Lynn St. Jacques says her family is still struggling with how their mother died at Stensrud Lodge, a care home in Saskatoon.

The family didn't find out how 68-year-old Simone Reinhart really died until a local coroner put together a report more than two weeks later. Reinhart died early in the morning on April 10, and her family believed that she had suffered a massive stroke or heart attack in her private room.

"It was very hard to know that she laid there and suffered, that she was alone, it hurts," St. Jacques said.

"I'm very angry, I know the rest of my family is angry also."

The family was called to the home after Reinhart died. St. Jacques arrived to find her mother in her bed, with her arms crossed, "looking very peaceful." Staff said she had been found on the floor next to her bed.

Reinhart was in the lodge because of a massive stroke in the fall of 2011 that made home care impractical.

A coroner was assigned to the case because the circumstances around her death were unclear.

After interviewing staff, the coroner discovered that Reinhart had, in fact, been found with her head caught between the bed rail and mattress, hanging halfway out of her bed.

She had choked to death.

The home has a "fall alarm" system in the rooms, but Reinhart's could not be attached to her bed because of the size of the bedrails. It was attached to her nightgown but, when she slid off the bed, it slid with her instead of going off because it was not affixed to the bed.

Staff had moved her back into the bed before calling the coroner – two hours later.

Coroner Kaylee Pavier made three recommendations:

  • Review the bed alarms currently used in Stensrud Lodge, particularly those requiring attachment to quarter-bed rails in order to alarm.
  • Review documentation protocols, including but not limited to, the timeliness and accuracy of documentation by all staff involved in patient care to ensure all relevant information is shared.
  • Staff Education regarding The Coroner's Act, 1999, particularly Section 61, which indicates that when a death has occurred under circumstances that require it to be reported to a coroner, the body is not to be moved or altered unless the coroner so directs. 

"It was hard to read, but if it brings justice to my Mom and anyone else afterwards," St. Jacques said. "That's the most important thing now. (We need) better care for our seniors."

Yvonne Morgan is head of Jubilee Residences Inc., which owns Stensrud Lodge.

"We always try to provide care to our residents that is respectful of all rules and regulations," she said.

"There are some elements in the coroner's report where we could improve our practice, and we will certainly be looking at those recommendations to make sure we provide greater care to all of our residents."