Science Question

Consider Joyce Eshaquan or Brian Sinclair’s stories for this reflection, share more about how you would be a change agent in these systems. Within both reports it was noted that racism was an influencing factor. In this hypothetical reflection, where there are no limitations to your creativeness (meaning unlimited $, staffing, time, etc.) You are a part of management that has been tasked with ensuing that this doesn’t happen again. What would be your plan (consider outlining types of educational topics, or types of programs would you like to implement? What types of programs have you seen before). I’ve attached the final reports to their investigations- I would say if you need some inspiration have a look at the recommendations.

Questions to consider:

1. How would do relate the client’s story? What feelings do you have as you consider doing this work?
2. How has this story changed your perspective on the Canadian Healthcare system? If so, how?
3. If you were in charge what would you do to educate/support your staff?
4. What safety measures would you put in place for Indigenous clients?

Investigation Report
Law on the investigation of the causes and circumstances of death
FOR THE PROTECTION OF HUMAN LIFE
concerning the death of
Joyce Echaquan
2020-00275
Me Géhane Kamel
Delta 2 Building
2875 Laurier Boulevard, Suite 390
Quebec City, Quebec, G1V 5B1
Telephone: 1 888 CORONER (1 888 267 6637)
Fax: 418 643 6174
www.coroner.gouv.qc.ca
Table of contents
INTRODUCTION ……………………………………………………………………………………………. 3
IDENTIFICATION OF THE DECEASED …………………………………………………………… 3
CIRCUMSTANCES OF DEATH ……………………………………………………………………….. 3
EXTERNAL EXAMINATION, AUTOPSY AND TOXICOLOGICAL ANALYSIS ………. 3
ANALYSIS …………………………………………………………………………………………………….. 4
THE FACTUAL OUTLINE ……………………………………………………………………………….. 4
The Sûreté du Québec investigation ……………………………………………………………… 4
Mrs. Joyce Echaquan……………………………………………………………………………………. 4
Care by the Centre hospitalier de Lanaudière ……………………………………………….. 5
MY FINDINGS ……………………………………………………………………………………………….. 7
Overworked staff ………………………………………………………………………………………….. 14
Training and meeting the other ………………………………………………………………………. 15
The social pact …………………………………………………………………………………………….. 18
CONCLUSION …………………………………………………………………………………………….. 20
RECOMMENDATIONS …………………………………………………………………………………. 20
ANNEX I ……………………………………………………………………………………………………… 22
THE PROCEDURE ………………………………………………………………………………………. 22
ANNEX II …………………………………………………………………………………………………….. 23
LIST OF EXHIBITS ………………………………………………………………………………………. 23
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INTRODUCTION
On September 28, 2020, Coroner André Cantin takes notice of the death of Mrs. Joyce
Echaquan.
Mrs. Joyce Echaquan died at the Centre hospitalier de Lanaudière following unsuccessful
resuscitation manoeuvres. Questions were raised about the quality of the care received by the
patient and the inappropriate comments made about her.
On October 6, 2020, the Chief Coroner of Quebec, Me Pascale Descary, ordered a public
enquiry into the death of Mrs. Joyce Echaquan, which occurred in Saint-Charles-Borromée on
September 28, 2020. I have been appointed to preside over this enquiry, to shed light on the
causes and circumstances surrounding this death, to identify the contributing factors and to
make recommendations, if any.
On April 28, 2021, Dr. Jacques Ramsay, Coroner, was appointed to act as an assessor at this
Inquest.
IDENTIFICATION OF THE DECEASED
Mrs. Joyce Echaquan was visually identified by a relative who was at her bedside at the
hospital.
CIRCUMSTANCES OF DEATH
An investigation report from the Sûreté du Québec’s Major Crime Section indicates that on
September 26, 2020, Mrs. Joyce Echaquan was transported by paramedics to the Centre
hospitalier de Lanaudière. Mrs. Echaquan had been suffering from stomach pains in the form of
stabbing pain for a fortnight; episodically at first and then in a crescendo, for the past 24 hours.
During her hospitalisation on September 28, 2020, Mrs. Echaquan suffered a cardiorespiratory
arrest and resuscitation manoeuvres were initiated by the medical staff, without result. She was
pronounced dead at 12:44 p.m.
The Sûreté du Québec handled this case in assisting the coroner.
EXTERNAL EXAMINATION, AUTOPSY AND TOXICOLOGICAL ANALYSIS
An autopsy was performed on September 29, 2020 at the McGill University Health Centre. In his
report, the pathologist notes the presence under microscopy of the heart, of characteristic cells,
named Aschoff’s cells, grouped in clusters forming Aschoff’s bodies. This is a very suggestive
(pathognomonic) sign of a rheumatic disease, in this case chronic and recurrent (active)
rheumatic carditis. This diagnosis was confirmed by a cardiopathologist at the Centre hospitalier
de l’Université de Montréal.
The heart is large and his ventricles are dilated, suggesting cardiac malfunction. This is
consistent with Mrs. Echaquan’s medical history, which includes episodes of heart failure that
fluctuate over time. Finally, the pathologist notes engorged and very heavy lungs (over 2000 g),
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suggesting that heart failure could be the cause of death. The presence of a defibrillator was
noted.
The Laboratoire de sciences judiciaires et de médecine légale conducted the usual toxicological
analyses on October 7, 2020. The tests revealed the presence of diphenhydramine,
acetaminophen and morphine, all within a therapeutic threshold. Traces of lorazepam, cannabis,
duloxetine and metoprolol were also detected.
On 7 January 2021, I requested an additional analysis to contextualize the intake of haloperidol
(Haldol®) (an anti-agitation medication). Again, the concentration found in the blood was at a
level considered as therapeutic.
ANALYSIS
The death of Mrs. Joyce Echaquan and the public enquiry that followed have caused deep
distress to her family and to the Atikamekw community of Quebec. It also harshly confronted
Quebec society as a whole.
In this regard, because of the very high emotional toll associated with this tragedy, it is
imperative to mention that my analysis is in no way intended to determine the criminal or civil
liability of the health care institution or of any individual. Rather, the entire process is intended to
seek the truth about the circumstances surrounding Mrs. Echaquan’s death and the factors that
contributed to it.
The analysis of the events leading up to the death (the factual framework) can be divided into
three factual segments: the conclusions of the Sûreté du Québec investigation, Mrs. Echaquan’s
medical history, and the treatment by the Centre hospitalier de Lanaudière (also known as the ”
Hôpital de Joliette”).
THE FACTUAL OUTLINE
The Sûreté du Québec investigation
On September 30, 2020, Mrs. Echaquan’s file at the Sûreté du Québec’s Major Crime
Investigation Service in Mascouche was seized from them, following the transfer of
responsibility from the investigation office of the Joliette MRC.
During the investigation and based on the information obtained from the various witnesses, the
Sûreté du Québec concluded that no criminal offence had been identified. Consequently, the file
was not submitted to the Director of Criminal and Penal Prosecution.
Mrs. Joyce Echaquan
Mrs. Echaquan is a 37-year-old mother of seven children, of whom she was very proud. She is
described by her partner and family as a loving mother, a religious person and a person
dedicated to her community. She loved life and, had it not been for her health problems, would
probably have had more children.
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Mrs. Echaquan was known to have a significant medical history, including diabetes and severe
non-ischaemic cardiomyopathy resulting in heart failure with an ejection fraction (EF)1
fluctuating at very low values as monitored over the years, i.e. between 38% and 10%. An
acetaminophen intolerance was also noted.
Care by the Centre hospitalier de Lanaudière
Mrs. Echaquan was hospitalised at the Centre hospitalier de Lanaudière between the evening of
September 26, 2020 and the early afternoon of September 28, 2020, when she was pronounced
dead.
I retained the services of Dr. Alain Vadeboncoeur, an emergency physician at the Montreal
Heart Institute, as an expert. His expertise was not contested by the parties. Dr. Vadeboncoeur
enabled us in particular, to determine the trajectory of the medical stay and to specify the cause
of Mrs. Echaquan’s death.
On September 26, 2020, at approximately 11:00 p.m., Mrs. Echaquan arrived by ambulance at
the Centre hospitalier de Lanaudière. The triage nurse’s initial assessment mentions in her
progress note that Mrs. Echaquan had been complaining of intermittent stabbing epigastric pain,
non-radiating, accompanied by palpitations and dyspnea (orthopnea) for the last two weeks.
The pain is said to be constant at 10/10 since the previous afternoon. She also suffers from
nausea and food vomiting after meals and has been eating and hydrating very little for the last
two weeks.
Upon arrival, and in order to rule out a coronary syndrome, which can sometimes manifest itself
as epigastric pain, an electrocardiogram and a cardiac enzyme test are ordered. These tests
are normal. The presumptive diagnoses retained are therefore epigastric pain with a gastric
appearance despite an unremarkable gastroscopy just a few weeks ago, and anaemia. Her
admission diagnosis was a recently exacerbated microcytic (small red blood cells) iron
deficiency anaemia (haemoglobin down from 107 to 81 g/L within a month) and epigastric pain
of an unknown cause. A referral was made to the on-call gastroenterologist and Mrs. Echaquan
was kept under observation. The gastroenterologist planned to do a colonoscopy the next day
to ensure that the cause of the anaemia was not in the large intestine. To do this, the
anticoagulant is stopped and a bowel preparation is given. For pain, the analgesia is adjusted.
On September 27, 2020, the gastroenterologist saw Mrs. Echaquan again, as she was showing
signs of agitation. A possible withdrawal from narcotics and cannabis was mentioned, but no
real use prior to the episode could be demonstrated.
Mrs. Echaquan reportedly said that she had taken medication and been prescribed morphine for
similar pain in August of 2019. An antiemetic (Maxeran®), a benzodiazepine (Ativan®),
acetaminophen and an opioid (morphine) were prescribed and administered to reduce nausea
and symptoms associated with withdrawal and pain.
1 The ejection fraction refers to the ability of the heart to eject a certain percentage of blood present in its
cavity.
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The gastroenterologist scheduled the colonoscopy for the next day. In order to determine
whether there was indeed a possible disorder related to drug use or withdrawal, a request for a
consultation was sent to the Joliette Addiction Rehabilitation Centre. This evaluation, as
reported to the doctor on September 28, 2020, concluded that the symptoms described by Mrs.
Echaquan were not related to physical withdrawal from opioids or stimulants.
Also on the afternoon of September 27, 2020, instead of a nurse, a candidate for the practice of
nursing (CPNP) was in charge of Mrs. Echaquan. Although the diagnosis was uncertain at best,
the nursing staff presented Mrs. Echaquan as a patient in withdrawal.
At about 8:00 p.m., the gastroenterologist saw Mrs. Echaquan again , as she was agitated and
complained of generalized pain. Despite the medication, the agitation was not controlled. Fourlimb restraints and a lap belt were applied. Close monitoring was prescribed. At 10:10 p.m., Mrs.
Echaquan was calmer and the restraints were removed. She remained calm until the morning.
On September 28, 2020, at about 7:40 a.m., a patient who is on a neighbouring stretcher asks
Mrs. Echaquan if she can borrow her mobile phone to reach her son’s school. Mrs. Echaquan is
cordial and the two women talk for a while.
At 9:53 a.m., Mrs. Echaquan exhibits agitation and generalized discomfort. She was given 1 mg
of Ativan®. At 10:10 a.m., Mrs. Echaquan screams and falls, initially described as intentional by
the nursing staff with probable cranial impact. This fall, according to the testimony heard, was
more likely to be accidental, due to a sudden movement of Mrs. Echaquan on his stretcher. The
doctor was informed of the situation. She prescribed a dose of Haldol ® 5 mg intramuscularly
and, if the Haldol ® was not effective, restraints would be used. Mrs. Echaquan was moved from
the stretcher to a cubicle with an anteroom and toilet. The Haldol® is administered at 10:25.
Sometime between 10:35 and 10:45 a.m., Mrs. Echaquan films herself with her mobile phone
and posts the video in real time on the Facebook social network. Two members of the nursing
staff were with Mrs. Echaquan at the time. It is understood from the video that Mrs. Echaquan
fell off her stretcher again. Denigrating words are spoken by the nursing staff. She was put back
on the bed, the intravenous infusion was reinstalled, and then restraints were applied, first to all
four limbs, before the abdominal belt was installed. The video is made without the knowledge of
the staff on site, except at the very end, and lasts 7 minutes and 12 seconds.
At 11:22 a.m., close monitoring was ordered. However, despite several requests to do so by the
CPNP, who had been given responsibility for patient Echaquan, the orderlies were unable to
carry out this monitoring. The CPNP therefore carried out visual surveillance through the cubicle
window until 11:35 a.m., at which time Mrs. Echaquan’s condition deteriorated. The CPNP
admitted that there was a discrepancy between the notes in the file and the actual surveillance,
as it was completely overwhelmed by the events, which were compounded by a particularly
busy day and several other users under its responsibility requiring significant surveillance.
At this point, Mrs. Echaquan is unresponsive and her pulse is barely perceptible at best, despite
the fact that the medical record shows 70 beats per minute. She is hardly awake, her pulse is
reportedly present and her breathing is regular. What is certain, however, is that from 11:39 and
onwards, there is no longer anything regular about her breathing, as evidenced by a second
video broadcast in real time on Facebook by her daughter when she arrives at her mother’s
bedside. This broadcast lasts 10 minutes and 49 seconds and is recorded between 11:39 and
11:49.
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At 11:49 a.m., the CPNP belatedly notes that Mrs. Echaquan is unresponsive to pain and
notifies the doctor. At 11:45 a.m., the vital signs indicated were “blood pressure 57/35, heart rate
77 beats per minute, oxygen saturation 90% on room air. A transfer to the resuscitation room is
requested by the CPNP and the doctor is notified. The room where Mrs. Echaquan is located is
equipped to perform resuscitation. There was a delay before the transfer because the room had
to be cleaned according to the rules applicable in the context of the health crisis related to
COVID-19. At 11:56 a.m., she was transferred to the resuscitation room: Her breathing was
shallow, with six breaths per minute, and there was no verbal response. The doctor was at the
bedside and the four-limb restraints and lap belt would be removed. At 11:58 a.m., the cardiac
monitor indicated an asystole. Resuscitation is initiated. Resuscitation was carried out according
to the established procedures, but to no avail, since death was declared by the doctor at 12:44
p.m.
MY FINDINGS
I have listened carefully to all the evidence and, although my investigation must focus on
detailing the cause of death and establishing the circumstances, I cannot ignore the context in
which the death occurred.
More than 44 factual witnesses were heard. During the testimony of the nursing staff, divergent
and sometimes contradictory versions were told. It is in this particular context that I had to base
my observations.
As soon as she arrived at the Centre hospitalier de Lanaudière, Mrs. Echaquan was quickly
labelled as a narcotics addict and, based on this prejudice, her calls for help were unfortunately
not taken seriously. For example, during her stay at the same hospital in August of 2020, Mrs.
Echaquan cries a lot and complains that she is not believed when she expresses her pain. The
doctor’s note is eloquent as it states “she is dissatisfied and has a tendency to manipulate”.
When she was hospitalised in September of 2020, once again, this label of drug dependence
followed her throughout her stay and guided the actions of the nursing staff until her death. The
medical staff even referred to alcohol withdrawal, which constitutes erroneous information. The
evidence heard during the hearing also showed that Mrs. Echaquan only consumed narcotics
that were duly prescribed and in quantities insufficient to create a dependence. At the time of
her admission to the emergency room, no Medication Reconciliation (MedRec) indicating the
medications that had been prescribed to Mrs. Echaquan was completed. A completed MedRec
would have been an essential working tool to enable the treatment team to properly document
Mrs. Echaquan’s pharmacology and to act accordingly.
When questioned in turn during the hearings, no doctor or staff member of the Centre intégré de
santé et de services sociaux (CISSS) de Lanaudière was able to tell us what Mrs. Echaquan’s
diagnosis of narcotics dependency was based on. Nor will they be able to inform us of the
clinical basis on which this diagnosis is established (apart from the notes in the previous
medical file, which date back a few years and have not been reassessed). In the testimony of
the gastroenterologist, he will admit that the term narcotics addiction may induce a bias in
people’s minds. A conversation also allegedly took place between Mrs. Echaquan and another
doctor at the hospital. This conversation is poorly documented in the medical file and leads us to
believe that Mrs. Echaquan was uncomfortable being relieved with morphine. Indeed, Mrs.
Echaquan criticized the health care providers for never resolving her pain and simply sending
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her home with painkillers. This is the most likely theory, given the side effects of her last
hospitalizations.
When discussing the various diagnoses, the doctor usually uses the question mark when raising
an untested hypothesis. It is therefore important, especially for other doctors and nursing staff,
to avoid jumping to conclusions, as seems to have been the case with Mrs. Echaquan. A
hypothesis must remain a hypothesis until it is validated.
This is the case when the gastroenterologist reports withdrawal due to lack of medication or
cannabis use. Mrs. Echaquan reportedly said she had taken medication. During the day, he
prescribes morphine and Ativan® and requests that she undergo a colonoscopy the next day.
He indicated that she could be discharged afterwards.
In this sense, the consultation with the Addiction Rehabilitation Centre on September 28, 2020,
is indicated since it aims to confirm or refute the diagnostic hypothesis. It should be recalled that
this evaluation concluded that the symptoms described by Mrs. Echaquan are not related to
physical withdrawal from opioids or stimulants.
The day before, on September 27, 2020, at 2.17 a.m., the nurse notes: “advised [sic] patient to
calm down and wait for medication to take effect [sic] […] agitated on stretcher, crying +++, lyre”.
When questioned about her choice of words, the nurse told us that we should rather translate
this as : “I understand your pain, Madam”. The rest of the night was particularly calm.
At 2:18 p.m., Mrs. Echaquan was questioned by the nursing staff about her consumption. It is
stated: “Says she uses pot 3 times a day and more, says she has never had withdrawal
symptoms. Blames nausea again”.
At about 5 p.m., the gastroenterologist is called on his pager by the nurse. The nurse’s note
states: “…patient has had an episode of palpitations and wants to know if he can prescribe a
drug for withdrawal”. Although the electrocardiogram taken earlier showed a sinus rhythm which
turned out to be normal, her palpitations should probably have prompted greater caution in
taking care of Mrs. Echaquan. The medication prescription was also transmitted.
At 7.20pm, Mrs. Echaquan said that she felt unwell, that she was having palpitations again and
that she did not want to die.
At around 7.45 p.m., Mrs. Echaquan got up from her stretcher and found herself on the ground.
She mentions feeling dizzy. She got up with the help of three staff members. However, no
incident or accident report was completed at that time, and no assessment of the pain was
made following the fall.
At 19:55, it is noted that Mrs. Echaquan is “cooperating but [is] very theatrical”. The words set
the tone of the care.
At 20:39, Mrs. Echaquan is agitated. She is placed in restraints. A private orderly service was
present at her bedside. At 9:39 p.m., still in restraints, the fluid intake protocol for the
colonoscopy was started. At 10:10 p.m., the restraints were removed.
Staff also weighed Mrs. Echaquan when she arrived at the hospital. She was weighed again on
September 28, 2020. She weighed 92.2 kg, which is surprising since the day before she
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weighed 87.09 kg. She would have gained 5.2 kg in a few hours. The doctor in charge of
hospitalizations in family medicine, justified this error by a reference weight recorded the day
before, and therefore not real, which is questionable at the very least.
On September 28, 2020, at 8:45 a.m., the gastroenterology resident also saw Mrs. Echaquan,
who had tremors, but these did not necessarily seem credible. When questioned about her
medical notes, including the fact that she indicated that the patient was narcotics dependent
according to the patient’s partner to whom she had not spoken to, and the fact that she had
taken the trouble to indicate that Mrs. Echaquan had seven children, the resident was not very
forthcoming. There is every reason to believe that the resident also drew on the previous notes
and also jumped to conclusions too quickly.
In the testimony of the doctor in charge of hospitalizations in family medicine, they explained
that the restraint measures were applied at Mrs. Echaquan’s request because she starts
screaming and getting agitated when she is in withdrawal and no longer feels like herself. I
would like to express my doubts concerning this allegation, as it seems absurd to me to imagine
a patient asking for restraints.
It should be recalled that the policy on the exceptional application of control measures
(restraints, seclusion and chemical substances), adopted on January 28, 2019 by the institution,
provides, among other things, that chemical substances, restraints and seclusion must be
considered only as a control measure and only as a last resort. In Mrs. Echaquan’s case, we
note that she was mechanically and chemically restrained and isolated without constant
supervision. Moreover, the same policy requires that a record be kept of the use of control
measures. This restraint was not documented on the form provided. At no time were alternative
measures offered to alleviate Mrs. Echaquan’s fears, such as the obvious and simple option of
having a member of the Atikamekw community stay at Mrs. Echaquan’s bedside. However, this
idea of cultural accompaniment never crossed the mind of any member of the hospital’s
caregiving community, despite the availability and presence in due form of an Aboriginal liaison
officer. In doing so, the choice of restraint, supposedly required by Mrs. Echaquan herself, was
certainly not an optimal solution in the circumstances.
At around 9:50 a.m., Mrs. Echaquan becomes agitated, screams and moans. The justification
for withdrawal was again mentioned. Shortly afterwards, she fell, which a witness first described
as intentional, but then changed their mind; the fall could have been accidental. The notes in the
medical file still state that “she is theatrical”. A few witnesses admitted that colleagues thought
she was acting at times during the morning. Mrs. Echaquan has clearly been labelled a difficult
patient. It is a prejudice that will remain ingrained in the minds of many staff. For her part, Mrs.
Echaquan’s stretcher neighbour said she had a front row seat to the lack of humanity of some of
the attendants and nurses, telling us that she heard one of them say to her colleagues, “She
threw herself to the ground, you know. According to this witness, Mrs. Echaquan screamed that
she was afraid of dying. A nurse reportedly said: “Stop shouting, you’re disturbing everyone
here. We’re not in a daycare centre here, we don’t manage babies. For this witness, the care is
simply devoid of empathy and she doesn’t understand why the nurses make fun of Mrs.
Echaquan. During the hearings, this testimony provided a clear picture of how care can be
provided with a double standard depending on where a patient comes from and with the label
they are characterized with.
At around 10:16 a.m., Mrs. Echaquan was still shouting, but she was not struggling and was
somewhat calmer. The doctor in charge of consultations and hospitalisations in family medicine
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then stated that she had been alerted on her mobile phone. She understood that the patient’s
screams were due to agitation and not to any pain.
However, without having seen Mrs. Echaquan, she then prescribed chemical restraint with 5 mg
of Haldol® and, if necessary, physical restraint with close monitoring. A witness told us that the
doctor had initially prescribed a dose of 3 mg, but then changed her mind and told the CPNP:
“We’ll give her 5 mg to calm her down as much as she needs. Although the dose is not strictly
inappropriate, since it is the same dose suggested in the manufacturer’s monograph, what we
believe to be true is that it is at least questionable. The doctor, by not taking the opportunity to
see the patient in crisis in person, also missed a great opportunity to better understand what
was causing her patient’s erratic behaviour. Instead, she endorsed the judgement of her
colleagues and supported a diagnosis of withdrawal that was not supported by any evidence.
Then came the time for the Haldol® injection, at around 10:20. Mrs. Echaquan is calm and even
exposes her buttocks to receive the injection. Just before the transfer, Mrs. Echaquan’s attitude
varied, according to the witnesses. She seems absent. In turn, she is seen repeatedly banging
her occiput against the wall, then cradling herself on the stretcher with her legs crossed. She
asks for her mobile phone. She no longer screams, but is obviously agitated, possibly suffering.
According to the staff heard during the hearings, this behaviour is worrisome, even frightening to
the other patients in the vicinity. Shortly after 10:25 a.m., it was therefore decided to transfer her
to alcove 10 and isolate her. At about the same time, Mrs. Echaquan’s cousin, who was also
under observation in the emergency room reported hearing Mrs. Echaquan say her partner’s
name and calling for help.
At around 10:27a.m. after her transfer, Mrs. Echaquan posted her video live on Facebook. The
comments speak for themselves. The translation was provided by the Sûreté du Québec:
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“Ni cta ni akohikon: It hurts me
Carol pe ntamici : Carol, come see me
Ni taci sa micta mackikikatakoiin: They are overdosing me with drugs
Wipatc tca: Make it quick […]
3 min 59 s: We’ll leave it on the ground for a while, eh.
4 min 21 s: We’ll look after you. I think you’re having a hard time taking care of yourself
right now. But we’ll do it for you, OK?
Asti of a thick tabarnouche.
This is better off dead […].
5 min 25 s: Patient starts moaning loudly.
Are you done messing around! Are you done with that… piss off.
Joyce: If you were in my shoes right now.
Hey, you’re thick in the head
Joyce: I don’t like it when people tell me I’m being silly about it.
Well, you made some bad choices, baby
What would your children think, seeing you like this?
Joyce: That’s why I came yesterday.
Well, it’s better for stuffing than other things… eh
Especially since it’s us who pay for it…
6 min 9 s : Joyce moans loudly.
His damn cell phone is there. ”
When the nurse realises that the conversations between her and her colleague are being
recorded, she grabs the mobile phone and hurries to erase the recording, which is not possible
because it has already been broadcast. As for the beneficiary attendant, according to her, her
comments should only be seen as benevolent. During her testimony, she defended herself by
saying that she had been taught to provoke patients to make them react. In fact, according to
her, these were not condescending or reductive remarks, but rather a way to make Mrs.
Echaquan feel proud so that she could take charge of her life.
Both would deny having any racial prejudice, one responding that she would have reacted the
same way to “a woman on welfare with lots of children”. We did hear the apology that the nurse
and the orderly made to the family during the investigation. The treatment of Mrs. Echaquan is
nonetheless unacceptable. Moreover, the fact that neither of these individuals admitted to
having a racist bias raises doubts about whether their introspection was sufficient. The very fact
that they did not admit to having a bias is even more distressing, as it illustrates this lack of
compassion for a human being.
In the meantime, another beneficiary attendant, who had been made aware of the video,
immediately notified the manager that Mrs. Echaquan had filmed employees. The manager then
inquired about the situation, but did not fully appreciate it until late in the evening when she was
sent the second video, which was recorded by Mrs. Echaquan’s daughter. Yet she had also told
the nurse earlier in the day not to worry, even though she had seen the video taken by Mrs.
Echaquan. The social worker had also informed her of a call from the clinic referring to insults to
Mrs. Echaquan, including calling her “thick”. She did not seek to investigate the situation with
the seriousness required when the events were related to her. When asked about alleged
derogatory remarks by staff, the head of the department said that this certainly existed, but that
she had not witnessed it. However, a nurse reported that she had informed the head of
department in the past that derogatory remarks had been made to a Syrian family who needed
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an interpreter, expressing the desire “not to waste too much time with them, [as] they are not
from here”. No sanctions or investigations were carried out as a result of this denunciation.
In the case of Mrs. Echaquan, had it not been for the video footage, it is likely that this event
would never have come to public attention. When the system withdraws defensively into itself,
that is the very definition of systemic racism. Systemic racism is insidious. The Commission des
droits de la personne et de la jeunesse (CDPDJ) defines 1it “as the sum total of disproportionate
exclusionary effects that result from the combined effect of prejudiced and stereotypical
attitudes, often unconscious, and policies and practices that are generally adopted without
regard to the characteristics of members of groups prohibited from discrimination. ” Although
sometimes unintentional, this form of racism has the effect of perpetuating the inequalities
experienced by people of indigenous origin. Unfortunately, Mrs. Echaquan is not alone in her
experience. Members of the community, including Mrs. Echaquan’s brother, have expressed
similar fears because of past experiences that were similar. When Mrs. Echaquan’s daughter
arrives, she films her mother. Mrs. Echaquan is in a five-point restraint. To her eyes, she looks
dead. Her testimony is heartbreaking, she tells us: “I will regret all my life that I did not untie
her”. The video recording allows us to see that Mrs. Echaquan’s respiratory amplitude is not
perceptible. About a minute into the video, CPNP is seen going to Mrs. Echaquan’s bedside.
The CPNP tries to get a response from Mrs. Echaquan by calling out to her and gently shaking
her shoulder. She takes the vital signs and obviously does not get the expected values, as she
tells Mrs. Echaquan’s daughter that she needs to make a call to transfer her to the resuscitation
room. The CPNP returns two minutes later and takes the vital signs. The CPNP explained,
without appearing very convincing, that Mrs. Echaquan’s lack of response was due to the
medication. In fact, and the expert also concurs, Mrs. Echaquan was in an advanced coma at
the time, which required immediate and vigorous treatment.
At about the same time, around 11:35, the gastroenterology resident sees Mrs. Echaquan and
her assessment is surprising. The resident introduced herself, as the patient had mentioned that
she wanted to leave the hospital before the procedure scheduled for early afternoon. She
therefore had to validate Mrs. Echaquan’s wishes and, if necessary, have him sign a refusal of
treatment. This refusal was of course not signed given Mrs. Echaquan’s condition. The doctor’s
notes indicate: “calm, attached to all 4 limbs, difficult to wake up”.
When asked about her assessment, the resident explained that, as she was not the attending
physician, her assessment had been cursory. Mrs. Echaquan’s daughter had hoped for more,
certainly that the doctor would detect her mother’s critical condition. In the end, the resident’s
visit was a blip. She found the atmosphere unpleasant and sought to leave the room quickly.
The daughter wanted the mother to be taken care of, and a family member said that they had
asked that the situation be taken seriously. The resident translated this conversation as threats
from them. When questioned about the threats, the resident was also less than forthcoming, as
she had no recollection of what had been said. She did not call the doctor who was responsible
for Mrs. Echaquan.
Simultaneously, at about 11:35 a.m., a nurse went to her department head to request a transfer
to the intensive care unit for Mrs. +Echaquan. In the meantime, the CPNP called the doctor
several times and, when she did not receive an answer, requested her urgently via the central
intercom. Several witnesses heard the CPNP’s repeated calls to the microphone for medical
assistance. The doctor’s version that she moved on the first call is simply not credible. The
1 Brief to the Office de consultation publique de Montréal as part of the public consultation on systemic
racism and discrimination. November 2019.
Page 12 of 28
evidence showed that the doctor had arrived slightly before or at the same time as the transfer
to intensive care. This situation unfortunately shows how the CPNP was left to its own devices
and how Mrs. Echaquan’s chances of survival were diminishing by the minute. In the end, it was
an experienced orderly who took the initiative to force the transfer to the resuscitation room. In
her eyes, Mrs. Echaquan was in a critical situation.
Once her death was confirmed, civilian witnesses heard the nursing staff express relief that this
patient was no longer an inconvenience. They said that they heard: “Indian women like to
complain about nothing, to get stuffed and have children. And it’s us who pay for it. At last she is
dead.”
On October 9, 2020, the head of the department sends an email to the health care team stating
that: “…from now on, when you use a 4 limb restraint you must notify the NCA (Nursing Care
Assistant). A private service will be requested and to the extent that it cannot be provided, the
patient will have to be transferred to intensive care. … Monitoring should be at least every 15
minutes if all 4 limbs are restrained. ” This note essentially repeats what was already provided
for in the establishment’s protocol on restraint measures. It should be remembered that Mrs.
Echaquan was not entitled to this monitoring and that her condition was not reassessed by a
doctor. Although intramuscular injections in themselves do not require special monitoring, in this
case, in the presence of a patient with a well-documented heart failure status, the injection of
the antipsychotic drug, combined with the additional physical restraint, required the utmost
caution. It is even more surprising to learn that prior to this death, the staff was not familiar with
the restraint protocol that was in place at the institution.
The CPNP probably did not have enough clinical experience to understand the risks involved.
This was not the case, however, with the experienced nurse who gave the injection. She did not
show more caution. Could it be that Mrs. Echaquan’s behaviour had clouded her judgement?
Without doubt, the comments heard on the recording suggest that this may have been the case.
As soon as the injection was given and the restraints were applied, she left for her lunch break
without worrying about any possible complications.
The CPNP admitted that the medical notes indicating Mrs. Echaquan’s condition were entered
late, that they were confusing, and that monitoring was done through the glass of the cubicle
because of time constraints. The CPNP was the only one to admit of this major shortcoming in
record keeping, while throughout the hearings we witnessed inconsistency between the
testimony and what was actually recorded in the file.
Page 13 of 28
The clinical situation could have been reversible if there was :
 Increased monitoring by an experienced nurse was put in place or, failing that, a
more rapid transfer to the resuscitation room was made;
 An assessment by the doctor responsible for inpatient admissions in family
medicine, had been made using a different approach before authorizing a new
sedative;
 Monitoring of the control measure (restraint) had been implemented as
prescribed;
 Early recognition of her precarious condition had been detected;
● A protocol for the early launch of a Code Blue existed;
● Early correction of sources of instability had been considered (hypoglycemia,
hypotension, pulmonary edema);
● Cardiac monitoring and saturometry had been installed.
The autopsy and the expert’s report suggest that Mrs. Echaquan died of pulmonary edema. No
arrhythmogenic event (which would have been observed on the pacemaker worn by Mrs.
Echaquan) was involved. Moreover, no ischaemic event was observed at the autopsy.
Therefore, cardiomyopathy must be referred to as the cause of death. Other factors could have
been involved, including the hypotension caused by the injection of Haldol® and the restraints
that kept Mrs. Echaquan pinned against her stretcher without the possibility of straightening up,
a natural gesture when there is an accumulation of water on the lungs. The presence of fluid in
the pulmonary alveoli can be responsible for a decrease in the quality of gas exchange, leading
to significant breathing difficulties.
Overworked staff
During the hearings, several employees described the work overload, particularly the disparity
between the emergency room at the Centre hospitalier de Lanaudière and the emergency room
at Hôpital Pierre-Le Gardeur. This disparity is real and well documented. It is therefore not
uncommon for employees to have to take time off from their breaks and lunches to provide care.
On August 12, 2020, an email from a nurse was forwarded to the head of the department
reporting great difficulties for the care staff, including the fact that they do not have time to
adequately supervise the CPNPs and that, at this rate, without the necessary staffing, the health
of the patients could be compromised. This nurse also informed him that, under these
conditions, she no longer wished to do replacement work as an ASI.
On October 29, 2020, the union representatives (FIQ-SIL) once again sounded the alarm by
reiterating that the care professional/patient ratios in the ED are inadequate: CPNPs working in
the emergency department are placed in situations that do not comply with the Regulation
respecting professional activities that may be performed by persons other than nurses, the
dyads between nurses and nursing assistants are not adequately defined and the care team
has expressed to its department head the need for clinical support by having access to clinical
monitors. These requests went unheeded under the former president and director general.
Furthermore, on the day of Mrs. Echaquan’s death, the occupancy rate at 8 a.m. was 37
stretchers at observation. At 11:00, 42 stretchers were occupied. The ED occupancy rate was
Page 14 of 28
therefore at 112% at 8:00 a.m. and at 127% at 11:00 a.m., which is not unusual for Quebec
EDs.
The issue of CPNPs was widely discussed during the hearings. According to the nursing rule
of the Centre intégré de santé et de services sociaux de Lanaudière (CISSS de Lanaudière),
adopted in July 2018, college-trained CPNPs cannot practice in the emergency department. It
also notes that, for all levels of education (college or university training), “CPNPs are not
authorized to practice in triage, in the shock room and in the ambulatory sector of the
emergency department.” Management has agreed to bring CPNPs back to the ED in 2019,
relying on experienced nurses to support and train their younger colleagues. However, the
CPNPs are considered full nurses in the staff planning of this department, which frequently
sees unstable patients. In other words, this solution was created to deal with staff shortages,
but it also created significant risks for patients in the Centre hospitalier de Lanaudière
emergency department. According to a senior management official, the Ordre des infirmières et
infirmiers du Québec has endorsed this practice. However, there is no written confirmation of
this. This situation alone was a harbinger of things to come.
When the CPNP requested assistance from the assistant head-nurse to provide close
supervision of Mrs. Echaquan, the assistant head nurse told the CPNP to find an orderly
herself, which the CPNP attempted to do, but without success. The assistant head-nurse never
visited Mrs. Echaquan to assess the situation, nor did she offer any support to the CPNP, who
had just under four months’ experience.
Training and meeting the other

Some of the witnesses heard from the hospital centre, stated that their work environment was
free of racism or even derogatory comments. A few ventured towards the opposite, claiming to
have heard clear prejudices against the Atikamekw community.
When asked about the mandatory three-hour training they all have to attend, which started after
Mrs. Echaquan’s death, the employees said that they did not learn anything in particular and
that it was not helpful in their daily practice. This is worrying as, since Mrs. Echaquan’s death, all
testified that the bridges between the two communities had been eroded. On one hand, the
Atikamekw community is even more afraid of going to the hospital to obtain necessary care and
on the other hand, the caregiving staff is afraid of not being up to the task or that their words will
be misinterpreted by Atikamekw patients.
I have not personally viewed the training, but I have had access to the details of the offer of
training. I note that the desire expressed by staff for ultra-targeted, concise training relevant to
their practice, while legitimate, also reflects a certain paternalism that would like racism to be a
simple concept, that can be addressed in the form of capsules before moving on to the next
topic. To be detected, racism must be understood as camouflaged in the dominant culture.
Saying Kwei (greetings) is good, but it is not enough.
In fact, fighting racism and prejudice starts with opening up to the other community. I believe
that this was the basis of the three-hour training offered to employees. Perhaps this training
could be improved, but looking for shortcuts to sustain the attention of the staff is perhaps
indicative of their lack of interest even after they have, individually and collectively, had to deal
with the devastating effects of Mrs. Echaquan’s death.
Page 15 of 28
Nevertheless, several witnesses asked for awareness training concerning problems faced by
Aboriginal women in particular, which would be carried out in collaboration with Aboriginal
communities. The Centre hospitalier de Lanaudière had also offered its employees training on
cultural safety in 2019, but barely 3% of those invited, mainly nurses, had participated.
Surprisingly, the CISSS sends the information to employees at their personal email address.
This raises legitimate questions about whether employees are receiving the communications
intended for them and whether the associated privacy settings are being respected. This
situation is not part of my investigative mandate, but it is nonetheless noteworthy.
An Aboriginal liaison officer from the Atikamekw Nation was also employed by the hospital at the
time of the events. Surprisingly, very few employees knew her and no one within the institution
had taken her under their wing to help integrate her. With no designated office, she wandered
the corridors or waited for requests for support from home. On the day of Mrs. Echaquan’s
death, despite her hospital card identifying her as a liaison officer, she was denied access to the
emergency room even though she was made aware of the situation by a community member.
She tried several times to enter the emergency room to be at his bedside. However, since her
ID card is not a real employee card, she is denied access. When she tries to make calls to
understand the situation, she is told that there is no time to talk to her, and then the discussion
is ended, despite the fact that she was the available and appropriate resource under the
circumstances. I would even dare to say that she was the only resource that could have made a
difference in terms of cultural safety for Mrs. Echaquan.
It must be admitted that this position has given the CISSS a good conscience, but has definitely
not been used to its full potential. In reality, the liaison officer is at best an ornament placed on a
shelf for show. If more attention had been paid to the fact that Mrs. Echaquan was Atikamekw,
not only would the Aboriginal liaison officer have been called in, but her medical file could have
been assessed with the cultural dimension associated to the situation. This would have allowed
health professionals to better consider the possible implications of her medical condition.
The CISSS recognized that the liaison officer had been left aside and committed to hiring two
cultural safety liaison officers. One of these positions has already been filled and the other is still
to be filled. This second position will be filled by a person from the Manawan community in order
to offer a 24/7 service. The real challenge will be to involve these liaison officers and to make
room for them within the institution. Real accountability will be required to reassure the
Atikamekw community about the reconciliation process.
In September of 2019, the report of the Viens Commission, the Public Inquiry Commission on
Relations between Indigenous Peoples and Certain Public Services, was tabled. This report set
out some calls to action directed at the CISSS de Lanaudière, including the lack of emergency
ambulatory service for Manawan. As indicated by Chief Paul-Émile Ottawa in his testimony, the
pandemic occurred a few months after the Viens Commission report, so the community and the
CISSS de Lanaudière did not have the opportunity to implement solutions to respond to the
report’s calls for action. However, the CISSS de Lanaudière had already responded to some of
the Viens Commission’s calls to action, even before the report was tabled. In fact, pre-hospital
transportation (ambulances) for Manawan was put in place, which was a priority for the
community.
The hospital’s leadership is aware of the gap that has been created. The new president, director
– general herself has acknowledged that the gaps between what is conveyed and what is
experienced are different worlds unto themselves. It was noted that the CISSS de Lanaudière
must take steps to deconstruct prejudice and eradicate discrimination. As stated by some of the
factual witnesses and by witnesses from the recommendations component, prejudices and
biases towards Aboriginal communities exist at the Centre hospitalier de Lanaudière. These
biases can be manifested implicitly through prejudices associated with Aboriginal communities
Page 16 of 28
(drug addiction, alcoholism, large families, unhealthy lifestyles, etc.) or explicitly through
inappropriate comments about Aboriginal communities. Unfortunately, these prejudices do not
seem to be exclusive to this hospital. They seem to exist everywhere in the Quebec health and
social services network, as testified to by Dr. Stanley Vollant and Mrs. Michèle Audette.
Each individual therefore has a personal responsibility and has to question his or her own
actions. The staff of the hospital is dedicated and this involvement is felt and recognised.
Acknowledging prejudice does not diminish the professionalism of employees. On the contrary,
it is when the problem is not recognised that professionalism is called into question.
The hiring of an Atikamekw person as vice-president or deputy director-general, is an important
first step towards this reconciliation. The new president and director-general’s open-minded
approach is an undeniable source of hope for the Atikamekw community and the Lanaudière
population in general.
Dr. Stanley Vollant has highlighted the disparities in treatment between Aboriginal communities
and native Quebecers. He himself had to fight these prejudices for a long time. He used the
image of the red apple on the outside, as the Innu that he is, but white on the inside, as the
doctor obeying his caste of affiliation, to illustrate how he sought to deny his own cultural history
in order to gain acceptance in the health system. This call to break down the walls of
misunderstanding, to train liaison officers, to hold facility management accountable for followups, to increase the number of health care workers in the communities, and to rebuild trust in
the health care system resonated during the hearings.
Cultural safety was one of the lines of thought provided by many witnesses, including Dr.
Stanley Vollant. However, he felt that it was necessary to go beyond this concept, i.e. to respect
culture and differences, but also to learn to communicate and understand the other,
independently of their culture and origin.

The Director of Aboriginal Affairs at the Ministry of Health and Social Services (MHSS) indicated
during the hearings that cultural safety is clearly a government and a sectoral priority. She also
presented the global plan for the implementation of this concept in the health network for 20202025, a plan that tentatively started in 2018, but whose work has been more significant since
November 2020. During the hearings, we learned that, within the MHSS, individuals are
designated to be responsible for Aboriginal issues throughout Quebec. When we consulted the
list of these people produced for the public enquiry, we found that, in the vast majority of cases,
they are senior executives or their deputies who are responsible for the Aboriginal file among
several other files under their responsibility, the exceptions being Nunavik, James Bay Cree
Lands and the Naskapi CLSC. Moreover, no plan, however laudable, can succeed without the
active participation of Aboriginal communities in its design and implementation. I note that both
the MHSS and the CISSS are still largely in the hands of white people. Should we be concerned
about this? In 2021, it is obvious and redundant to say that the presence of Aboriginal
communities is a prerequisite in the development of all policies and programs that concern
them.
That being said, the work of the MHSS is necessarily a sign of hope. This plan shows several
similarities to the Joyce’s Principle proposed by the Atikamekw Nation, without naming or
adopting the principle. Joyce’s Principle aims to ensure that all Aboriginal people have the right
to equitable access, without discrimination, to all health and social services and the right to
enjoy the highest attainable standard of physical, mental, emotional and spiritual health. In
doing so, the MHSS plan aims to put in place a plan with $15 million in funding to implement
cultural safety by 2025 in all healthcare settings. The five actions planned between now and
2025 are the implementation of continuous training, the accompaniment of the network’s
Page 17 of 28
establishments, the creation of liaison officer positions, services browsers and the overhaul of
the complaints review system.
With respect to the complaints process in particular, it needs to be rethought. We understood
during the hearings that mistrust of institutions makes it difficult for a person of Aboriginal origin
to initiate the complaint process and then to pursue it in a system in which that person does not
recognize themselves. In this regard, we should be remember that in recent years, only about
ten complaints from people of Aboriginal origin have been recorded at the CISSS de
Lanaudière.

In this regard, the MHSS’s advisory commissioner for the complaints examination system came
to present the law aimed at strengthening the complaints examination system in the health and
social services network, which came into force on June 1, 2021. The establishment of an
advisory commissioner for Aboriginal issues within the MHSS is one of the interesting avenues
put in place to guide local commissioners.
The aim is to continuously improve the quality of services in a non-punitive way. Knowing that
written communication is not a common vehicle for Aboriginal communities, the possibility of
formulating a verbal complaint is considered. In addition, a position has also been created for an
assistant commissioner for complaints and the quality of services offered to the Aboriginal
communities of Lanaudière. This person will be responsible for collecting and processing
complaints from Aboriginal users in the region and making recommendations to correct
problematic situations. This is a significant step forward.
During the hearings, we noted that a certain consensus was emerging both among the experts
who came to present the bases of a real social pact and among the chiefs and grand chiefs of
the indigenous communities.
Professional orders have come out in favour of the Joyce Principle, including the Collège des
médecins du Québec. The delegation from the Fédération interprofessionnelle de la santé du
Québec also adopted Joyce’s Principle at its congress, which was held on June 7, 9 and 10 in
2021.
According to Professor Browne, who is a Distinguished University Professor and Scholar at the
University of British Columbia (UBC) School of Nursing in Vancouver, the literature clearly
indicates that the population in any province or territory is affected by racism. Because the
health care system is often a focal point, there are many instances of racism, both individual
and systemic. This discrimination is documented and it is time to demand strong leadership to
put strategies and policies in place in a constructive, non-accusatory manner.
In his testimony, Dr. Samir Shaheen-Hussain went further to say that inaction is the biggest
problem in our society and that medical colonialism, which he has already denounced several
times, contributed to Mrs. Echaquan’s death.
For Mrs. Viviane Michel, President of Quebec Native Women, racism and discrimination kill, as
Mrs. Echaquan received poor care because of racist and misogynistic prejudices. In this
context, and since this has been noted on a few occasions, if the words did not kill her literally, I
can only agree that they were hurtful and humiliating.
The social pact
In the days following Mrs. Echaquan’s death, the notion of systemic racism was raised on
several occasions and was brought to the National Assembly. This shows how uncomfortable
Page 18 of 28
the population is with the care that is being administered to the Atikamekw community. It is
therefore my duty, as coroner, to do everything in my power to prevent a member of the
Aboriginal community or of any other origin from receiving care such as that offered to Mrs.
Echaquan.
It is no longer time to take stock. We have witnessed an unacceptable death, and we must
ensure that it is not in vain and that we have learned as a society from this tragic event. It is no
longer acceptable for the greater part of our society to deny such a well-documented reality.
The Viens Commission, well before this death, had called for reconciliation and had warned
about the fears expressed by the Atikamekw community regarding the Centre hospitalier de
Lanaudière. The Grand Chief of the Atikamekw Nation Council, Constant Awashish, the Chief of
the Atikamekw Council of Manawan, Paul-Émile Ottawa and the Chief of the Assembly of First
Nations of Quebec and Labrador, Ghislain Picard, reminded us of the importance of cultivating
fertile ground in order to build lasting bridges. Although actions have been taken by the
government to re-establish this necessary communication, the recognition of a disparity in
treatment is fundamental, even vital, to working within a spirit of trust.
It is clear that the road to reconciliation is a long and arduous one. Efforts are all the more
necessary, as the findings of this enquiry indicate that Mrs. Echaquan was indeed ostracised,
and that her death was directly related to the care that she received during her hospitalisation in
September of 2020, and that her death could have been avoided.
The courage in the words aiming at pacifying our relationships with others is crucial. We must
have a firm will to name, but without having a cosmetic intent regarding a principle that is so
clear: The right of all to goodwill and to living in a free and democratic society, in the hope that
every human being deserves the same services with dignity and respect and who above all,
deserves to live.
Page 19 of 28
CONCLUSION
Mrs. Joyce Echaquan died as a result of pulmonary edema caused by cardiogenic shock in the
context of a diseased heart (pre-existing cardiomyopathy, probably rheumatic) associated with
possibly deleterious effect manoeuvres, such as the supine restraint without adequate
supervision.
The racism and prejudice that Mrs. Echaquan faced was certainly a contributing factor to her
death.
This was an accidental death.
RECOMMENDATIONS
To prevent such a situation from happening again and to protect human life, I
recommend :
That the Quebec government :

Acknowledge the existence of systemic racism within our institutions and commit
to helping eliminate it.
That the Centre intégré de santé et de services sociaux de Lanaudière :

Ensures that the Manawan liaison officer is effectively integrated into the
institution, particularly by involving him/her in the care teams;

Ensures a collaborative mechanism between the Manawan clinic and the Centre
hospitalier de Lanaudière emergency room so that medical information
concerning the patient is transmitted in real time;

Ensures that the notes in the medical record reflect the reality of a patient’s care;

Reviews its nursing and orderly ratios in accordance with provincially recognized
standards in order to offer safe services to the population;

Applies an emergency management model based on the guiding principles of the
Emergency Management Guide;

Maintains periodic training in the facility’s code of ethics, restraint measures,
monitoring of patients following a fall, and record keeping;

Rapidly implements training and activities for the inclusion of Aboriginal culture in
cooperation with the Manawan community;

Refines the model of the nurse/practical nurse dyads and ensures that each
understands their role.
Page 20 of 28
That the Collège des médecins du Québec reviews the quality of the medical acts of
the physician responsible for hospitalizations in family medicine and the gastrology
resident who provided care to Mrs. Echaquan during her hospitalization in September of
2020.
That the Ordre des infirmières et infirmiers du Québec:

Reviews the quality of the services of the nurses who provided care to Mrs.
Echaquan during her hospitalisation from September 26 to 28, 2020;

Reviews the integration practices of college candidates for nursing practice
(CPNPs) in hospital emergency departments across the province.
That the Ministry of Higher Education for its educational institutions (colleges and
universities) that train doctors, nurses and nursing assistants:

Includes training in the care of indigenous patients that takes into account the
realities of indigenous communities within the school curriculum;

Establishes along with Aboriginal communities a greater number of internships for
both nurses and medical residents.
Montreal, September 8, 2021.
Me Géhane Kamel, Coroner
Page 21 of 28
ANNEX I
THE PROCEDURE
On October 6, 2020, the Chief Coroner of Quebec ordered a public enquiry to clarify the causes and
circumstances of the death of Mrs. Joyce Echaquan, which occurred on September 28, 2020 at the
Centre hospitalier de Lanaudière.
I was mandated to chair this public enquiry. Dr. Jacques Ramsay, coroner, assisted me as assessor.
From the beginning of the hearings, I recognised as interested persons those who had asked me to do
so, namely :

Mr. Carol Dubé, Mrs. Joyce Echaquan’s eldest daughter, Mrs. Maria Wasianna Echaquan
Dubé, her brother, Mr. Stéphane Echaquan, her parents, Diane and Michel Echaquan, as
well as other members of the extended family, who are represented by Me Patrick MartinMénard (Ménard Martin, Attorneys);

Centre intégré de santé et de services sociaux de Lanaudière, represented by Me Anne
Bélanger (Lavery, lawyers);

The Fédération interprofessionnelle de la santé du Québec – FIQ, represented by
Me Émilie Gauthier and Me Audrey Limoges-Gobeil;

The Syndicat des travailleuses et travailleurs du CISSS de Lanaudière – CSN, represented
by Me Franccesca Cancino (Laroche Martin, Service juridique de la CSN);

The Atikamekw Nation Council and the Conseil des Atikamekw de Manawan, both
represented by Me Jean-François Arteau (Kesserwan Arteau, lawyers);

Quebec Native Women, represented by Me Rainbow Miller.
I was assisted throughout the preparation and the public enquiry by Me Dave Kimpton and Me Julie
Roberge, public enquiry prosecutors of the Coroner’s Office.
The public hearings took place from May 13, 2021 to June 2, 2021.
I heard 44 factual witnesses and 115 exhibits were produced. The exhibits are public except for those
that are prohibited from publication or broadcast under The Causes and Circumstances of Death
Inquiry Act (preceded by an asterisk in the list of exhibits in Appendix II).
Page 22 of 28
ANNEX II
LIST OF EXHIBITS
Code
Description
C-1
Investigation order
*C-2
Toxicology expert report
*C-3
Addendum to the Toxicology Expert Report
*C-4
Final autopsy report MUHC
*C-5
Report Dr. Charles Leduc (pathology – CHUM)
*C-6
Analysis report of the pacemaker-defibrillator
*C-7
Medical file of the Centre hospitalier de Lanaudière
*C-8
Medical file Montreal Heart Institute
*C-9
Medical file – Last hospitalisation before death
*C-10
Outpatient and Emergency 2020
*C-11
Hospitalizations April 2020
*C-12
Hospitalizations January 2020
*C-13
Consultations summary examinations hospitalizations 2014 to 2019
C-14
Cellular messages (JE) to be translated (SQ report)
C-15
Atikamewk-French translation of text messages
C-16
JE cell extraction ratio (SQ)
C-17
1st live video by Joyce Echaquan
C-18
Atikamewk-French translation 1st video (SQ)
* C-19
2nd live video (Marie-Wasianna Echaquan-Dubé)
C-20
Facebook Video Recovery Report (SQ)
C-21
List of emergency staff (September 26-28, 2020)
C-22
List of emergency physicians (September 26-28, 2020)
C-23
Hospital sketch (witness Paméla Dubé)
Page 23 of 28
Code
Description
C-24
Sketch of the site (witness M. B.)
C-25
Sketch of the site (witness P. R. )
C-26
Sketch of the resuscitation room (witness C. S. )
C-27
Emergency observation sketch (witness M.-D. F.)
C-28
Sketch (witness Josiane Ulrich)
C-29
Letter (witness Annie Desroches)
*C-30
Nursing Practice Report 12 January 2021
*C-31
Management Practices Analysis Report 18 November 2020
*C-32
Summary report administrative enquiry 12 January 2021
C-33
FIQ-SIL union observation report (Marie-Chantale Bédard)
C-34
Policy Application of control measures 2019-01-28
C-35
Protocol Applications control measures 2019-01-28
C-36
Protocol for the practical supervision of CPNPs
C-37
Regulation on professional acts
C-38
Expert report by Dr. Alain Vadeboncoeur (March 11, 2021)
*C-38.1
Extracts from the ICM file – Dr. Alain Vadeboncoeur
C-38.2
CV Dr. Alain Vadeboncoeur
C-38.3
Presentation of the expert report
*C-39
Digoxin analysis report (April 13, 2021)
C-40
Access to care for First Nations – Discussion Paper (AFNQL)
C-41
Emergency Plan – CHDL
C-42
Emergency management guide MHSS and AQESSS
C-43
Presentation of the MHSS
C-44
Testimony and presentation by Mrs. Viviane Michel (FAQ)
C-45
Presentation and testimony of Dr. Annette Browne
Page 24 of 28
Code
Description
C-46
Summary of presentation (Witness Samir Shaheen-Hussain)
C-47
Full text message extraction report
C-48
Complementary text vs. audio messages by SE Martin Pichette #11310
C-49
Order appointing Jacques Ramsay Assessor
* C-50
Family meeting on 29 September 2020 (Dr. Thanh)
C-51
Statement by Karine Echaquan
C-52
Commitment 3 CISSS-LAN internal communiqués (October 13 and 14, 2020)
C-53
Commitment 2 Emergency plan by sections
C-54
Emergency plan – Identification of the various areas
(white circles for zones C-10 and C-14.2 and black circles for zones C11 and R-4)
C-55
Cultural Security at Atikamekw Nehirowisiw CIUSSS (202010-13-)
C-56
Requests received at the Office of the Service Quality and Complaints
Commissioner CISSS-LAN (2017-2021)
C-57
Audio statement (Witness Josiane Ulrich)
C-58
Audio statement (Witness Stéphane Guilbault)
C-59
Mandate as liaison officer (Barbara Flamand)
C-60
Organisational issues – email to manager
C-61
New procedure on restraints
C-62
Recommendations from a health professional witness (Joliette ER)
C-63
Commitment 1: Chronology of Mrs. Echaquan’s medical care (September 2628, 2020)
C-64
Alexandre St-Jean: Training on Atikamekw cultural competencies and security
for the CISSS-LAN
C-65
Alexandre St-Jean: Clinical report on Atikamekw cultural competencies and
security for the CISSS-LAN
C-66
Specific service agreement between CISSS-LAN and Services de santé
Masko-Siwin
C-67
Action plan for service trajectories of the Centre de santé Masko Siwin and
CISSS-LAN
C-68
Letter of request for an ambulance in Manawan
Page 25 of 28
Code
Description
C-69
Letter concerning the termination of the Atikamekw interpreting agreement
C-70
Follow-up on the termination of the Atikamekw interpreting agreement
C-71
CISSS-LAN presentation plan
C-72
Translation of the Facebook video by Marie Wasianna Dubé Echaquan
(September 28, 2020)
*C-73
Screenshot of Marie Wasianna Dubé Echaquan’s Facebook video (September
28, 2020)
C-74
Presentation of the Advisory Commissioner Mrs. Dominique Charland to the
Complaints Review System of the Ministry of Health and Social Services
C-75
Good practices identified by the AFNQL
C-76
Presentation by Dr. Stanley Vollant
C-77
Joyce’s Principle – Exhibit filed at the request of the Atikamekw Nation Council
and in support of the testimony of Grand Chief / President Constant Awashish
C-78
Presentation Mrs. Michèle Audette (recommendations)
C-79
Presentation Mr. Samir Shaheen-Hussain (SJS Collective)
C-80
Presentation of the Fédération interprofessionnelle de la santé du Québec FIQ
C-81
Plan for the testimony of Grand Chief Constant Awashich
C-82
Chief Paul-Émile Ottawa’s recommendations for the Manawan Atikamekw
Council
*C-83
Commitment 11: Alternative approaches to September 28, 2020
*C-84
Undertaking 5: Requests for narcotics by Mrs. Echaquan (Extracts from
medical file)
C-85
Commitment 19: List of persons responsible for the Aboriginal file at the MHSS
*C-86
Undertaking 16: Reason for departure of a nurse from the Joliette Hospital
C-87
Commitment 6: Heavy users’ binder (Joliette emergency)
*C-88
Undertaking 14: Form H-223 for the death of Joyce Echaquan
*C-89
Commitment 15: Letter of employment for a CPNP (Joliette Emergency)
C-90
Joliette Hospital’s internal press release on the event of 28 September 2020
Page 26 of 28
Code
Description
C-91
Press release concerning the cancellation of the population forum for the
population of Haute-Matawinie
C-92
Press release on CISSS-LAN’s invitation to the population of the HauteMatawinie to a population forum
C-93
Correspondence between the President and CEO of CISSS-LAN and the
Chief of the Atikamekw Council of Manawan concerning the death of Joyce
Echaquan
C-94
Presentation of CISSS-LAN for Mrs. Maryse Poupart
C-95
Presentation by Mr. Samir Shaheen-Hussain (SJS Collective)
C-96
Joyce Echaquan’s family’s recommendations to the Coroner
*C-97
Commitments 7 & 8 (FIQ): Correspondence between a nurse and the
manager of the Joliette emergency room and analysis documents on the
situation in the emergency room on September 28, 2020.
*C-98
Commitment 10: Proposed mentoring by a nurse from the Joliette emergency
room
C-99
Commitment 17: Letter of invitation to the CISSSLAN population forum -to the
Chief of the Atikamekw Council of Manawan (February 28, 2020)
C-100
Commitment 20: Extract from the minutes of the 82e meeting of the CISSSLAN Board of Directors (March 8, 2021)
C-101
Commitment 20: Press release on the union of the CISSS-LAN and the
Atikamekw Council concerning cultural security and the reconciliation
committee
C-102
Commitment 20: Press release on CISSS-LAN’s commitment to the cultural
safety of Aboriginal communities (March 10, 2021)
C-103
Commitment 19 (MHSS): List of persons who have held the position of person
responsible for indigenous issues
C-104
Email from the Fédération interprofessionnelle de la santé du Québec – FIQ
confirming the non-filing of a brief (June 25, 2021)
C-105
CSN email regarding representations (July 1, 2021)
C-106
CISSS-LAN written submissions (July 2, 2021)
C-107
Written submissions from Quebec Native Women (July 2, 2021)
C-108
Written representations of the Manawan Atikamekw Council (July 2, 2021)
C-109
Written submissions from the Echaquan family prosecutors (2 July 2021)
Page 27 of 28
Code
Description
C-110
Corrected translation of the testimony of Mrs. Marie Wasianna Echaquan (May
13, 2021)
C-111
Corrected translation of the testimony of Mrs. Pamela Dubé (May 14, 2021)
C-112
Email confirming that the FIQ will not file a brief in support of the
representations made at the June 2, 2021 hearing
*C-113
Commitment 12 (CISSS-LAN): Break schedules for nurses and orderlies
(September 28, 2020)
*C-114
Commitment 9 (CISSS-LAN): Extraction and logging in the “Médurge” system
for Joyce Echaquan’s stay (September 26 to 28, 2020)
*C-115
Commitment 18 (CISSS-LAN): Minutes of the Joliette Hospital Management
Committee (September 4, 2018)
Page 28 of 28
Manitoba
a. mbudsman
March 11,2019
750 – 500 Portage Avenue
Winnipeg, MB R3C 3X1
Telephone: 204-982-9130
Toll Free in Manitoba: 1-800-665-0531
Fax: 204-942-7803
E-mail: ombudsma@ombudsman.mb.ca
www.ombudsman.mb.ca
500 avo Portage, Piece 750
Winnipeg, MB R3C 3X1
Telephone: 204-982-9130
Sans frais au Manitoba: 1-800-665-0531
Telecopieur: 204-942-7803
Courriel : ombudsma@ombudsman.mb.ca
www.ombudsman.mb.ca
The Honourable Margaret Wiebe
Chief Judge
Provincial Court of Manitoba
5th Floor – 408 York Avenue
Winnipeg, MB R3C OP9
Our files: 2014-0553,0554,0555
& 2015-0122
Recommendations
re Inquest Report for Brian Lloyd Sinclair
Dear Chief Judge Wiebe:
As you are aware, it is the practice of my office to follow up on inquest recommendations when
they relate to a provincial department, agency or municipality.
I am writing to advise you of the results of the inquiries made by my office concerning the
inquest report recommendations into the death of Mr. Brian Lloyd Sinclair. The December 9,
2014 inquest report ofthe Honourable Judge Timothy J. Preston was issued on December 12,
2014.
BACKGROUND
The inquest report detailed the circumstances of Brian Lloyd Sinclair’s death. Mr. Sinclair died
on September 21,2008, at age 45, in the Emergency Department (ED) at the Health Sciences
Centre (HSC).
Many hours earlier, Mr. Sinclair had attended at an inner city primary health care facility (the
Health Action Centre or HAC) complaining of abdominal pain and problems with his Foley
urinary catheter. He was assessed by a physician, provided a letter from the physician and told to
give the letter to the Health Sciences Centre Emergency Department (HSC ED) staff when he
arrived there.
At the HSC ED, Mr. Sinclair spoke to the Triage Aide at the ED reception desk and waited. He
did not receive assessment or treatment for the next 34 hours, until discovered by another visitor
in the ED. Thus, Mr. Sinclair had passed away in the waiting room of the HSC ED, hours prior
to when HSC staff discovered he was dead.
The 63 recommendations made by the Honourable Judge Preston were noteworthy, in light of
the circumstances of Mr. Sinclair’s death. In the course of our monitoring efforts, we
communicated with Manitoba Justice and Manitoba Health, Seniors and Active Living
(MHSAL).
By its most recent letter dated January 25,2019, MHSAL advised that of the 63
recommendations, 55 recommendations have been completed and eight are not completed. Of
the eight recommendations that are not completed, seven are partially completed and only one
recommendation remains open. Regarding the one recommendation that is open
(Recommendation #22), MHSAL indicated it is unable to provide a timeline for completion, due
to the operational status of the newly created Shared Health, the organization tasked with the
recommendation.
RESPONSE TO INQUEST RECOMMENDATIONS
Below are the 63 recommendations
MHSAL have addressed them:
Recommendation
and detailed summaries of how Manitoba Justice and
#1
That the Office of Public Trustee and the RHAs review their policies and procedures
ensure the primary care giver and service providers of any Committee of the Public
Trustee are made aware of the Committeeship.
to
MANITOBA JUSTICE: … When the Public Guardian and Trustee (PGT) is appointed as
committee under The Mental Health Act, steps are taken to notify a variety of agencies
and services of the appointment and the extent of the PGT’s role in managing the affairs
of the client. There is a delegation of a variety of responsibilities involving the needs of
each client, to the regional health authority (RHA) where that client resides …. In
addition, the PGT contacts Manitoba Health to ensure the involvement of the PGT as
committee can be included in the individual’s health record. The PGT advises that the
delegation made by the PGT to a RHA continues to be appropriate and forms one
element of the communication strategy required to support the client.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure primary care provider notification of committeeship status.
The MHSAL “Communication of Public Committeeship Status” Policy addresses this
recommendation, requiring each RHA, the Selkirk Mental Health Centre (SMHC) and
Health Corporations to have policies that set out a process for communicating a public
committeeship status of a person to the primary care and service providers, ensuring
providers’ awareness.
2
Recommendation #2
That Winnipeg Regional Health Authority (WRHA) Home Care review its policies and
procedures to ensure that Home Care updates service providers concerning any
hospitalization of their clients.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHA policies and
procedures that have been updated and implemented, will ensure service providers are
provided information regarding hospitalization of clients.
This response applies to this recommendation and recommendations 3, 4 and 5. MHSAL
and RHAs assessed the recommendation against the 28 current MHSAL Home Care
policies, as well as RHA operational policies, procedures and guidelines. A policy gap
was identified in two areas – (i) information sharing at points of transition of care and (ii)
the policy on Home Care Service was suspended or withdrawn. RHAs undertook policy
and procedures development to address these gaps.
The establishment of provincial policy to set expectation(s) for RHAs to have a policy is
not yet finalized. Draft provincial policies are completed but finalization is pending the
future state of MHSAL, to ensure alignment for policy oversight, going forward. This
work is contingent on the operational status of Shared Health (SH).
Recommendation #3
That WRHA Home Care review its policies and procedures to ensure that each service
provider is made aware of the specific care plan for each Committee.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHAs have policies and
procedures that have been implemented, which will ensure service providers are aware of
client care plans.
MHSAL repeats the last paragraph of its response under Recommendation#2
here.
Recommendation #4
That WRHA review its policies and procedures to ensure that when a medical service is put
on hold, suspended or withdrawn from any client for any reason, that there is an alternate
plan in place or that the hold be reviewed on a regular basis.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHAs have policies and
procedures that have been implemented, which will ensure service providers are aware of
changes to client care plans.
MHSAL repeats the last paragraph of its response under Recommendation#2
here.
3
Recommendation
#5
That WRHA Home Care reviews its policies and procedures to ensure the provision to
service providers of relevant background information of their vulnerable clients.
MHSAL: RHAs and MHSAL have undertaken policy reviews. RHAs have policies and
procedures that have been implemented, which will ensure care providers are aware of
relevant information of home care vulnerable clients.
MHSAL repeats the last paragraph of its response under Recommendation#2
Recommendation
here.
#6
That the RHAs and the Office of the Public Trustee continue to review the feasibility of
compatible electronic charting of all relevant medical information for clients of the Public
Trustee.
MANITOBA JUSTICE: … With respect to health and medical records, the PGT has no
greater entitlement to health information than would have been available to the client. In
most situations, the PGT does not need access to a client’s health records. When medical
information is required, the PGT will request it from the health provider in a manner
similar to how the client would have made a request. In that context, implementing the
recommendation that consideration be given to develop some form of shared database
amongst RHA, MHSAL and PGT would be problematic from a records management and
privacy perspective.
MHSAL: An Information Communication Technology (lCT) study had been undertaken
to assess the feasibility of compatible electronic charting of all relevant medical
information for clients of the Public Trustee. The feasibility study addressed all ICT
recommendations from the Brian Sinclair Inquest, identifying that an investment of
$300M ongoing operating costs and approximately $50M one-time cost would be
required to accomplish the recommendations. Further, the assessment identified that the
existing ICT capital plan will address, over time, the majority ofICT inquest
recommendations.
Consequentially, the ICT plan will be sustained, ensuring, over time, all ICT issues
identified in the Brian Sinclair inquest recommendations are addressed.
Recommendation
#7
That the Office of the Public Trustee and the RHAs review their policies and procedures
ensure that when a patient is a Committee of the Public Trustee, the patient’s
Committeeship status is clearly flagged on that patient’s medical chart.
to
MANITOBA JUSTICE: … The discussions with the WRHA and MHSAL have explored
the possibility of changing how and when the involvement of the PGT as committee is
4
communicated to each of those organizations and health service providers generally. The
PGT is supportive of changes which lead to better communication and is prepared to
make any changes necessary to PGT processes, procedures or systems that are required to
accommodate changes made by RHAs and!or MHSAL.
MHSAL: The ICT feasibility assessment determined that the flagging of Public Trustee
committeeship status is not presently in scope in the ICT plan. Further, it has been
determined that the absence of this flag, poses the most material risk to RHAs being able
to assure information communication across service entities (relative to committeeship
status) and upholding the RHAs responsibilities therein.
As such, a recommendation to government will be forthcoming proposing specific one
time and ongoing operating investments in an ICT solution to mitigate this ongoing risk.
Recommendation #8
That the RHAs review the feasibility of electronic charting for all their facilities.
MHSAL: An ICT study had been undertaken to assess the feasibility of electronic
charting for all in .scope facilities. The existing ICT capital plan will address, over time,
electronic patient record deployment and eChart across all in scope facilities. The
financial investment required to achieve this recommendation’sooner is not feasible.
Furthermore, MHSAL indicated that its response to recommendation 6, 2nd paragraph (page 4)
also applies to this’recommendation.
Recommendation #9
That the protocol that requires primary care physicians sending patients to an Emergency
Department (ED), to notify the ED in advance by phone, be maintained – including
verification of whether a letter has been given to a client to present to the ED staff.
MHSAL: Assessments have been undertaken, affirming that the requirements established
by the College of Physicians and Surgeons of Manitoba remain in place and are
requirements of physician practice. The College of Physicians and Surgeons of Manitoba
(CPSM) has practice standards! guidelines in place that guide the communication process
between primary care physicians and Emergency Departments (EDs).
Recommendation #10
That the RHAs continue to review their policies and procedures to examine the feasibility
of letters from primary care physicians to EDs being sent electronically.
MHSAL: In the fall of2016, the Health Senior Leadership Council limited the scope of
this recommendation to only those individuals under the public trustee. An assessment of
policies and procedures were undertaken, identifying that the limiting enabler in doing
this function is the absence of identification of individuals who are committees. This
5
recommendation is not feasible in the absence of the implementation of the ICT solution
proposed in recommendation 7.
Recommendation #11
That WRHA review its policies and procedures to ensure that primary care facilities
develop a uniform protocol for the transportation of clients with mobility or cognitive
challenges to other health care facilities.
MHSAL: In the fall of2016, the Health Senior Leadership Council limited the scope of
this recommendation to only those individuals under the public trustee. A review of RHA
current practices, degree of risk presented by this issue, implications on RHA operations
and alignment with RHA mandates occurred. MHSAL and RHA policies have been
developed.
Operational governance roles are of particular question with the establishment of Shared
Health (SH), thus some operational governance policies previously held by MHSAL may
move to SH. Thus, the implementation of the policies is contingent on the operational
status of SH.
Recommendation #12
That all RHAs review their policies and procedures to ensure that vulnerable persons,
including persons with mobility issues, are assisted by staff with the triage process
immediately upon their arrival at an ED.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
The MHSAL policy “Emergency Department Registration, Triage and Waiting Room
Monitoring Policy” was implemented in August 2016. It required all regions to have
policies and protocols in place, in response to a variety of policy gaps identified through
the inquest (recommendations 12, 15, 17, 19 and 33). RHAs were audited on compliance
with the policy in January 2017.
Recommendation #13
That paper triage lists at any ED be eliminated and that each presenting person’s
information be entered electronically into a hospital registration system upon first point of
contact by ED staff.
MHSAL: Paper triage has been eliminated in EDs; policies have been developed and
audited, entrenching this requirement. Registering the patient, at the first point of contact,
is incongruent with the national triage standards to triage first. The objectives of the
policies developed establish the intent to do both triage and registration simultaneously.
The ability to electronically register patients at first point of contact is further limited at
6
in scope facilities by ICT and infrastructure. The deployment of Emergency Department
Information System (EDIS) has addressed ICT requirements. The infrastructure
assessment completed has identified the highest risk sites for this issue and proposes risk
mitigation on these sites through safety and security (see recommendation 14 and 24).
Paper triage was eliminated across Manitoba following direction to do so within 3
months of the release of the inquest recommendations on December 12,2014. RHAs
were required to report to MHSAL, confirming they had eliminated paper triage methods
and RHAs reported compliance with the direction.
Recommendation
#14
That RHAs review the floor plan of all EDs to ensure that no persons in the ED waiting
room requiring medical care face away from the triage desk.
MHSAL: Floor plans reviewed. Infrastructure assessments completed. Future
infrastructure recommendations are coming forward to address high-risk sites which
cannot meet this recommendation and recommendation 24, based on existing ED layout
and infrastructure.
All rural emergency departments with greater than 10,000 visits per year have made
accommodations to ensure that persons in the waiting rooms can be seen at the triage
desk, predominantly the addition of CCTV cameras. As this work is ongoing and longterm, a time line cannot be estimated.
Recommendation
#15
That RHAs review their policies and procedures
rooms are awakened at regular intervals.
to ensure that persons in ED waiting
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
In addition, the department repeated its response to recommendation #12, per the second
paragraph in blue text under that recommendation.
Recommendation
#16
That the RHAs review t~e feasibility of secondary traumatic
stress training for all ED staff.
MHSAL: Assessment of existing activities in place and RHA investments required to
attain this recommendation, have occurred. Training standards will be imbedded into
operational and governance policy to be implemented and audited on a go forward basis.
7
The following training is available across regions: Vicarious trauma training is provided
to all RHAs. Additionally, Northern Regional Health Authority (NRHA) provides online
psychological First Aid for all ED staff to complete.
Recommendation #17
That the RHAs review their policies and procedures to ensure that staff intervenes when a
person is vomiting in an ED.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
Recommendation #18
That the RHAs review their policies and procedures with respect to interview notes taken
on behalf of hospital Administration after the occurrence of critical incidents, with a view
to having the notes dated and initialed or otherwise authenticated by the interviewee.
MHSAL: Policy analysis and feasibility assessment was conducted, determining that this
recommendation is incongruent with critical incident policy and legislation, and is not
feasible.
The Critical Incident Reporting and Management Policy provides direction to regional
health authorities and provincial organizations with respect to critical incident reporting,
investigation, disclosure and recording, and notification to the Minister in accordance
with the legislation. The review detelmined that undertaking this recommendation would
be incongruent with this policy.
Recommendation #19
That the RHAs review handover policies in the ED to ensure that the oncoming triage and
reassessment nurses are fully briefed on the status of persons present in the waiting room.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
In addition, the department repeated its response to recommendation #12, per the second
paragraph in blue text under that recommendation.
8
Recommendation #20
That all RHAs review the feasibility of a security presence at the entrance to an ED.
MHSAL: A feasibility assessment was undertaken by all RHAs, identifying that to
address this recommendation, an investment of approximately $4.SM ongoing operating
would be required for all in scope facilities. The relative risks necessitating a 2417
security presence at in scope EDs have not materialized, and as such, this has been
determined to not be feasible or required at this time.
Recommendation #21
That ED Security staff receive training in the areas of substance abuse and dealing with
persons with physical or mental challenges.
MHSAL: Assessment of existing activities in place and RHA investments required to
attain this recommendation have occurred. Training standards will be imbedded into
operational and governance policy to be implemented and audited on a go forward basis.
Recommendation #22
That all RHAs review the feasibility of implementing the recommendations of the Brian
Sinclair Critical Incident Review Committee.
MHSAL: This recommendation was determined to be redundant of most other
recommendations with the exception of the RHA development of role descriptions for all
Emergency Department (ED) staff, presently underway. Shared Health Manitoba (SH)
will also playa role in establishing the standards for education and roles of ED staff
provincially.
Accordingly, actions associated with this recommendation are contingent on the
operational status of SH, which is undertaking provincial oversight including the
development of standardized job descriptions. A timeline for this work cannot be
estimated at this time.
Recommendation #23
That all RHAs review the feasibility of the presence of a Community Support Worker for
EDs, where deemed appropriate.
MHSAL: Feasibility assessment was undertaken, identifying that an ongoing operating
investment of approximately $3.34M per annum would be required. Recommendations
on pursuit of this investment have been deferred, awaiting outcomes of the Health System
Sustainability and Innovation Review (HSIR), aka KPMG Report, and ED Wait Times
Task Force recommendations.
9
Recommendation #24
That all RHAs review the feasibility of creating a distinct pre-triage area for EDs, where
deemed appropriate.
MHSAL: Infrastructure assessments have been completed. Future infrastructure
recommendations are being worked on, to address high-risk sites that cannot meet this
recommendation and recommendation 14, based on existing ED layout and infrastructure.
Recommendation #25
That all RHAs review the feasibility of replicating the HSC ED front-end procedures
throughout the system, where deemed appropriate.
MHSAL: Given the variation in infrastructure, leT and staffing at all in scope EDs, this
recommendation has been determined not feasible.
Recommendation #26
That the RHAs continue to review, create and implement long-term strategies for the
recruitment and retention of nurses.
MHSAL: Evidentiary documentation has been compiled provincially and for each RHA
on existing strategies for mid and long term nursing recruitment.
The review resulted in identifying multiple strategies in place across regions, including
but not limited to the Nursing recruitment and retention fund, relocation assistance,
refresher programs, various education grants, various mentorship programs, and regional
implementation of the “Grow your own” program.
Recommendation #27
That the RHAs continue to review a rotation of roles and hours of work for ED Nurses in
an effort to reduce fatigue.
MHSAL: The regions review and adjust staffing rotations and hours of work in
emergency departments, on an annual basis and more frequently as part of regular
operational planning. RHAs have submitted evidentiary documentation confirming that
these activities occur annually and as part of regular operational planning processes.
Recommendation #28
That RHAs, health care site Directors, Nurse Directors and Manitoba Nurses Union
(MNU) representatives continue to convene ongoing meetings focused on an
interdisciplinary, integrated health care model for Emergency Medicine.
10
MHSAL: All RHAs, with the exception of Northern Regional Health Authority (NRHA),
have submitted responses indicating that ongoing interdisciplinary meetings on integrated
health care for Emergency Room (ER) Medicine services occur regularly. Follow up with
NRHA will occur.
Recommendation #29
That the WRHA review the feasibility of establishing Transition Centres for vulnerable
patients discharged from urban EDs, where deemed appropriate.
MHSAL: Health System Leadership Council (HSLC) directed an alternate solution be
implemented, as transitional housing for homeless individuals is not within the mandate
of the health care system. RHAs were directed to identify processes by which the RHAs
engage with social support I homelessness service entities within each RHA. Evidentiary
documents from each RHA, addressing the matter, have been submitted accordingly.
Recommendation #30
That the RHAs identify staffing demands in all EDs and strategically plan to supply
adequate staffing for all EDs.
MHSAL: The regions regularly review and identify staffing demands in emergency
departments, on both an annual basis and as part of regular operational planning. RHAs
have submitted evidentiary documentation confirming that these reviews occur annually
and as part of operational planning processes.
Evidentiary documentation reviewed included: RHA’s daily assessments of staffing
ratios and scheduling. The assessments included ensuring hours of work are compliant to
existing collective agreements.
Recommendation #31
That an ongoing review of staffing ratios for all EDs be undertaken by all RHAs, to match
supply to demand.
MHSAL: The regions regularly review and identify staffing ratios for all EDs to ensure
the supply of staff matches the demand for them. RHAs have submitted evidentiary
documentation indicating that these reviews occur annually and more frequently as part
of regular operational planning processes.
Recommendation #32
That the RHA Directors, Site Directors, ED Directors and the Ministry of Health review
the feasibility of strategic planning to implement accountability structures, including
measurement and reporting systems.
11
MHSAL: A feasibility review has been completed. The province and the regions follow a
framework that sets out processes for strengthening the accountability of the health
system. The framework document is available at:
http://www.gov.mb.ca/hcalthirhaJdocs/ahsa2009·rulf
In satisfaction of this recommendation, the province and regions have developed
evidentiary documentation, outlining how accountability processes occur regularly.
Recommendation #33
That the RHAs review the feasibility of creating a region-wide Overcapacity Protocol, such
as the Alberta Overcapacity Plan, where deemed appropriate.
MHSAL: RHAs and MHSAL have undertaken policy reviews and put in place policies to
ensure this recommendation is addressed. RHA policy audits were undertaken in January
2017.
In addition, the department repeated its response to recommendation # 12, per the second
paragraph in blue text under that recommendation.
Recommendation #34
That the RHAs review the feasibility of providing on-site diagnostic equipment in EDs,
where deemed appropriate.
MHSAL: An assessment of the operational requirements of RHAs, at in scope facilities
(necessitating increased on-site diagnostic equipment) was conducted. The assessment
concluded that current diagnostic equipment available at in scope facilities, is sufficient
for patient and provider requirements.
Recommendation #35
That the RHAs review the feasibility of a seven-day workweek for the office of the Home
Care Coordinator.
MHSAL: This recommendation was incorporated into Home Care review &
recommendations. It will be addressed by actions determined through the home care
review. This recommendation will be further addressed through Shared Health / RHA
Clinical Services planning, and is accordingly contingent on the operational status of
Shared Health.
Recommendation #36
That the relevant utilization representative(s) meet with the Ministry of Health, Housing
and Healthy Living representatives to continue to review bed registry and guidelines for
transfers and discharge of patients from hospitals, including the feasibility of a seven-day
workweek.
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MHSAL: It has been determined that the Ministry of Housing does not have a role to play
in the long-term clinical care and associated housing of patients. WRHA has
implemented a 7-day workweek for utilization managers. It has been determined that this
requirement is not warranted in facilities outside of Winnipeg.
Discharge guidelines have been reviewed by RHAs and will be further informed by
standards developed by SH. Shared Health will also review and propose
recommendations on bed registries provincially. Accordingly, this recommendation is
contingent on the operational status of Shared Health.
Recommendation #37
That RHAs review the feasibility of the implementation of the delivery of primary care,
after-hours, urgent services, where deemed appropriate.
MHSAL: Evidentiary documentation has been prepared demonstrating the current and
planned actions of the province and RHAs in satisfaction of this recommendation.
The following have been undertaken to achieve after hours service delivery of primary
care:
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•
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In 2014, the CPSM issued a policy statement to all physicians, which outlined
practice coverage of physicians for after hours and vacation.
As part of the Doctors Manitoba Agreement, physicians employed or contracted
by a RHA are requi…