Son of man who died waiting for care at Fredericton ER speaks of heartache, frustrations
After inquest, Ryan Mesheau describes seeing security video of his father Darrell's last moments as 'awful'
For nearly two years, Ryan Mesheau has known the details surrounding the death of his 78-year-old father Darrell while he waited for care at the Fredericton hospital's emergency department.
But at the coroner's inquest Tuesday, Mesheau saw for the first time security video of his father's last moments, as he sat alone, slumped and motionless in a wheelchair, before a licensed practical nurse discovered he was unresponsive around 4:30 a.m. on July 12, 2022.
"That was awful," Mesheau told reporters.
Deputy chief coroner Emily Caissy had warned the video might be upsetting to some people and gave them an opportunity to leave.
Mesheau and other relatives remained steadfast in the front row, but were visibly distressed as they watched the last half-hour of their loved one's seven-hour wait for treatment at the Dr. Everett Chalmers Regional Hospital, when other patients sat mere feet away and at least one nurse walked by.
At one point, one family member shook her head, as if in disbelief.
Later, two others glanced at one another, looking perplexed.
"Every medical professional seemed to fail my father the night of his death," Mesheau said.
The night of July 11, 2022, "he was dropped off by ambulance at the DEC ER at 9:30 … left alone in a wheelchair for seven hours in the middle of the floor, and died perhaps 40 minutes before anyone noticed."
If his father had been checked on sooner, Mesheau "absolutely" believes he would still be alive.
Was triaged as Level 3, urgent
The two-day inquest heard that Darrell Mesheau called 911 at 8:56 p.m. and told the paramedic he felt weak and short of breath on exertion. He arrived at the Chalmers ER by ambulance at 9:33 p.m.
At 10:44 p.m., registered nurse Danielle Othen noted he looked pale. She triaged him as being Level 3, based on the Canadian Emergency Department Triage and Acuity Scale, which ranges from Level 1, the most serious, requiring immediate, aggressive intervention, to Level 5.
Level 3 is considered urgent. The national guidelines call for these patients to be seen by a doctor within 30 minutes and reassessed by a nurse every hour.
Othen did not note any of Mesheau's medical history, which included a heart attack and quadruple bypass, diabetes, and high blood pressure. She could not recall if she asked him and said she had no way to access his medical history from the triage area, but agreed with Crown prosecutor Chris Titus such information could be helpful in making an assessment.
A pathologist subsequently determined Mesheau died from heart failure, the jury heard.
Othen, who was working alone in triage during her 12-hour shift that night because the ER was short a nurse, was also responsible for checking the vital signs of patients in the waiting room, but couldn't do both, she said. There were 52 patients in the ER between 7 p.m. on July 11 and 5 a.m. on July 12, and 14 of them were Level 2s, or emergent.
"There was a lineup of patients to be triaged," she said.
"And we were short-staffed, meaning we didn't have all of the staff that we should have had to work properly." Even washroom and food breaks "don't exist when you're short," said Othen.
You know, triage Level 3 is supposed to see a doctor in 30 minutes, and he didn't see one until he was dead, seven hours later.- Ryan Mesheau, son
Licensed practical nurse April Knowles, who was assigned to work on the psychiatric side of the waiting room the day of Mesheau's death but volunteered to help out in the ER, said she checked Mesheau's vitals around 11:15 p.m. before she helped him to the washroom because he complained of feeling weak. His heartbeat, breathing rate, temperature and blood pressure were all within normal limits, she said.
She checked them again at 2:03 a.m. and there was no real change, but she was concerned because he was so pale, so she bumped his chart ahead of three other patients.
But Mesheau still hadn't been seen by a doctor by around 4:30 a.m., when another licensed nurse practitioner told Knowles "he didn't look so good." That's when she went to take his vitals again and found him unresponsive. By then, he was already cool to the touch, meaning he hadn't had any circulation in "quite a while," ER Dr. Shawn Tiller testified.
Ryan Mesheau thinks the system failed his father from the beginning.
"You know, triage Level 3 is supposed to see a doctor in 30 minutes and he didn't see one until he was dead, seven hours later."
Like 'rearranging the deck chairs on the Titanic'
His father's death sparked outrage across the province and prompted a major shakeup of New Brunswick's health-care leadership three days later.
During a news conference, Premier Blaine Higgs announced the firing of Horizon Health Network president and CEO John Dornan, replaced Dorothy Shephard as health minister and removed the boards of both Horizon and Vitalité.
Mesheau described these as "small, insignificant changes," or "window dressing," instead of addressing the "larger, more important issues."
"I guess you can call that rearranging the deck chairs on the Titanic."
Mesheau, who lives in California, said he doesn't have the answers, but hopes the jury's three recommendations will be implemented, even though they're non-binding, and will help. He and his wife still have family and friends here and they worry about their safety, he said.
"I would just like to see, you know, health-care fixed — someone who would tackle this and take it on instead of riding it out and just ignore it."
"The primary reason for government is the health and safety of the citizens."
Difficult but important process
It's been a long and arduous two years for the family, said Mesheau.
"The time kind of deepens the loss."
But they felt it was important to be part of the inquest process.
"We want to … ensure the public is aware of the details surrounding my father's death, and to make sure it doesn't ever happen again," he said.
His father would have believed in the inquest process too, he said. The former diplomat had lived and travelled all over the world, but loved New Brunswick and was active in the community — everything from theatre to church dinners.
"He was a huge member of this community … and this is just really all about helping New Brunswickers."