Quebec coroner finds deficiencies in medical care for man who sought MAID after bedsores

A Quebec coroner has called on the province’s health officials to do better when it comes to preventing and treating patients after spinal cord injuries. a quadriplegic man requested medical assistance in dying in March 2024 due to bedsores following an ER stay.

In January 2024, 66-year-old Normand Meunier spent four days on a stretcher Saint-Jerome Hospital emergency room Coroner Dave Kimpton wrote in his report published Tuesday that there was no access to specialized mattresses because the hospital was over capacity.

The pressure sore on her buttocks grew to such an extent that the bones and muscles were exposed and visible – making her recovery and prognosis bleak.

In its report, Kimpton highlighted the need for guaranteed and prompt access to therapeutic mattresses for spinal cord injury patients. He also called on the province to create an advisory committee aimed at preventing and treating bedsores with new equipment and training.

“The prevention and management of these complications is not the responsibility of any single medical specialist,” the report said, emphasizing a multidisciplinary approach.

Special mattress, concerns not given priority

At the public inquiry into Meunier’s death earlier this year, Kimpton heard from staff at the Saint-Jérôme hospital, Meunier’s widow, Sylvie Brosseau, as well as. Moël Épinier et Motricité Québec (MEMO-QC) – An advocacy group for people with spinal cord injuries.

During his testimony, Brosseau described the Saint-Jérôme hospital as “totally negligent”.

Kimpton says that despite repeatedly stressing the importance of a proper mattress for Meunier and the worsening of his wounds, Brosseau’s concerns were not prioritized.

He says there must be a change in institutional culture in this regard, as spinal cord injury patients and their partners are developing an expertise that should be valued.

Instead, there was a significant decline in trust between Brosseau and hospital staff during Meunier’s last visit between late February and March 5, 2024, when he was “cast in the role of adversary to health care professionals,” Kimpton says.

On March 4, Meunier requested medical assistance in dying (MAID). He died a few weeks later on 29 March.

Since 2023, at least a dozen MEMO-Qc members have requested MAID due to health problems and “a health care system that doesn’t take care of them”, the group’s president, Walter Zelaya, testified at the inquiry.

inadequate equipment, lack of communication

Meunier first developed bedsores in 2022 after a series of hospitalizations and by 2023, they became incurable, meaning Meunier’s specialized nurse who dealt with the wounds focused on treating existing wounds and preventing new ones.

Lesions develop when the soft tissue communication between the bone and the solid surface is disrupted due to prolonged pressure on the area.

Kimpton writes, “Analysis of his medical history shows that all of the injuries identified arose or worsened during his hospitalization.”

He says that the various hospitals Meunier visited focused only on the problem described at the beginning of his visits without adequate consideration of his condition or susceptibility to bedsores.

At the Saint-Jérôme hospital, in addition to inadequate equipment, Kimpton says there was a lack of communication between staff and improper record-keeping to keep track of Meunier’s wounds or how often he was moved, which was required to happen every two hours.

Coroner described widow as ‘real warrior’

Kimpton addressed its 31 recommendations to Santé Québec, CISS des Laurentides, which manages Saint-Jérôme Hospital, Quebec’s Ministry of Health. College des Medicines and the Order of Nurses of Quebec.

In a statement, the CISSS des Laurentides says it met the coroner’s recommendations “with great openness and a firm commitment to continue the reform measures already taken since Mr. Meunier’s death.”

Kimpton says that Brosseau was a “real warrior”, a tireless supporter of Meunier in the fight for survival.

He says, “However, this observation makes me think especially about all those people with spinal cord injuries who are not fortunate enough to receive this kind of support.”

“I sincerely hope that a comprehensive approach inspired by my recommendations will bring about a wave of change.”