Family of woman found dead on floor at Lakeshore General Hospital ER suing for $1M

The family of Candida Macarine, an 86-year-old woman who was found dead on the floor of a room in the ER at Lakeshore Gen‐ eral Hospital in 2021, is suing the agency that over‐ sees health care on Mon‐ treal's West Island for $1 million.

The lawsuit also names an ER doctor and a nurse at the Lakeshore as defendants.

"The medical services and care provided to the plaintiff‐ s' mother throughout her stay at the hospital's ER were wholly inadequate, causing crucial, cumulative incidents that led to the avoidable death," the lawsuit filed last week alleges.

After the death, hospital staff only told Macarine's family she'd died of cardiac arrest. The hospital didn't tell the family Macarine had been found dead on the floor of an isolation room in the ER that had been flagged to managers as being prob‐ lematic.

The night before her fu‐ neral, Macarine's children came across a CBC News story about an unnamed pa‐ tient who died in that room. They quickly realized the story was about their moth‐ er.

"Staff at the hospital pur‐ posely and voluntarily con‐ cealed critical information from the family," the lawsuit alleges.

"As such, the defendant's staff wrongfully and negli‐ gently failed to inform the plaintiffs about pertinent fac‐ ts leading to their mother's death" the lawsuit says.

The health agency - the

Centre intégré universitaire de santé et de services soci‐ aux (CIUSSS) de l'Ouest-del'Île-de-Montréal - issued a statement a month after the death apologizing for what it called "incomplete communi‐ cations" with the family.

Lawsuit alleges several flaws in care

Macarine died a few hours after being admitted to the hospital with respiratory distress in February 2021.

She was found dead on the floor beside her bed in one of three negative-pres‐ sure rooms in the ER being used at the time for sus‐ pected COVID-19 patients.

Nurses had warned man‐ agers several times in the weeks before Macarine's death about difficulty looking directly into those rooms, making it hard to monitor pa‐ tients there.

The family has been fight‐ ing to get clearer answers ever since. They pushed for a coroner's investigation, but ultimately found the results lacking. After the coroner re‐ fused to reopen the investi‐ gation, they requested their mother's complete medical file, and used both that and the coroner's report to build their case.

The lawsuit makes several allegations about flaws in Macarine's care during her short stay at Lakeshore the day she died, including:

Failure to check on her every 15 minutes as required based on her initial diag‐ nosis. Failure to adequately address two critical test re‐ sults, troponin and blood gas, received earlier in her admission that should've been red flags to send her to the ICU immediately. Failure of nurses at the nursing sta‐ tion to notice or react to au‐ dio and visual alarms that should have alerted them to Macarine's declining condi‐ tion. Contradictory notes from staff working that night as to the exact time a code blue was launched and when Macarine was found dead, raising questions about whether staff were slow to start CPR.

The lawsuit is seeking a total of $1 million: $100,000 for each of Macarine's eight surviving children and $100,000 for each of the fam‐ ilies of two of her children who are deceased.

Assumptions about lan‐ guage

The lawsuit also alleges hospital staff made false as‐ sumptions about Macarine's knowledge of English.

The statement of claim says the ER doctor who first saw Macarine that night indi‐ cated in her notes that the patient spoke "no English, no French."

"The plaintiffs' mother spoke English but did not have her hearing aid with her," the lawsuit says.

"It is unclear how the de‐ fendant communicated with the plaintiffs' mother given this linguistic error, nor whether the nurses shared this assumption," the lawsuit says.

The family alleges that by failing to understand Macarine's linguistic abilities, the hospital contravened her right to information and communication.

'Pattern of negligence' alleged at ER

The lawsuit also alleges "a documented pattern of negli‐ gence at the hospital," citing a Montreal Gazette investiga‐ tion about six troubling deaths in the ER since 2019.

In response to the Gazette story, Health Minister Christ‐ ian Dubé commissioned an independent report on the hospital's emergency room, which recommended urgent renovations to protect pa‐ tient safety.

None of the allegations in the lawsuit have been tested in court.

Alexandre Cadieux, direc‐ tor of communications for the West Island CIUSSS, re‐ sponded to CBC News in an email.

"The staff at the CIUSSS understand that these times are difficult for loved ones," Cadieux said, noting that CIUSSS management had met with the family.

Cadieux said the CIUSSS would not comment on the specific allegations in the

lawsuit, but he said the CIUSSS has made several ad‐ justments to improve the quality of care in the ER at Lakeshore, including:

Monthly meetings of ex‐ perts to analyze adverse events and improve prac‐ tices. Integration of four nursing advisors specializing in emergencies to supervise and support new nurses, pro‐ vide training and strengthen nursing practice. Staff mem‐ bers designated to regularly monitor users at risk of falling making rounds every 15 minutes.

Cadieux also said as of next month the ER will be transferred to a new tempo‐ rary modular building de‐ signed to add space, which he said would guarantee a modern and safe environ‐ ment.

A full-scale renovation of the ER is still years away.

The Macarine family will hold a news conference with the Center for Research-Ac‐ tion on Race Relations on May 9 to talk about the law‐ suit.