11 hours without care: Quebec coroner cites hospital's organizational failures in senior's death

An 80-year-old man died of heart failure at a Châteauguay, Que., hospital after waiting more than 11 hours in an overcrowded emergency room — a case a Quebec coroner says was made worse by organizational dysfunction at the institution.

On Nov. 29, 2023, Yvon Brossoit presented himself at the hospital due to abdominal pain.

He was classified as a code 3 in triage, which means he should have been reassessed every 30 minutes while waiting to see a doctor, coroner Dr. Jean Brochu wrote in his report published Saturday.

But that never happened.

Brossoit's condition deteriorated and he died 11 hours later from a ruptured abdominal aneurysm without having been seen by a medical professional.

Brochu said certain precautions, that would have placed Brossoit in a separate area with a cardiac monitor, were not applied.

And the emergency room was operating at 191 per cent capacity on the day he died.

Majority of recommendations already in place, says CISSS

In his report, Brochu made a number of recommendations, including setting up a computer case management system in the emergency room and assigning a nurse to patients who are waiting on stretchers. 

An investigation carried out by the team in charge of quality, evaluation, performance and ethics following Brossoit's death concluded that "the organizational context, the organization of resources and the operation of the emergency department on Nov. 29, 2023 at Anna-Laberge Hospital certainly had an impact on the evolution of Mr. Brossoit's condition and on the possibility of directing him to the required treatment area."

The investigation also showed that the criteria for referring patients to the emergency department – implemented in February 2023 during a visit by a team from the Ministry of Health and Social Services – were not in place on that day.

"The implementation of these criteria would have allowed Mr. Brossoit to be directed to a stretcher area with a heart monitor and not to be returned to the waiting room," read Brochu's report. 

In an email to CBC News, the office of Quebec's health minister said it would leave it to the hospital to comment on the situation.

The CISSS de la Montérégie-Ouest, the agency that manages the hospital, said it has reviewed the report and implemented the "vast majority" of recommendations.

"There has been a 20 per cent reduction in ER occupancy, a 20 per cent increase in the number of admissions, a reduction in the number of ambulance patients and a significant drop in the average length of stay," said Jade St-Jean, an agency spokesperson, in a statement.

"Among the actions put in place are the implementation of a hospital flow management centre, the addition of a computerized management system in the emergency department [and] improvements to the reassessment process."