Quebec’s chief coroner has ordered a public inquiry into the death of a quadriplegic man who sought medical assistance in dying (MAID) in the weeks after a hospital stay left him with a severe and painful bedsore.
Normand Meunier, 66, was stuck on a stretcher in an emergency room at the hospital in Saint-Jérôme, Que., for four days in January.
Without having access to a special mattress, Meunier developed a major pressure sore on his buttocks that eventually worsened to the point where bone and muscle were exposed and visible — making his recovery and prognosis bleak.
He was told the sore — a gaping hole a few centimetres in diameter — would, at best, take several months to heal, according to the experts they consulted.
Speaking with Radio-Canada the day before his death, Meunier said he preferred putting an end to his physical and psychological suffering by opting for a medically assisted death.
He died at home on March 29.
Days after his death, Moëlle Épinière et Motricité Québec, an advocacy group for people with spinal cord injuries, demanded the Quebec government launch an independent inquest into what happened at the hospital.
The office of Health Minister Christian Dubé said it is determined to find out what happened and take “corrective action.”
It said Dubé personally called Meunier’s partner, Sylvie Brosseau, a few weeks ago to offer his condolences and let her know that an investigation would be launched.
“A situation like the one experienced by Mr. Meunier in the Saint-Jérôme Hospital should not happen,” the statement said.
Coroner Dave Kimpton will oversee the inquiry, which will hear from interested parties and make recommendations aimed at preventing similar situations in the future.
The details and date of the hearings have not yet been announced.
Special mattress requested
Meunier had previously suffered from other bedsores, but nothing as disabling as the pressure sore he developed after his hospitalization in Saint-Jérôme, a city in Quebec’s Laurentians region about an hour north of Montreal.
He had warned staff he would need an alternating pressure mattress, 145 of which were available upon staff request to the regional health authority overseeing the hospital. But Steve Desjardins, the authority’s director of nursing, previously said adapted mattresses and beds weren’t available in emergency rooms.
“That’s why, if necessary, we’re going to work actively to give them access to a bed in an inpatient unit,” Desjardins said when CBC/Radio-Canada first reported Meunier’s death.
A rotation schedule every two hours is generally necessary for a person confined to bed, according to a Quebec Health Ministry reference sheet.
Brosseau said that as she advocated for her partner, she was told the special bed had to be ordered.
The health authority released a statement reacting to the news, saying it will “fully collaborate” with the inquiry.
“We take the situation regarding Mr. Meunier’s case very seriously. The priority of the CISSS des Laurentides remains to ensure quality and safe care and services for the entire region,” wrote spokesperson Valérie Maynard.
‘Treated like annoying patients’
Patrick Martin Ménard, the lawyer representing Brosseau, says they requested such an inquiry due to its independent and public nature.
“It’s the only forum in which witnesses can be compelled to testify publicly and where we can directly question witnesses about the facts to which they’re privy,” Ménard said.
News of a public inquiry comes as a relief to Ariane Gauthier-Tremblay, a community organizer with Moëlle Épinière et Motricité Québec.
“We are receiving numerous testimonies from our members about gaps in knowledge, in resources and even in basic nursing practices,” said Gauthier-Tremblay.
“Disabled people are often treated like annoying patients rather than knowing patients and this must be denounced and changed.”
She says her organization plans to be a part of the hearings and is supporting Brosseau.
A horrific trip to the emergency department led a Quebec man who is quadriplegic to choose medical assistance in dying after he developed a severe bed sore. Disability activists say Normand Meunier’s death is the result of ‘pure neglect’ at the hospital, which should have had the proper equipment and staff to care for him.
Following the incident, Desjardins said the hospital has been working on skill-development for wound-care nurses.
The Laurentian health authority confirmed that an internal investigation is not yet complete, and that its office that oversees quality and complaints has one complaint related to this situation.
That office has managed 39 complaints and interventions related to bedsores over the past three years.
