Internal report on Argyll death released

The results of an internal investigation by the CIUSSS de L’estrie – CHUS, the Eastern Townships’ regional healthcare institution, into the events that led up to the death of a patient at the Argyll Pavillion in October of 2016 were released on Friday. The study, carried out separately from investigations conducted by the police and coroner, includes an action plan featuring 23 recommendations.

"This tragic event shook residents, their families, and our staff,” said CIUSSS Deputy President and Directorgeneral Johanne Turgeon. “We quickly put in place the necessary steps to learn what happened and to minimize the risk of it happening again,"

Conclusions of the internal investigation The investigation was conducted by an ad-hoc committee based on the Canadian Incident Analysis Framework of the Canadian Patient Safety Institute. The objectives of the survey were to analyze the event, identify causes, identify contributing factors, establish links between them and propose measures to avoid the recurrence of such events.

At the end, 23 recommendations were made, grouped under three main themes: clinical recommendations, recommendations on environmental safety (living environment) and recommendations on the alert process.

Action plan

"The action plan in place allows us to respond to all the recommendations, and several actions have already been implemented or are underway," confirmed Robin-marie Coleman, Assistant Director of Nursing. A follow-up of the progress of these actions is also being carried out among the directorates concerned and with the family.

Key recommendations include:

• Collect daily data on observations of residents' behavior.

• Ensure that a complete view of the unit is available from the nursing station to optimize the surveillance of the users (e.g. installation of additional surveillance cameras).

• Review the organization of work and adapt it according to the characteristics and needs of the clientele in the specific unit (note that at the time that the death occurred, the staffing on hand met standards).

• Clarify the alert process in an unusual situation (call the police, call the coroner, etc.). To this end, a review was carried out with the custodial staff on the events for which an alert is mandatory, including the suspicious death of a user.

"We wish to reiterate our sincere sympathies to the family,” Turgeon said. “We are all very shaken by this sad event and we sincerely hope that light will be shed on the causes and circumstances that led to the death of this resident. As soon as they are known, we will follow up on the coroner's recommendations. I can assure you that we have a great concern to provide a safe and quality living environment for our residents."

The full report of the internal investigation cannot be made public due to the confidential and nominative information it contains.