Patient death at Longueuil hospital last summer caused by 'human error': CISSS

Maurice Leblanc died at 8 a.m. on June 5, 2020. He was among nine COVID-19 patients who were suddenly deprived of oxygen when Charles-Le Moyne hospital's medical gas network was shut down temporarily.

Maurice Leblanc, 71, had been in a coma for 23 days before incident

Charles-Le Moyne hospital, located in Longueuil, has adopted new measures to prevent such incidents in the future, the local health agency says. (Radio-Canada)

The regional health authority that oversees Longueuil's Charles-Le Moyne hospital is blaming "human error" for the death of a 71-year-old patient last June.

According to the CISSS de la Montérégie-Centre, Maurice Leblanc was suddenly deprived of oxygen on June 5 after the hospital's medical gas network was cut during some routine maintenance.

Leblanc, a COVID-19 patient who had been in a coma for 23 days, was one of nine people affected by the gas network being cut.

Martine Lesage, a spokesperson for the CISSS, told Radio-Canada that Leblanc was in such a fragile state of health that he did not survive the sudden loss of oxygen. 

The eight other patients did not suffer serious consequences.

Work in the hospital's former emergency room required the medical gas network to be stopped temporarily and the operation was carefully co-ordinated with all the affected units in order to prevent disaster, the CISSS says.

However, the short-stay COVID-19 unit was not defined as a sector included in the temporary shut down.

The COVID intensive care unit is "at the other end of the work site," Lesage said.

"The incident originated due to human error in the interpretation of the medical gas networks plan," she said.

Maurice Leblanc died at 8 a.m. on June 5, 2020, in Longueuil's Charles-Le Moyne hospital. (Submitted by Maurice Leblanc's family)

Lesage said respiratory therapists, nurses and other staff quickly mobilized to restore oxygen to patients in the unit, including by providing manual ventilation.

The health authority's investigation of the event first came to light following a report by La Presse.

The CISSS made recommendations to prevent such a situation from recurring and those have since been adopted by the hospital, Lesage said.

Leblanc's wife, Carole Larochelle, isn't blaming the hospital for her husband's death.

His condition was so serious that doctors estimated that he would need three to six years of rehabilitation if discharged from the hospital.

She said the error relieved her and her family of having to make the painful decision of taking Leblanc off life support.

Paul Brunet, a patients' rights advocate, said that these kind of errors are avoidable and the hospital should at least apologize to the patients and their families.

with files from Radio-Canada

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