A Quebec coroner has released the last of three reports looking into the deaths of people receiving care at Val-d’Or Hospital — ones that prompted concerns about the facility’s policies regarding vulnerable patients.
The common thread, Quebec coroner Stéphanie Gamache said, is a lack of co-ordinated care for patients with numerous mental and physical health problems at the hospital in Quebec’s Abitibi-Témiscamingue region.
The three reports make several recommendations, and in this final report Gamache said many of them are already being addressed.
“The hospital and local health agency are working on several fronts to consolidate and improve the services,” Gamache said.
In 2024, the coroner’s office ordered a public inquiry to look into the three deaths, which happened within three months of each other between December 2022 and February 2023.
Ultimately, Gamache decided to conduct three separate investigations, with hearings into the death of 72-year-old Gilles Gaouette held in 2024, and into the death of 32-year-old Pasha Ekoomiak last year.
At the request of the family, the final investigation into the death of a 26-year-old man was not part of the public hearings.
Gamache interviewed witnesses and reviewed documents privately. The final report was made public this week.
Inaction led to marginalization
The 26-year-old was an Indigenous dialysis patient with diabetes who also suffered from schizophrenia and substance abuse problems.
He was taken to the hospital in late December 2022, after family members contacted police saying he had stopped taking medication and going to dialysis treatments.
After seeing a doctor in the ER, he was released.
He died 48 hours later of complications related to kidney failure.
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Gamache noted in the years preceding his death, the patient frequently missed regular dialysis treatments and often ended up in the ER, but that ER staff never questioned him about why he was missing treatments.
“There is no information in the patient’s clinical file which allows me to understand why this situation became a simple inevitability without concerted reflection on the part of the various stakeholders,” Gamache said.
“It seems to me that this inaction in the face of the situation contributed to the patient’s marginalization, leading him to break with the health system that should normally help him get treatment,” she said.
No co-ordinated care for complex health problems
In the final report, Gamache noted that while the circumstances of the three cases were very different, they were connected.
Gaouette was living on the street and dealing with addiction problems when he died. Ekoomiak was also unhoused and a regular drug user with heart problems. The 26-year-old patient was living with family members.
All three had multiple interactions with the hospital and local health and social services organizations in the months leading up to their deaths.
But in each case, Gamache said multiple physical and mental health problems were often looked at in isolation, without any co-ordinated care.
“A common denominator exists, namely the importance of maintaining adequate concerted support to ensure optimal care and services for vulnerable users,” Gamache said.
In the report into the 26-year-old patient’s death, Gamache noted he was living with complex interconnected problems in a precarious social situation.
“A holistic approach could have greatly improved both his physical and mental health,” she said.
Dozens of recommendations
In total, Gamache’s three reports contain dozens of recommendations.
She praised the Val-d’Or Hospital for adopting many of them even before her final report was released.
“The presence of an Indigenous navigator and liaison officer, since October 2023, for doctors and staff at the Val-d’Or Hospital as well as for Indigenous partners is certainly a noteworthy step forward,” Gamache said.
In her report into Ekoomiak’s death, she said the Indigenous navigator position has improved co-ordination and consolidation of complex cases at the hospital.
In the latest report, however, Gamache criticized poor record-keeping at the hospital which she said was a factor in all three cases.
“I cannot help but think that up-to-date and orderly information could have helped in the concerted support needed for the trajectory of services and care offered to this patient,” Gamache said.
Other recommendations included in the three reports include:
- Improving communication between the hospital and Lac Simon Health Centre, where the 26-year-old was also receiving care.
- Training for ER doctors on rules and responsibilities for keeping extremely vulnerable patients in hospital against their will.
- Investigating the possibility of the local health agency creating an emergency shelter for people with addiction problems.
- Studying the possibility of creating transition beds for homeless people to use when they’re discharged from the hospital.
- Ensuring hospital staff request the services of a translator for Indigenous patients when needed.
The local health agency, Santé Québec Abitibi-Témiscamingue, reacted to the latest report in a statement.
“The coroner’s recommendations are being treated with the utmost seriousness and rigour,” the agency said.
“Several areas addressed by the recommendations are already being acted upon or have been implemented in recent years,” it said.
Read More: Lack of co-ordinated care contributed to 3 patient deaths at Val-d’Or Hospital: coroner |