Death at the Saint-Raphaël CHSLD: the Coroner Formula four recommendations

Better evaluating the patients accommodated whose state deteriorates considerably. Nevertheless, this is the first recommendation of the Coroner Arnaud Samson, who looked at the death of a resident of the Center for Hosting and Long-Term Care (CHSLD) in Saint-Raphaël, in Bellechasse.

The 93 -year -old lady died last January after a fall. Furthermore, In its report, the Coroner notes the lack of medical clinical evaluation within 24 hours of falling.

All this While the state of [la résidente] was significantly deteriorated. Therefore, to the point of requiring the administration of opioids for pain relief.

This is why he recommends at the integrated center for health. In addition, social services (CISSS) in Chaudière-Appalaches and at CHSLD death saint-raphaël chsld: coroner formula of Saint-Raphaël to ensure that a doctor performs a complete clinical evaluation in the event of significant degradation of the state of health of a resident in CHSLDespecially when the hospital transfer is dismissed.

He also recommends raising better awareness doctors with professional obligations surrounding the evaluation of a symptomatic. Meanwhile, resident in the context of long -term care.

Doctor consulted by phone – Death saint-raphaël chsld: coroner formula

It was during an afternoon of the end of January that the. Similarly, resident suffering from major neurocognitive disorders fell trying to get up from her chair.

She was immediately taken care of by the nursing staff. Nevertheless, who noted that she seemed unable to put weight on the left legunderlines the coroner. death saint-raphaël chsld: coroner formula However, At that time, the resident receives acetaminophen to relieve her pain.

For his part. Moreover, the attending physician was notified by phone of the accident until the next morning, while the pain of the resident persisted. Meanwhile, He called one of his relatives to present the risks and advantages of a transfer to the hospital.

A few hours later. Therefore, it was a physiotherapy technician who came to assess and try to immobilize the resident, still suffering. Therefore, During the night, she received antipsychotics.

The next day. almost two days after the resident fell, A nursing note mentions a suspicion of hip fractureindicates the report. In the morning, the doctor was again contacted by phone. It increased the dose of analgesics.

At the beginning of the afternoon. a discussion between the nurse and the relatives of the resident made it possible to reassess the level of care, these then being reoriented towards comfort. The lady dies in the evening.

The Patient Protection Council requires better

The account of death saint-raphaël chsld: coroner formula events shocks Paul Brunet. president of the Council for the Protection of Patients. [Cette] fall should not have taken placehe said, indignant.

Since the 10 years that I have commented on the annual reports on accidents. incidents [en milieux de soins]the falls still come firsthe deplores.

According to him, the resident follow death saint-raphaël chsld: coroner formula -up protocol should have been better applied. There must be follow -up as soon as the fall occurred. then that it is brought to the attention of the staff. Someone, a doctor, a practitioner nurse must do somethinghe believes. If that is not done, it’s like it didn’t matter.

Paul Brunet says he can see that his organization receives more. more complaints from families, a loved one died following a fall.

According to him, it is a deplorable increase, because there are several ways to reduce the incidence of a fall. How is it that the beds are not lower. that there are no alerts when the person falls from his bed? Are there mattresses, cushioned floors?illustrates the president of the Council for the Protection of Patients.

Two other coroner recommendations

Coroner Arnaud Samson makes death saint-raphaël chsld: coroner formula two other recommendations to Cisss of boiler-appeals in connection with this event.

He first recommends him to watch to what discussions in CHSLD Regarding the level of care is systematically carried out by a doctor. a specialized practitioner nurse (IPS)as required by ethical rules. This was only done once in two in this case.

Then he advocates clarify with teams CHSLD The respective roles. responsibilities of nursing staff, doctors, and other stakeholders in the clinical decision -making process.

Two death saint-raphaël chsld: coroner formula coroner surveys in a year in Saint-Raphaël

This is the second time this year that. the Coroner office has focused on the death of a resident in the CHSLD of Saint-Raphaël after a fall.

In January, he published a report concerning the death of a resident in July 2024, mediated in the regional press. The 75 -year -old man had lost his life while the CHSLD de Saint-Raphaël were moved to the former infirmary of the Saint-Damien-de-Buckland convent due to work.

The septuagenarian died after a series of four falls. In his case, the Coroner Nancy Gilbert had concluded that these falls were avoidable.

When the resident arrived at CHSLD From Saint-Raphaël, the teams had screened its risk factors for falling. A second screening had been redone a month later and was accompanied by security measures.

However, after his move to Saint-Damien-de-Buckland, he had not undergone any new screening, despite a contrary indication of the procedure.

After having looked at the thread of the events. the Coroner Gilbert had recommended recalling to nursing staff the importance of applying the prevention program for falls Cisss of boiler-appetizers following a change of living environment.

CISSS studys recommendations

By email. the Cisss de Chaudière-Appalaches indicates that he is currently analyzing the recommendations of the Coroner concerning the death of January 2025.

For the death in July 2024. We made sure that the recommendations are walking with the team of CHSLD For their implementation, among other things for the application of the fall prevention program, both following a change in living in life and at the other times provided for in the resident’s life pathindicates the Cisss by email.

A reminder was made to all managers of CHSLD to plan the re -evaluation during possible movesconcludes a spokesperson.