The story is about an 81-year-old woman suffering from Alzheimer's who took her last breath late last spring, barely a month after arriving at the CHSLD Cooke in Trois-Rivières. The Information Coops contacted a relative of the deceased who preferred that her identity not be revealed.
Eight days before the woman's death, an assistant nurse noted that her right hand was “swollen, bluish and cold,” coroner Marie-Ève Dagenais reported in her report. The employee then completed a report stating that the octogenarian's identification bracelet was causing “wrist compression.” When the bracelet was cut open, the octogenarian's skin was accidentally scratched, resulting in “two cuts of about a centimeter each,” the forensic pathologist explains.
degradation
Removing the bracelet does not bring any improvement. The next day the swelling was still present and the top of the hand had turned black. Circulatory disorders then extend to the entire forearm and the pulse. [nâest] “more tangible,” the coroner wrote. At this point, a remote consultation was conducted with a vascular surgeon who determined that there was “no surgical intervention” that could improve his condition.
A few days later, signs of infection are noticed. The octogenarian's arm is hot and his body temperature is high. The lady's health continues to deteriorate. The family then agrees to receive comfort care rather than opting for amputation.
CHSLD resident Cooke then began having trouble breathing. She died the next day.
“A Tourniquet Effect”
Me Dagenais emphasizes in his report that this death “was reported late to the coroner’s office,” which prevented an additional report from being carried out.
His analysis says the octogenarian wore a bracelet because his neurocognitive disorder prevented him from identifying himself. The report said the bracelet caused “a congestion effect” on the right wrist of the lady, who already had health problems affecting her blood circulation. The compression caused a lack of blood supply to the right arm and a “superinfection,” the coroner explains.
HAS”[La dame] His health was precarious, but if his wrist had not been caught by the identification bracelet, his death would not have been expected in the short term. This event is the starting point of the cascade of events that led to his death. From this we conclude that death [â¦] is traumatic in nature.”
– Excerpt from the report of coroner Marie-Ève Dagenais
In this context, the coroner “questions the quality of the care provided.” [â¦] in a patient with neurocognitive disorders.
Recommendation
Me Dagenais, while concluding that it was “an accidental death”, recommends that the Mauricie-et-du-Centre-du-Quebec (CIUSSS MCQ) analyze “the quality of care” given to the octogenarian since from his arrival at CHSLD until his death and that “appropriate measures” would be taken if necessary to avoid further similar situations.
The CIUSSS MCQ was asked to respond to the coroner's report and reiterated its condolences to the octogenarian's relatives. The organization states that “following the death, an independent team from the Care and Services Quality Department quickly conducted an internal analysis,” which led to the reporting of the coroner’s file.
The CIUSSS MCQ adds that even before receiving the report, measures were taken “to prevent such a situation from occurring again, in particular reminders and follow-up to teams to check the fit of the wristband when donning it upon entry.” Verify During the bath, carefully check the condition of the identification bracelet [et] to check the relevance of wearing the bracelet every three months.”