A four-year-old boy from western Quebec who was hit in the head by a falling tree in his backyard waited 45 minutes to be transferred to the Children's Hospital of Eastern Ontario for treatment, despite repeated calls from the emergency team at the Papineau Hospital, a report from the Quebec coroner's office has found.

Malik Lafontaine died six weeks later, on July 29, 2015, of severe cranial trauma at Roger's House, a residential hospice for kids on the grounds of CHEO.

Investigating coroner Dr. Pierre Bourassa wrote in his French-language report that he didn't believe a quicker transfer to CHEO would have prevented the boy's death, due to his "catastrophic injuries."

'While the coroner concluded that the transfer did not play a role in this boy's tragic death, we feel it is very important for us to review the events to learn where improvements can be made.' - Eva Schacher, CHEO spokeswoman

Still, he underlined that "inappropriate delays" seemed to stem from CHEO's "reluctance" to accept the transfer of the boy, who was from L'Ange-Gardien.

CHEO spokeswoman Eva Schacher told CBC News in an email that the hospital received the coroner's report on Dec. 16, 2015 and a review of the transfer is expected to be complete it in about three months.

"We receive hundreds of emergency transfers a year, from hospitals across Ontario, Quebec and Nunavut. We know each one is critical, and our team works to mobilize as quickly as possible and to provide phone support to the clinicians," Schacher wrote.

"While the coroner concluded that the transfer did not play a role in this boy's tragic death, we feel it is very important for us to review the events to learn where improvements can be made."

'Isolated' incident

Bourassa also recommended that his report be handed over to the regional health authority in Quebec to highlight difficulties surrounding medical transfers to Ontario.

Geneviève Côté, from the regional health authority, said a committee between CHEO and hospitals in western Quebec has been created to review the delay, which she characterized as "isolated."

Côté said Quebec hospitals usually wait about 20 minutes for a response from CHEO — not 45 minutes.

"This committee will do follow-ups to help prevent unfortunate situations such as this one," she said in French.

Boy hit by rotting tree 

Malik Lafontaine and his brother were pretending to chop down trees in their backyard in L'Ange-Gardien on the afternoon of June 11, 2015, when a dying birch tree that was rotting from the inside toppled over, the coroner's report said. The tree, which was three to four metres tall and 15 to 20 centimetres in diametre, hit Malik in the head.

Paramedics were called at 5:50 p.m., arrived at 6:05 p.m. and left for the Papineau Hospital at 6:16 p.m., arriving at the emergency room at 6:30 p.m., the coroner's report detailed.

It continued to state that emergency room staff contacted CHEO at 6:40 p.m. for a transfer but it wasn't until 7:25 p.m., after several calls, that CHEO accepted the transfer, the coroner's report detailed. 

Bourassa said in his report the wait seemed "unsual and counterintuitive" given that delays in treatment can lead to increased chances of death.