A SON’S ANGUISH
Mother’s death in care home haunts man
Jeannette Fleury lay crumpled on the ground outside Carlingview Manor for an hour last April before officials at the long-term care home found her, according to her son. When found, the 79-year-old woman had no pulse. Luc Fleury said Friday he’s angry about the death of his mother, who plummeted from her third-floor bedroom window at the Carling Avenue long-term care home on April 17. He said he’s especially angry it took so long for anyone from the home to find her. “It’s supposed to be a secure floor. I know everyone is (shortstaffed), but why didn’t they look more? They found her an hour later, that’s what they told me.” According to a provincial investigation, security cameras captured Jeannette Fleury entering her room at 8 a.m. She was recorded falling head first to her death less than two minutes later. A staff member who entered the room at 8:30 a.m. noticed it was cold and that the lower slider windows had been removed. She called maintenance and had the windows put back in, all without looking for Jeannette Fleury, who was supposed to be closely monitored because of her frequent attempts to escape, according to inspectors. The worker told investigators she was busy with another resident and assumed Jeannette Fleury had gone to breakfast. “They saw she wasn’t in the room but thought maybe she’s someplace else, so we’re going to put back the window and that’s it,” said her son. “They didn’t look.” Inspectors with the Ministry of Health and Long-Term Care found that windows at the eight-storey building, which were supposed to open no more than 15 centimetres to prevent falls, were in poor repair, not inspected regularly and routinely removed by cleaning staff, sometimes in front of residents. Cleaning staff could easily take the windows out of their frames without the help of special tools, according to the report, and sometimes had difficulty putting them back in securely. Revera Inc., which runs the home, said it bolted every accessible slider-style window shut after Fleury’s death. It has also conducted a window safety audit of its 50 long-term care homes across the province and is “making safety enhancements” to prevent windows from being removed from tracks, Brooke Allen, vice-president for operations and long-term care, said in a statement. “Revera has reviewed the Ministry of Health and Long-Term Care’s report in detail and is working to ensure that this kind of tragic incident does not occur again in any of our homes,” said Allen. “Our thoughts remain with the family of the resident who passed away.” Fleury said he was told another resident was in the fourperson room when his mother fell from the window, but that unnamed person would not be capable of giving any information about what happened. The third floor of the long-term care home is a locked ward, mainly for residents with dementia or those who wander. Speaking publicly for the first time about his mother’s death, Fleury said his mother was discovered between a large garbage container and the rear wall of the building around 9 a.m. on April 17. Police notified him of her death later that afternoon. She had recently been moved to the third floor from the second, he said, where she had been involved in a relationship with a male patient. Because both patients had some level of dementia, staff decided they would have to be separated, Fleury said. Once she was moved to the third floor, she became agitated, talking about being in a “jail” and wanting to get out to see her friend one floor below. In the days before her death, she pulled the fire alarm and managed to get into the stairwell and onto the second floor, according to the investigation. Because of her “exit-seeking” behaviours, she was supposed to be checked at least once an hour, something that wasn’t done the morning she fell. “She wanted to get out and they didn’t want to let her go out, and they didn’t have any person to go with her to take a walk, so she was stuck on that floor.” Fleury was told that video footage from a camera behind the building showed that his mother first stuck her hands out of the window and then her head, before plummeting to the ground. She had her purse and a scarf with her. He was told by officials at the home that she didn’t try to kill herself. Fleury said he believes she simply wanted to get out, and stuck her head out the window to see how far it was but lost her balance. Fleury said his mother was healthy and only had mild cognitive impairment, as far as he knew. She had lived at Carlingview for several years, originally in an apartment on an upper floor with a male partner. When he died, she was moved into a room and eventually onto the secure floor. The ministry’s inspection report found that the home knew she had exit-seeking behaviours and knew that the windows could be easily removed. Fleury said Friday he hadn’t received a copy of the ministry’s investigation into his mother’s death. The regional coroner’s office has been in touch with his family, he said. He’s waiting for the coroner’s investigation to be complete before deciding what his next steps will be. The death is still under investigation, said regional coroner Dr. Louise McNaughton-Filion, and will likely be referred to the geriatric and long-term care death review committee. The committee reviews deaths and makes recommendations to prevent future deaths. Fleury, meanwhile, said he remains shocked at the way his mother died. “I know some day everybody has to die, but not that way.”
They saw she wasn’t in the room but thought maybe she’s someplace else, so we’re going to put back the window and that’s it.