'Our hearts were broken, just shattered': recalling deadly mix-up at former Sudbury hospital
Inquest ruled that at least 9 of the 23 deaths investigated were caused by blending of gas lines
After months of complicated testimony and finger pointing, in the spring of 1974, the inquest into 23 patients who may have been killed by mixed up gas lines at the former Sudbury General Hospital, narrowed it down to nine.
Jacqueline Dupuis was relieved to see her sister Suzanne's name on the list.
The 16-year-old had tried to kill herself in June, 1973 by taking too many of her dad's pain pills. She then had second thoughts and asked her mother to take her to the hospital.
She never walked out.
During the inquest it had been argued that she died of a drug overdose and not due to a deadly blend of nitrous oxide and oxygen in the mask that was applied to her face.
"The thought of her dying because she committed suicide was more than we could bear," said Jacqueline Dupuis, now 64. "Because we knew her as such a wonderful person. I couldn't take it."
Jacqueline Dupuis said her sister had found out she was pregnant and feared how her strict father, who worked at the Copper Cliff smelter, would react.
Her parents and six other brothers and sisters never fully recovered from Suzanne's death and are stalked by addictions to this day, Dupuis said.
"Our hearts were broken, just shattered."
She married the same year as the inquest, and in 1975, returned to the general hospital to give birth to her daughter.
"I was totally petrified that they were going to kill me too," Dupuis remembered.
"I kept saying to my husband 'don't let them put any masks on me. Don't leave my side. Don't leave the baby's side.'
"I knew it was probably not going to happen again," she continued. "But they killed my sister. And that's how I look at it. I don't look at it as an accident. I look at it as neglect and negligence."
Dupuis said she thinks of her sister often, especially now that's living with terminal cancer.
"She's going to be at the gates waiting for me. I can't wait to see her, but I'll wait," she laughed, who, despite her diagnosis, is planning to get married next summer.
What happened?
A new wing at the hospital was added over the winter of 1972-73, with the first patients being admitted to the new emergency rooms in May, 1973.
Over the next five months, there were 23 suspicious deaths that would eventually be the subject of a coroner's inquest.
It was called following the death of Catherine Dominic, 6, in September, 1973. The Dowling, Ont. girl broke her arm falling off a swing, but died on the operating table after an oxygen mask was put on her face.
Some blamed the hospital, others pointed the finger at doctors and nurses who didn't test the gas before hand, but most of the focus was on the contractor and architect hired for the $6 million project and the flawed schematics for the gas system that were followed during the construction.
In the end, no specific fault was assigned.
"It is safe to say that many of those involved only gave 75 per cent. Which was not enough," coroner Ross Bennett said at the inquest.
The inquest jury concluded that at least nine of the deaths were directly connected to the gas problem:
- Richard Lagrandeur, 3, of Garson, near drowning.
- Andrew Solomon, 54, Wikwemikong, cardiac arrest
- Gervais Albert, 75, Sudbury, stroke
- Catherine Dominic, 6, Dowling, broken arm
- Suzanne Dupuis, 16, drug overdose
- Anna Bihum, 68, Sudbury, cardiac arrest
- Hilma Lehto, 72
- Alina Jacobson, 55, Walden, shortness of breath
- Randolphe Freake, 16, Agincourt, cut his leg during visit to Sudbury
The CBC television program Newsmagazine, hosted by Lloyd Robertson, did an episode on the Sudbury inquest. It aired in March, 1974, before the jury had ruled and the lawyers for the hospital argued they should be barred from watching it.
The coroner said he didn't have the power to enforce that kind of restriction on them.
Here is the audio from that program:
