Montreal Gazette

Senior's suffocatio­n death could have been avoided, coroner says

- STÉPHANIE MARIN

A death in a seniors' residence at the start of the pandemic last year could probably have been avoided, according to the coroner leading the investigat­ion into Quebec's long-term care facilities deaths.

Sixty-year-old Jacques Lévesque died at Manoir Liverpool in Lévis in April 2020. Lévesque, who did not contract the virus, died of suffocatio­n during an episode of hypoglycem­ia. Coroner Géhane Kamel is trying to determine what happened.

“I find that extremely sad and distressin­g,” Kamel said Wednesday morning at the public hearings into Lévesque's death in Quebec City.

Kamel is responsibl­e for probing the many deaths that occurred in Quebec's CHSLDS and retirement homes during the first wave of COVID -19. One death per residence was chosen to facilitate the investigat­ion.

Lévesque suffered from several medical problems including diabetes. He had hypoglycem­ic attacks, during which he became agitated, even aggressive, according to several employees who testified.

On Wednesday morning, Kamel also heard the testimony of a nursing assistant who looked after Lévesque on the day of his death. The woman could not be identified under a coroner's order preventing the publicatio­n of nursing staff names.

This nursing assistant testified that around 4 p.m. on April 26, 2020, she noticed something was wrong. Lévesque was hungry, his blood sugar was low, so she quickly brought him food and tube glucose. She did not make a glucose injection because there was none in her reserved locker, she said, seemingly unaware that the drug is kept in the refrigerat­or.

Despite the nursing assistant's help, Lévesque's condition deteriorat­ed rapidly.

The woman testified that she wanted to approach Lévesque to assist him, but that her colleague — an orderly — told her not to approach him because of his aggressive­ness. She also told Kamel that she was afraid of Lévesque.

Asked why she didn't call for help, the nursing assistant replied that her priority was to take care of Lévesque, so she chose to call 911. Other employees were later called.

Both the nursing assistant and the orderly then attempted cardiopulm­onary resuscitat­ion manoeuvres on Lévesque while the man was halfway out of bed, which Kamel noted is contrary to practice.

A specialize­d educator, sent to assist the staff at Manoir Liverpool, recounted that the nursing assistant and another staffer told her that Lévesque had suffocated, and that the Heimlich manoeuvre had not been attempted because the employees were afraid of being assaulted. Both women were in shock and cried on the day of Lévesque's death, the educator reported.

When the nursing assistant finished testifying Wednesday, an irritated Kamel did not ask her any questions.

“What I take away from your testimony is that as a nursing assistant, you don't look at your medical records, you don't know the protocol, you don't assist someone who is agitated,” Kamel said. “I remain with this feeling, very present, that it was a death that could have been avoided.”

About half of the COVID-19 deaths in Quebec during the first wave occurred in residences for the elderly and vulnerable, Kamel noted more than once. Coroner's investigat­ions do not aim to find those responsibl­e, but rather to make recommenda­tions to avoid other deaths in the future.

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