Family asks coroner to reopen investigation of woman found dead on floor of Lakeshore ER


The household of Candida Macarine, the 86-year-old woman who was found dead on the floor of a room within the ER of Montreal’s Lakeshore General Hospital in February 2021, has written to Quebec’s chief coroner asking her to reopen the investigation into the dying.

CBC has obtained a duplicate of a letter the household drafted with the assistance of Center for Research-Action on Race Relations (CRAAR) to Quebec’s chief coroner, Pascale Descary.

“The household and CRARR have critical and legit causes to consider that the report made by coroner [Amélie] Lavigne incorporates main omissions of essential and pertinent proof,” the household mentioned within the letter. 

The household believes if the case had been extra totally examined, the coroner would have come to a special conclusion on the causes and circumstances of Macarine’s dying.

And they counsel that race and language might have performed a job within the remedy Macarine acquired on the hospital.

Candida Macarine, pictured right here with one of her 17 grandchildren and her first nice grandson, was the matriarch of a big Filipino household based mostly in Montreal. (Submitted by Emmanuel Macarine)

The report from coroner Lavigne launched final month concluded Macarine probably died naturally of a coronary heart assault, and that there was nothing to counsel attainable negligence or abandonment on the half of nursing employees.

The report’s lone suggestion was for the hospital to enhance surveillance of visible and auditory alerts of patient-monitoring programs. 

At the time of Macarine’s dying, the hospital didn’t inform the household that Macarine had been found dead of the floor of a room within the ER that employees had flagged to managers as having visibility issues, making it troublesome to monitor sufferers there.

The household solely found that after seeing a CBC information story the morning of Macarine’s funeral.

Since then it has been an uphill battle to get extra data from official sources, and the coroner’s report is simply the newest in a string of disappointments.

Family says coroner missed key information in medical file

The household wrote to the coroner after reviewing all of the medical recordsdata the coroner had in its possession. The detailed letter spells out a number of issues the household believes the coroner missed, together with:

  • When Macarine was admitted to the hospital, she was given a triage code of P2 — that means she ought to have been assessed by a nurse each quarter-hour — however there isn’t any document of anybody checking on her for practically three hours the night time she died
  • Macarine was stored in preventive isolation in a room removed from the nurse’s station with restricted visible entry regardless of her critical situation and the very fact she had examined adverse for COVID-19.
  • A blood gast check indicated that Macarine had a “very vital acidic situation” that ought to have been handled.
  • There’s no proof Macarine was ever positioned on a cardiac monitor regardless of her historical past of critical coronary heart issues.

The household believes Macarine wasn’t correctly monitored and may have been positioned in intensive care hours earlier.

“The coroner didn’t even query how, regardless of each audio and visible alarms, there was nobody on the nursing station who heard and noticed these alarms,” mentioned the household.

“These are questions that the coroner ought to have probed and defined in her report,” they mentioned.

Family: coroner ought to have thought-about language, race

The household additionally famous one of the docs on obligation that night time wrote in his notes that Macarine spoke neither English nor French. The letter mentioned that is not true and that Macarine may communicate English however wasn’t carrying her listening to support that night time.

“That ought to have triggered a reflex to evaluate extra rigorously the character and high quality of care given to Ms. Macarine,” the letter mentioned.

“How did this perceived lack of data of spoken official languages affect her remedy?” the household’s letter requested.

“The troubling query that has sadly lingered within the minds of members of the family upon studying this ‘no English, no French’ line is: ‘How did hospital employees talk along with her through the 4 hours she was within the hospital?'” the household’s letter mentioned.

Macarine’s household additionally attracts comparisons between the investigation into Macarine’s dying and the investigation into the dying of Joyce Echaquan, the Atikamekw woman who died in a Joliette hospital in 2020 after employees made racist remarks.

A coroner’s report concluded systemic racism performed a job in Echaquan’s dying.

“When in contrast to the spectacular contextual evaluation and examination by the coroner of medical employees’s conduct and testimonies within the Joyce Echaquan investigation, which, in our opinion, units new requirements for investigation of conditions of deaths of individuals whose race or ethnicity might be an element, Coroner Lavigne’s report is critically flawed,” the letter mentioned.

“We urge you to order a brand new investigation into the dying of Ms. Macarine in gentle of missed information and new information introduced to your consideration,” the letter concludes.

Jake Lamotta-Granato, a spokesperson for the coroners workplace, responded to CBC in an electronic mail.

“The chief coroner will look at and rigorously analyze any request from the household as quickly as attainable,” Lamotta-Granato mentioned.

The hospital had promised to renovate the ER to enhance monitoring of sufferers within the weeks after Macarine’s dying, properly earlier than earlier than the coroner’s report was launched.

Those renovations haven’t but occurred.  A spokesperson for the native well being company that oversees Lakeshore, the CIUSSS de l’Ouest-de-l’Île-de-Montréal, advised CBC in an electronic mail Monday that these renovations are nonetheless within the “planning levels.”

Members of Macarine’s household and CRARR are set to maintain a information convention Tuesday in Montreal to focus on the case additional.


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