By Ruby Pratka
Local Journalism Initiative
A coroner is recommending that the CIUSSS de l’Estrie-CHUS “put the necessary measures in place” to improve emergency room intake procedures following the death of a cardiac patient who was sent home from the Brome-Missisquoi-Perkins Hospital emergency room in late December.
Coroners investigate accidental deaths, deaths that occur due to violence or suspected negligence and deaths that occur in public facilities such as prisons and rehabilitation centres; they also investigate deaths where the circumstances are not immediately clear. The patient, a 50-year-old man who lived with his partner in Brigham, died at home on Dec. 30, 2024. Coroner Dr. Yves Lambert investigated the man’s death.
In his report, Lambert describes the patient as suffering from type 2 diabetes, morbid obesity and dyslipidemia, a metabolic disorder characterized by abnormally high levels of fat in the bloodstream. “These are all risk factors for cardiovascular disease,” observes the coroner, adding that the patient had a family history of heart disease and had stopped taking medication prescribed to treat high cholesterol in the months before his death. However, the report goes on to say that the patient himself had no known heart problems.
On Dec. 26, the patient went to the BMP emergency room complaining of a fever and tightness in the chest; after tests, which included a chest x-ray and an EKG, he was diagnosed with pneumonia, prescribed antibiotics and told to return if his situation worsened.
Early in the morning of Dec. 30, the patient went to the emergency room again after he was woken up by acute chest pain. On the basis of an EKG, without seeing the patient, a doctor prescribed an antacid and further tests; two hours later, a doctor saw the patient, wrote that the pain had cleared up and prescribed two new medications. “The doctor released [the patient] from the emergency room without noting what follow-up would be done or what [the patient] should do if the pain worsens,” Lambert wrote.
The patient and his partner then drove home, although the report noted that his “partner was driving because he was still experiencing chest pain.” The pain continued throughout the morning, although the patient preferred to wait and see if the new medication would help rather than go to the ER a third time. He suffered a sudden cardiac arrest shortly before noon and couldn’t be revived. An autopsy found a blood clot in the right coronary artery as well as atherosclerosis (hardening of the arteries), the combination of which, in Lambert’s estimation, led to his death.
Lambert noted that coroners did not have the power to attribute responsibility for a death to any one person or institution, nor to analyze the work of a health professional. He recommended that the CIUSSS de l’Estrie-CHUS “review the quality of intake and care provided to the deceased person in the ER between Dec. 26 and 30, 2024, and if needed, put in place appropriate measures to improve intake of patients in similar circumstances.”
In an unsigned statement, the CIUSSS said the patient’s case was still being evaluated but that the agency was committed to implementing Lambert’s recommendation. “First of all, we would like to offer our sincere condolences to the [patient’s] loved ones and family. Our teams are committed to ensuring access, quality and continuity of care and services, while effectively responding to the needs of the population,” they said. “It is in this spirit that we have reviewed the coroner’s report and are committed to implementing all of the recommendations. The file was submitted on July 14 for an analysis of the quality of the care and treatment provided. We will not comment further as we are still awaiting the evaluation by the responsible committee.”
The Collège des médecins du Québec, Association des médecins urgentistes du Québec and Fédération des médecins spécialistes du Québec, which have all raised concerns about ER physicians’ workload in recent years, have not commented publicly on the case.