Guy Maisonneuve

Masham senior died after substandard care at Villa

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By Trevor Greenway

A Quebec coroner has concluded that Masham resident Aline Maisonneuve died of a kidney infection “in a context of suboptimal care” that she received while staying at the Villa des Brises care home in Hull.

Maisonneuve, 95, was found “drowsy and hypotensive” in her bed on the morning of April 12, 2024, after several fellow patients reported hearing her screams go unanswered the night before. She died two days later at the Hull Hospital, where doctors reported finding bed sores and bruises across her torso and neck. 

An external examination of Maisonneuve’s body on April 16, 2024, and an autopsy performed on April 23, 2024, confirmed these wounds and her cause of death. 

The external examination revealed “two bedsores in the [tailbone] region and three bruises on the back,” wrote Coroner Marie Pinault in her report, which the Low Down has obtained. “Ms. Aline Besner died of pyelonephritis in a context of suboptimal care,” she stated in the report.

Besner is Aline Maisonneuve’s legal surname, however she is known around the Hills as Maisonneuve. 

Pyelonephritis is a kidney infection that needs prompt medical treatment, according to Health Canada. If not treated properly, an infection can cause lasting damage to the kidneys, or the bacteria can spread to the bloodstream and cause a potentially life-threatening infection. This is what happened to Maisonneuve, according to the coroner’s report. 

The autopsy, performed at the Laboratory of Forensic Science and Medicine in Montreal, revealed “acute pyelonephritis with blood-borne spread to the lungs and liver,” wrote Pinault. “In addition, the pathologist noted pressure sores on the back of the shoulder blades, calves and heels, as well as a one-centimetre superficial ulcer on the sacrum.”

Maisonneuve had been staying at Villa des Brises since Feb. 26, 2024, and within just a few weeks her condition had deteriorated rapidly, according to her son, Guy Maisonneuve. She was admitted after caring for her became too much for Guy and his wife, Shelley Langlois so she was moved to the Wakefield Hospital on Dec. 22, 2023, where she was treated for “delirium and loss of independence” until Feb. 26, 2024, according to the report. 

She was later admitted to Villa des Brises, but the move there wasn’t supposed to be permanent, as Maisonneuve was waiting for a spot to open up at the Masham long-term care facility, the CHSLD. But she never made it there. 

Patient wasn’t bathed for two weeks: commissioner

A Quebec Commissioner for Complaints and Quality of Services report released in May suggested that Maisonneuve hadn’t been given a bath in two weeks while staying at the home. Commissioner John Benoit concluded that she was the victim of “physical and organizational abuse through negligence” by staff at the care home and the CISSS de l’Outaouais home support (SAD) clinical team. 

Benoit’s report also noted incomplete records at the Villa, the absence of a treatment plan for the period from April 1 to April 12, 2024, and “delays (or lack thereof) in responding to call bells” – alarms that residents can use to alert staff when they need help. The report also showed that Maisonneuve had fallen four times between March 20 and 30, 2024; no incident/accident reports had been filed and follow-up was very poor. 

The commissioner’s report also highlighted several shortcomings at the Villa, including problematic “hygiene and sanitation concepts, infection prevention and control, regulations on the certification of private residences for seniors, assessment of the quality of the living environment, the medication, nursing care and risk management.”

Following the commissioner’s report, an action plan was developed at Villa des Brises. While some of the improvements are ongoing, a new manager with a nursing background was appointed last fall, and her office is located at the Villa. 

However, questions remain surrounding why Maisonneuve was fully dressed in her daytime clothes when she was found unresponsive at the Villa and why the bedsores and bruises were not reported. 

“It was not possible to determine why Ms. Besner was dressed early in the morning when she was found unconscious,” wrote Pinault. “In addition, staff at the residence and SAD denied any skin integrity issues when she left for the hospital on April 12, 2024, while hospital staff reported bedsores that same day.”

Family endured year of ‘agony’

Maisonneuve’s son, Guy told the Low Down Sept. 1, about a week after the coroner’s report was published, that despite already being aware of the disturbing details of his mother’s death, reading the coroner’s report was yet another traumatic day in their 17-month fight for justice. 

“It was not fun to reread it, but it’s not the first time or last – we’ve gone over this so many times, and you don’t get used to it,” said Guy. “I will never get used to hearing the descriptions of my mom’s conditions. I’m going to have to find a place for it because it’s never going to be okay; I will never be okay with what happened to her.”

While the family will never have their mom, mother-in-law, and “Grandmama” back, Guy and Langlois are satisfied with the report, the findings and the action plan that the Villa has been implementing.

When asked if he feels justice has been served, Guy said, “To a certain degree.” He said that the multiple stories published in this local community paper helped the family push forward and ultimately led to the community knowing her story. 

“I think that this is part of what has helped my mom get some justice – we told her story, it was acknowledged, it was talked about, and if it can even help one person…” he trailed off with emotion. 

“It feels like we did accomplish something. And it wasn’t just Shelley and I,” he continued. “It was, again, with your help and with the help of Dr. Pinault. I think she did get some justice. They didn’t know her name. They had no idea –  she was just an anonymous patient, but now I’m pretty sure they know her name.”

“They can’t ignore her now,” added Shelley. 

The Centre intégré de santé et des services sociaux de l’Outaouais (CISSSO) told the Low Down that it implemented a “continuous improvement plan” to improve care at the home and monitor for quality control following the death of Maisonneuve. The regional health authority said that it installed a CISSS manager following her death and has implemented “safety nets” to address alleged abuse or negligence. 

“The CISSS de l’Outaouais takes each of these incidents seriously and has investigated them with the support of the Nursing Department (DSI) and the Quality, Performance Evaluation, and Ethics Department (DQEPE),” said CISSSO spokesperson Qeren Boua. “We were proactive in this matter and, following this event, a CISSS manager was present at Villa des Brises. As soon as we became aware of the situation, we implemented, in collaboration with the RPA, a continuous improvement plan that allowed us to monitor the actions taken and ensure the quality and sustainability of services.”

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Masham family ‘abandoned’ after care home death

Local Journalism Initiative / / / , , , ,

by Trevor Greenway
Local Journalism Initiative
It’s been more than five months since Aline Besner died while under the care of an elder home in Gatineau, and her Masham family still has no answers about the circumstances surrounding her death.
Besner’s son, Guy Maisonneuve, and his wife, Shelley, have been anxiously awaiting a coroner’s report and said they’ve been left in the dark about how their mother and mother-in-law died. The Masham couple have a running clock for how long they’ve been waiting for answers. It was 144 days when the Low Down visited their Masham home on Sept. 12.
“We feel just utterly abandoned,” said Guy. “We haven’t heard from anybody,” added Shelley, explaining that they have now filed a complaint with the ombudsman because of the multiple delays in their file.
Besner died on April 14 after her cries for help three days earlier were ignored by staff at the Résidence Villa des Brises care home, according to several other patients who were staying at the facility.
Doctors at the Hull Hospital later discovered bed sores all over Besner’s torso, neck and back and immediately filed a complaint against the care home, which triggered a coroner’s investigation.
Following Besner’s death, the Maisonneuves have been trying to wade through mounds of government red tape and said that over the past five months, nobody from the Centre intégré de santé et des services sociaux de l’Outaouais (CISSSO), the health minister’s office, their own MNA Robert Bussière or even the care home itself, has attempted to reach out to the grieving family. They have sent multiple letters and emails to the ministry and to Bussière’s office, but said their pleas for answers have been ignored.
“It’s excruciating,” added Shelley. “But I get the funny feeling that everybody’s under a gag order – ‘Don’t talk to the families because you could say something,’” she suggested. “It is mentally and physically exhausting to have to chase this down,” she added about getting answers to her family’s inquiries.
The Maisonneuves said they’re also shocked and appalled that nobody from the ministry, the CISSSO or MNA Bussière have reached out to them following Besner’s death – no sympathy calls, no apologies and no commitments from political leaders to bring about change.
Their heartbreaking letter sent Aug. 21 to Bussière, Minister Dubé and Premier François Legault details the grief the family has endured since Besner’s death.
“Not only am I now faced with the grief of losing my mother, but I also have the added stress of dealing with a coroner examining the cause and circumstances of my mother’s death,” wrote Guy. “My mother has now been dead for 130 days, and we still haven’t received a response to our complaint from the Office of the Service Quality and Complaints Commissioner, the first step in the complaint process that your office directed us to.”
This was the second letter the family has sent since March 17 – the first one was sent before Besner died asking for help to get her out of the care home. That first letter coldly referred them to a complicated, multi-step complaints process, and the latest one was ignored.
The Maisonneuves have a thick binder on a table full of documents, witness statements and other information they’ve compiled for their case. And despite sometimes feeling overwhelmed or deflated, Guy said he won’t give up until he gets the answers he and his family need to fully grieve their 95-year-old “Grandmama.”
“It feels intentional; it feels like they’re trying to wear us down,” said Guy. When asked if it was working, he replied, “there’s no goddamn way.”
“The memory is so, so fresh, and I’m constantly reminded of it,” he added, referring to the horror he and his family endured when discovering the state of his mother’s body – and after learning that her screams three nights earlier went ignored. “I just have to conjure my mother. And that’s my motivation.”
Care home routinely ignoring patients
Low resident Steve Connolly was another patient at the home and documented the daily neglect he and other patients witnessed at Villa des Brises. His 44-page diary shown to the Low Down describes orderlies at the home routinely ignoring patient alarms, neglecting patient needs and one instance where Besner’s calls for help were ignored, and Connolly found her lying on the floor alone, helpless.
According to CISSSO, which jointly manages Villa des Brises’s second floor as a post-acute and overflow ward for those needing rehab or a transfer to a long-term care home, an “improvement plan” has been initiated at the care home since Besner’s death. CISSSO spokesperson Camille Brochu-Lafrance told the Low Down in June that the health organization has a full-time manager at the home to “report discrepancies” if any are found.
“The CISSS de l’Outaouais takes each of these events seriously, and they were investigated with the support of the Nursing Directorate (DSI) and the Quality, Performance Evaluation and Ethics Directorate (DQEPE),” wrote Brochu-Lafrance. “In accordance with our anti-abuse policy, as soon as there is suspicion of neglect or abuse, a report is made and safety nets are immediately established in collaboration with the residence. A complete analysis of each situation is then made with a view to correction or improvement.”
Health Minister Dubé and MNA Bussière did not respond to the Low Down’s queries regarding Besner’s death. CAQ spokesperson Léa Fortin told the Low Down that, because Villa des Brises is in the Hull sector, it is under the responsibility of Hull MNA Suzanne Tremblay. However it’s important to note that Guy and Shelley Maisonneuve both live in Masham and are constituents of Bussière.
Following our interviews with the family, Bussière’s office finally responded to the Maisonneuve’s on Sept. 16. Pascale Labelle, Bussiere’s political attaché emailed to “offer you and your family my deepest sympathies following the death of your mother.”
“Once again, Mr. Maisonneuve, I would like to apologize for the situation. Mr. Bussière has immense respect for the citizens of the riding he represents. It is very important to him that citizens who contact the office are satisfied, receive the necessary support, are directed to the right resources, are accompanied if necessary, etc. Regardless of age, social status, culture or other, all citizens are important and deserve respect.”
However, the family still has not received a call, email or letter from Bussière himself.

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