all six exits and show when there's an anomaly. 

Her other recommendations include:

• Checking stairways and touring outdoor exits after any alarm is triggered;
• Conducting a head count of residents in each of the residence's three towers after an alarm sounds and coming up with a written emergency procedure for reintegrating residents after an alarm goes off.
• Designating one staff member to be in charge of the residence's safety and to monitor surveillance cameras.
• Making sure residents' medical files reflect their current situations [and are "coded" as such].

A spokesperson for the coroner's office said Kamel met the management of the Lux Gouverneur, and the residence had already been in the midst of updating the buildings' emergency procedure. 

In a separate news release, Lux Gouverneur said it is implementing the coroner's recommendations. It highlighted a line the report pointing out that control of the building is turned over to the Montreal fire service once an alarm goes off. 

Staff were shaken by what happened, it said, and the safety and well-being of residents are a priority.

Quebec Premier François Legault said he was saddened by the death. 

"We can't imagine something like that happening to our mother or grandmother," Legault said.

He said he had read the report, concluding the government wasn't a target of the coroner's findings. 

Just the same, he said, Quebec's minister in charge of seniors, Marguerite Blais, is working on new safety procedures for seniors' homes in the province, "so that never again will this sort of terrible accident happen."