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

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

In January 2024, 66-year-old Normand Meunier spent four days on a stretcher in the Saint-Jérôme Hospital’s emergency room without access to a special mattress due to hospital overcapacity, coroner Dave Kimpton writes in his report published Tuesday.

A pressure sore on his buttocks worsened to the point where bone and muscle were exposed and visible — making his recovery and prognosis bleak.

In his report, Kimpton highlights the need for guaranteed and prompt access to a therapeutic mattress for patients with spinal cord injuries. He also calls on the province to create an advisory committee aimed at preventing and treating bedsores with new tools and training.

“The prevention and management of these complications are not the responsibility of a single medical specialty,” reads the report, which stresses a multidisciplinary approach.

Special mattress, concerns not prioritized

At a public inquiry into Meunier’s death held earlier this year, Kimpton heard from Saint-Jérôme Hospital staff, Meunier’s widow, Sylvie Brosseau, as well as Moëlle Épinière et Motricité Québec (MEMO-Qc) — an advocacy group for people with spinal cord injuries.

During her testimony, Brosseau described the Saint-Jérôme Hospital as “totally negligent.”

Despite insisting multiple times on the importance of a proper mattress for Meunier and deterioration of his wounds, Brosseau’s concerns weren’t prioritized, says Kimpton.

He says there must be institutional culture change in that regard given that patients with spinal cord injuries and their partners end up developing an expertise that should be valued.

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

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

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

Insufficient equipment, lack of communication

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

The sores develop when circulation to the soft tissue between a bone and a solid surface is cut off due to prolonged pressure to the area.

“An analysis of his medical history reveals that all the identified injuries emerged or worsened during hospitalizations,” writes Kimpton.

He adds the different hospitals Meunier visited seemed to solely focus on the problem reported at the start of his visits without giving enough consideration to his condition or vulnerability to bedsores.

At the Saint-Jérôme Hospital, on top of insufficient equipment, Kimpton says there was a lack of communication between staff and improper record-keeping to track Meunier’s bedsores or how often he was moved, which needed to occur every two hours.

Coroner describes widow as ‘real warrior’

Kimpton addresses his 31 recommendations to Santé Québec, the CISSS des Laurentides which manages the Saint-Jérôme Hospital, Quebec’s Health Ministry, the Collège des médecins and Quebec’s order of nurses.

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

Brosseau was a “real warrior,” a relentless advocate for Meunier through his fight to survive, says Kimpton.

“This observation, however, leads me to think especially of all those with spinal cord injuries who are not fortunate enough to receive such support,” he says.

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