2023-12-05 16:30:00
A 57-year-old man died because emergency medical staff at a Montreal hospital ignored his heart monitor’s alarm for 50 minutes in 2021. It was the second death in a few months to occur at the hospital. hospital, where an alarm sounded in vain.
“It’s pure and simple negligence, no compassion,” says Donna Steele Conlin, the sister of Peter Steele, who died at LaSalle Hospital two years ago.
The 50-minute delay before getting to the patient’s bedside is “totally out of the ordinary and directly contributed to the death of Mr. Steele,” deplores coroner Julie-Kim Godin in her report.
«[…] “Excessively precious and vital minutes were lost, even though the situation was urgent,” she wrote. Especially since this was the second similar event to occur at the CIUSSS de l’Ouest-de-l’Île-de-Montréal in 2021, where an alarm was not heard.
Sidelined
Peter Steele was hospitalized following the installation of a cardiac simulator, explains the coroner. The Montrealer suffered from breathing difficulties and had flu symptoms. So, he was placed in administrative segregation.
Peter Steele died in October 2021 at LaSalle Hospital. The alarm on his heart monitor sounded for 50 minutes before staff came to his bedside. PHOTO PROVIDED BY THE FAMILY
But three days later, he was still on a stretcher waiting for a bed, in an area away from the nurses’ station.
At 3:21 p.m. on October 7, 2021, Mr. Steele experienced an episode of ventricular tachycardia, a cardiac arrhythmia, which triggered the heart monitor’s alarm.
A nurse comes by after 10 minutes and notes that the patient “screams at times for no specific reason”, without doing more. “The nurse probably did not perceive the urgency of the situation,” notes Me Godin.
It was not until 4:10 p.m. that a nearby physiotherapist heard the alarm and notified the nursing staff. Mr. Steele is found in cardiopulmonary arrest.
He died from this arrhythmia and because “no care was provided to him”.
His sister, who lives in Edmonton, Alberta, is still struggling to find the personal belongings her brother brought to the hospital, like his phone. “He came in as Peter Steele and died as John Doe,” she said.
Several shortcomings
The coroner notes that the emergency room was 136% occupied that day and that a nurse was missing. The emergency room had seven nurses for 18 patients.
The emergency room of the LaSalle Hospital of the Integrated University Health and Social Services Center of the West Island of Montreal. Photo Agence QMI, JOEL LEMAY
She deplores the lack of surveillance at LaSalle Hospital, the sound level of the alarm being too low, the desensitization of staff to these alarms, the relatively closed and remote location where the patient was located and the lack of staff, among other things. .
No one at the CIUSSS was available to comment on this death linked to the actions of staff. By email, we indicate having added a console to make the monitors more visible and removed the “silence” functions. Training was also provided to read these monitors and reminders were given to staff to remain vigilant.
In February 2021, an elderly woman was found dead at Lakeshore Hospital, without staff “noting or hearing the alarm”.
Excerpts from the report of coroner Julie-Kim Godin
“Such a delay, particularly in the emergency room and given Mr. Steele’s health problems, appears to me to be completely out of the ordinary and directly contributed to Mr. Steele’s death.”
«[…] Excessively precious and vital minutes were wasted, even though the situation was urgent. Mr. Steele did not receive treatment and subsequently died.”
“A safe environment, staff available to ensure continuous monitoring and timely treatment would have significantly increased his chances of survival.”
«[…] A nurse noted that Mr. Steele was in bed and screaming for no specific reason. The nurse probably did not perceive the urgency of the situation, even though it was his responsibility to watch over Mr. Steele.”
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