Tragic deaths at West Island Manor : shocking facts revealed by the Ombudsman

MONTREAL, Oct. 26 /CNW Telbec/ - The Wilson family, with the support of the AQDR (Association québecoise de défense des droits des retraités), is making public the startling revelations found in the Québec Ombudsman's report.

This is following the tragic death of Willard Wilson, 94, who died in January 2009 at the CHUM (centre des grands-brûlés) after he was scalded in his bath tub at the West Island Manor in Pierrefonds. The family reported the death to the Coroner, whereas the CHUM completely neglected to do it.

Mr. Wilson was the second person in two years to die of scald burns at this private seniors residence, where 83% of the beds are contracted by the Agence de la santé et des services sociaux de Montréal ('Agence de santé').  The first death (in June 2007) was the subject of a coroner's report in June 2008.

According to the Ombudsman, the residence should have acted with "diligence and promptness following the first death".  The Ombudsman felt that "the establishment was lax in not rapidly performing a verification and rigorous inspection of the hot-water protection system by a competent professional after each of the two incidents".  The Ombudsman added that certain alternative measures could have been taken without delay. 

The family is outraged by the facts and observations in the Ombudsman's report, concerning the West Island Manor and the Agence de santé:

1. The family observes that the Ombudsman revealed that several of his requests for telephone communications were not answered, and that certain documents were not forwarded, despite repeated requests.  The family wonders how an establishment which gets 80% of its budget from the public system, appears to believe that it is above the law.
2. The family is shocked to read that "despite the requests made by the Agence de santé and the Ombudsman that the residence take action following the second death and recommendations by the Coroner following the first death, the West Island Manor finally installed a new hot-water safety device only on November 30, 2009, which was ten months after the second death".
3. The family questions the judgment of the Agence de santé's management. The Agence de santé has "the responsibility to ensure the safe delivery of services of health and social services to all the users in its territory". How can it maintain a service contract with an establishment that conducts business in such an erratic manner; and is so hostile with respect to its responsibility to a very vulnerable clientele, and to the Coroner's recommendations? 

For its part, the AQDR is shocked by the facts and by the Ombudsman's observations concerning the actions of the West Island Manor and the management of the Agence de santé:

1. The AQDR considers it unacceptable that the management of the Centre Hospitalier Universitaire de Montréal (CHUM) did not report the death to the Coroner, as obliged by the law on investigation of cause and circumstance of deaths.  The AQDR hopes that the Minister of Health takes action against the management of this establishment.
2. The AQDR is concerned about lapses of the Agence de santé's management, with respect to receiving, processing, and follow-up on Coroner's reports, in the context of these two violent deaths. All the circumstances of the deaths would not have come to light had the Wilson family not contacted the Ombudsman. It is noteworthy that the Agence de santé was not informed of the first death until two years after the fact. And it was in July 2009, while following up on the coroner's recommendations after the first death, that "the Agence discovered, by chance, that another death had occurred in January 2009".
3. The AQDR is concerned about similar negligence from the Agence de santé involving follow-up procedures with other institutions where such incidents may be happening.
4. The AQDR denounces the reckless attitude and nonchalance on the part of the residence, in the death of two seniors for whom it had responsibility.

The family and the AQDR, in light of the Ombudsman's recommendations:

• Agree with the recommendations made to the Ministry of Health and Social Services, concerning all the measures that need to be taken to ensure the establishment, control and auditing of standards, procedures and equipment connected to hot water in institutions, all across Québec.
• Ask the Ministry to institute a stronger procedure for the control of the Agences de santé, regarding follow-up of accidents causing injury and Coroners' reports.
• Demand - considering the numerous shortcomings on the part of management of the Agence de santé de Montréal observed by the Ombudsman - an inquiry into the procedures regarding the purchase of beds in the private sector by the Agence de santé de Montréal.

For further information:

Louis Plamondon, president, AQDR, cell : 514-713-7373 or 514-935-1551

Eric Wilson (son of Willard Wilson), 514-919-8208