Sherbrooke man, 73, 'probably' died from attack by fellow patient, coroner finds

A Quebec coroneris calling for a review of how a public long-term care institution (CHSLD) deals with aggressive patients who suffer from dementiaor other cognitive disorders.

Coroner Richard Drapeau's recommendations come after the death of a patient last fallthat was "probably"provoked by the punchhe received froma fellow resident at the ArgyllPavilion, a CHSLD in Sherbrooke.

Serge-AndrGurin, 73,diedon Oct. 3, 2017. A patient living in the same wing as he did entered his room at around 10:15 p.m.

An orderly who walked in minutes later saw the patient strikeGurinin the face.

Gurin, who was sitting on his bed, went into cardiac arrest andwas pronounced dead just 15 minutes later.

The pathologist who carried out the autopsy concluded that "the altercation may have increased the physiological demand on an already weak heart," Drapeauwrote in his report.

History of violence

The coroner foundthat Gurin'sassailant had numerous past episodes of violenceand hadtried to hit an orderly hours before attacking Gurin.

In a previous episode, he had struck another patient, breaking the person's tooth.

The coroner's investigation revealed that despite this history of violence, the assailant was living in a wingreserved for patients whoshow signs of problematic behaviour, but behaviour that has"little or no consequences" for others.

Drapeaualso noted that the incident with the staff member was not reported to the medical team that night. He recommends that the CHSLDkeepmore accurate records of theirpatients.

The coroner is also recommending theArgyllPavilion review its methods of determiningthe best living arrangements for patients who show signs of aggression.

Patients' rights lawyerJean-PierreMnardsaid while he considers therecommendations appropriate, he said the ArgyllPavilion should have already had all of theprotocols called for by the coronerin place.

"The situation has confirmed a serious lack of basic precautions in that case," said Mnard, who is not representing Gurin's family in this case.He said he hopes the report will raise awareness.

"There was a major lack of organization, assessment and follow-up in this case, and we hope it will be enough to bring change," he said.

Hospitals brings in extra staff, cameras

SylvieMoreault, a director at theCIUSSS de l'Estriewhich manages the Argyll Pavilion, said the regional health agencywelcomes the coroner's recommendations.

Moreault said many of themeasures have already been put in place following the internal investigation that was launched after Gurin's death.

She said an additionalorderly has been added to the night shift, and there is one more nurse on duty during the day to evaluate patients andassesswhether they need more surveillance.

"If the behaviour has changed between the morning and the evening, we have tore-evaluatethe patient right away," said Moreault.

Moreault said the CIUSSS has also encouraged its staff to share patient information more efficiently.

Extra cameras have been added toallow nurses to have better oversight of activity on theirfloor from their work station.

Despite all these changes, Moreaultsaid it's still possible an incident like this one could happen again.

"Zero risk doesn't exist," she said.

Moreault said Quebec's aging population means long-term care facilities across the province will have to increase efforts to deal with a growing number of patients suffering from dementia.

"We are all confronted with the evolution of this clientele which can have unpredictable behaviour," Moreault said.

Criminal charges against the assailant were thrown out because of his mental state.

Residentleft in bed for 36 hours

The coroner's report comes justmonths after Quebec's ombudsman launched aseparate investigation at the Argyll pavilion in November 2017, after families filed complaints alleging residents were sometimes left in their bed for long periods.

The ombudsman contacted the family of one female patient after Radio-Canada reported the woman had been left in her bed for 36 hours.

At the time, the CIUSSS admitted this had been a problem because ofstaffing issues they were trying to resolve. The CIUSSSthen issueda directive to staff, limiting the time a resident could stay in bed to 24 hours.

The ombudsman's report on that investigation hasn't yet been released.