“Improvements are necessary” regarding the management of medical devices at Hull hospital, indicates the coroner’s report on the death of Jean Malavoy, unveiled Monday.
If the man’s death was “accidental”, the Outaouais Integrated Health and Social Services Center (CISSSO) lacked “communication”, but also “resources” and “leadership”, concludes Me Julie-Kim Godin.
The former general director of the Muséoparc Vanier, in Ottawa, died suddenly on October 2, 2020, at the age of 71, following “complications” from a fall down the stairs of his home that occurred the day before, can we read in the document. In February 2022, the chief coroner ordered a public inquiry to “shed light on the circumstances surrounding” the death of the Franco-Ontarian.
An important figure in the Ontario Francophonie, Jean Malavoy was notably director general of the Association of Authors of French Ontario as well as the Assembly of the Francophonie of Ontario.
At the end of public hearings during which the spouse and daughter of the deceased, as well as doctors and a sergeant from the City of Gatineau Police Department, spoke, the coroner concluded that the death was “accidental”. She also mentions that the investigation does not evaluate “the quality of the care provided” and does not aim to “search for culprits”. Me Godin, however, makes two recommendations to the CISSSO so that it can “better protect human life”.
Coming and going between hospitals
To better understand the facts, let us first recall them.
1er October, late in the evening, Jean Malavoy fell down the stairs of his home. He then presents “trauma to the head and back pain”, it is written in the report. As expected for trauma patients, he was brought to Hull hospital in less than an hour.
After having had a chest x-ray, the patient must undergo a “ CT scan », an “irreplaceable” and “essential to make a diagnosis and establish a treatment plan”, a CT scan, but the hospital’s only machine is broken. Mr. Malavoy was then urgently transferred to Gatineau hospital.
But here too, the device experiences an “unforeseen technical problem”, which will eventually be resolved. The examination shows a “ruptured spleen” and “profuse active internal bleeding” caused by the fall, which represents “a surgical emergency.”
However, the only surgeon on call is “already in the operating room with another patient”. Without the possibility of treatment, the medical team at the Gatineau hospital decided to send Mr. Malavoy to the Hull hospital. After the operation, the Franco-Ontarian’s condition deteriorated, and Mr. Malavoy died on October 2 at the end of the afternoon.
The return trips between the two hospitals will have “generated additional delays of almost two hours”, indicates the coroner, stressing that they had an impact on the patient’s prognosis.
Lack of communication
Hull hospital has “only one CT scan at the time of the events and it was broken,” notes Me Godin. A biomedical engineering technician was called earlier in the evening to repair the device. Around 11:35 p.m. — about 35 minutes before Mr. Malavoy arrived at the hospital — he identified the problem. Around 1:50 a.m., authorities were informed that the CT scan is functional. However, in fact, it was functional from 1:29 a.m., notes the coroner, without knowing why the activity coordinator and emergency personnel “were not immediately notified”.
The transfer to the Gatineau hospital, which began at 1:33 a.m., could therefore have been avoided if the doctor on duty had had this information, she adds, indicating that, despite the protocol provided for in the event of a broken device, “procedures and communication” were not “optimal”.
The fact remains that the CT scanner at Hull hospital should have been changed well before October 2020. In fact, the estimated lifespan of the device obtained in 2007 “expired in 2017”, it is written in the document. The “possibility of service interruption was a known risk” by the CISSSO.
The CISSSO and the Ministry of Health and Social Services (MSSS) “began planning its replacement” in 2016. But the project stagnated until intensivist doctors signed a letter and sent it to the management of the Hull hospital, in 2017. Two days later, the CISSSO informed the MSSS of “the urgency of obtaining two CT scans and a second magnetic resonance imaging (MRI) machine.”
It was not until January and February 2021 that the two CT scanners were put into operation, around five years later. “Delays that are difficult to justify”, notes Me Godin, which could have been reduced with “better planning, greater resources and strong leadership from 2016”.
Questioned by the coroner, the CISSSO mentions the “complexity of the acquisition process and the consequences of the pandemic” to justify the delay, without however giving reasons for the “delays encountered before 2019”, notes the coroner.
As for the second MRI machine, there is no trace in the report of it being turned on. The CISSSO did not respond to questions from the Duty on this subject, who wanted to know if the establishment had indeed equipped itself with such equipment.
However, the health center declared by email that it “favorably” welcomed the investigation report, and assured that it would implement its recommendations. “Several actions were put in place the day after Mr. Malavoy’s death, well before the public inquiry was held,” he wrote.
A proactivity noted by the coroner, who said she “perceived a desire from the CISSSO to collaborate and improve its ways of doing things”. According to Me Godin, the establishment “learned several lessons” from the events.
This report is supported by the Local Journalism Initiative, funded by the Government of Canada.