Family says coroner's report offers few answers on why woman was found dead on Montreal ER floor

The day after his mother's funeral March 8, 2021, Emmanuel Macarine walked into the emergency room at Lakeshore Hospital and asked to see where her body had beenfound.

He was initially turned down but Macarine insisted and was finally allowed to see the negative pressure room where Candida Macarinedied on the floor, abouthalf an hour before her body was discovered by staff on Feb. 27, 2021.

Themorning of her burial, CBC News had revealed the 86-year-old woman had beenfound on the floor, a detail the hospital omitted when informing the family of her death.

"Our emotions were going from sadness to anger, restlessness," PlacidoMacarine, Candida Macarine's other son, said at the time.

In the more than 18 monthssince, her family says they have met constant roadblocks when trying to seek information on the circumstances of her death.

They say a coroner's report, released to them on her birthday, Sept. 20, has not helped much.

"I thought finally I could go to her grave and say, 'Mom, we finally have answers for you.' Then again, there are still more questions than answered questions," Emmanuel Macarine said alongside his sister Gilda Macarine Tuesday morning.

The two held a news conference at the offices of theCenterfor Research-Action on Race Relations (CRARR) in downtown Montreal, announcing they would be asking Quebec's chief coroner,Pascale Descary, to reopen the case.

The three-page report by coroner Amlie Lavignesays Macarinelikely died naturally of a heart attack,and it makes one recommendation: to improve the surveillance of visual and auditory alerts of patient-monitoring systems at the hospital.

"No element suggests possible negligence or abandonment on the part of the nursing staff," Lavigne said.

Was cardiac monitor used?

But Macarinesays the report failed to dig deeper into some of his family'sconcerns about the events leading up to their matriarch's death.

For example, Lavignenoted that a system to monitor a patient's cardiac activity was available in Macarine's room,but does not question whether it was used at all, or whether staff members did not hear or simply did notrespond toan alarm indicating her distress.

"According to the information gathered, it seems that staff did not notice or hear the alarm at the nursing station," the coroner wrote.

Lavigne also wrote that a blood test conducted on Macarine at 10:26 p.m., hours before she died, displayed "elevated risk" of heart attack, due to a high level of the protein troponinin her blood.

After another test at 2:11 a.m. revealed troponin levels "significantly" increased, staff did not check on Macarineagain for nearly 20 minutes, according to Lavigne.

"My mom should have been brought to the [intensive care unit] immediately for close monitoring," at that point, said Gilda Macarine, who herself works as a nurse's assistant in a long-term care home. She believes her mother was treated differently because she was not a white anglophone.

Lavigne said she questioned why Macarine wasn't checked on soonerbut that experts she consultedat the local health board, CIUSSSde l'Ouest-de-l'le-de-Montral, noted higher quantities of troponinare normal in patients already at risk of heart attack.

The health board oversees Lakeshore Hospital.

Macarine's patient file from the Jewish General Hospital indicated she had a host of health issues, including diabetes, high blood pressure and chronic obstructive pulmonary disease.

Fo Niemi,the director of CRARR, who has been representing the Macarine family, calledLavigne'sreport "skimpy," and said her observations appearambivalent. He wonders whether Macarine's well-being was dismissed due to her existing health issues.

"The question is: Was there no one monitoring her? Shouldn't there be even more monitoring if she is at high risk of a heart attack?" he asked.

Niemi said there were discrepancies between what Lavigne wrote and what family members had read in handwritten notes from staff working that night. The familyreceived those notes in a brown envelope sent to them by an anonymous source.

The document showed Macarine went into cardiac arrest at 2:45 a.m., but the coroner's report said it was 2:30 a.m. Both documents reported her official time of death, following resuscitation attempts, at 3:04 a.m.

Emmanuel Macarinesaid he had also been made aware that a venous blood gas test, which measures oxygen, carbon dioxide and acidity levels, was conducted on his mother. There was no mention of the test in the coroner's report.

Weeks after Macarine's death, the health board admitted "communications with the family were incomplete," and sent the case to Quebec's coroner's office for investigation.

The coroner who was originally appointed to the casewas eventuallyforced to step aside, after the family discovered that she had previously worked as head of the legal affairs for the CIUSSS and could be in conflict of interest. Lavigne replaced her.

A recent memo sent to staff and obtained by CBCincludes a note for staff not to close alerts on cardiac monitors.

"Please do NOT turn off call bell volumes on cardiac monitors or those at patients' bedside. This is an extremely dangerous practice putting the patients and staff licenses at risk," said the note in red letters.

'She was strong'

The Macarinefamily emigrated to Canada in 1992 from their plot of farmland on Mindanao, one of the main island regions of the Philippines. Nine of Candida and Manuel Macarine's children came with them and the two eldest followed in later years.

Emmanuel Macarine, who at 44 is the youngest of six boys and five girls,says his mother was proud of her family's farming roots, and that she was devoted to helping raise her grandchildren.

"Every time I would bring my daughter to their place, she would spend the whole time with her. She was a loving grandma, and that's what I will miss," he said.

The night before his mother was admitted to hospital for trouble breathing (not due to COVID-19), Macarine said she seemed in good spirits, even walking without a cane.

He said he remembers her going to the hospital only one other time since the family arrived in Quebec.

"She was strong, that's who she was," he said, adding his mother relied on traditional herbal medicine, knowledge she gained growing up surrounded by nature.

Candida Macarine is now buried at the Rideau Cemetery in Dollard-des-Ormeauxin Montreal's West Island, alongside her husband, Manuel Macarine, who died a few years before her.

Her son said he hopes her death will push Lakeshore Hospital and the health board to improve their practices and transparency.

"This is not only for my mom," Emmanuel said. "How many families have gone through this situation?"