Hull

Masham senior died after substandard care at Villa

Local Journalism Initiative / The Low Down / September 4, 2025 / A Quebec Commissioner for Complaints and Quality of Services report, Aline Besner, Aline Maisonneuve, Autopsy, Guy Maisonneuve, Hull, Masham, Quebec Coroner, Seniors care, Shelley Langlois, The Centre intégré de santé et des services sociaux de l’Outaouais (CISSSO), Trevor Greenway, Villa des Brises

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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Closed OR rooms…so he has to leave

Local Journalism Initiative / The Low Down / June 5, 2025 / anesthesiologist, Chelsea, CISSS de l’Outaouais (CISSSO), Dr. Trevor Hennessey, Gatineau, Hull, Outaouais, Outaouais operating room closures, Trevor Greenway

By Trevor Greenway

An anesthesiologist from Chelsea is being forced to find work elsewhere in the province because there aren’t enough functional operating rooms in the Outaouais.

Staffing levels are so low at the CISSS de l’Outaouais (CISSSO) that just seven out of the region’s 19 operating rooms will be functional this summer, sending medical specialists like Dr. Trevor Hennessey hundreds of kilometres across Quebec and Ontario just to find work.

“Our CISSS is dying,” said Dr. Hennessey. “Surgeons can’t operate in a hallway, and anesthetists can’t operate without the operating room team. The surgeons and anesthetists in the Outaouais are ready, willing and want to work. We’ve entered into the profession to help and care for the population, and the lack of access to the operating rooms is really a big impact.”

Hennessey, the head of anesthesiology at CISSSO, said that his department has absorbed 17 full weeks of “essentially forced time off” because there was not enough staff to open operating rooms in Hull or Gatineau. This week, Hennessey is doing replacement work at the Roberval Hospital in the Saguenay–Lac-Saint-Jean region.

He also had to travel as far as Estrie near Sherbrooke and also had to get certification in Ontario to work at the Montfort Hospital for six weeks last year in order to give some of his local immigrant colleagues the local work.

“We brought them from overseas. We brought them with their family. They’ve moved their entire lives here, and then we tell them to sit at home and don’t work and you can’t make any money? I don’t want to lose these colleagues. I don’t want them going back home either.”

He said he’s flexible and doesn’t have kids, so he has agreed to take remote jobs so his recruited workers can stay and work locally.

The problem, according to Hennessey and healthcare advocates in the region, comes down to money – specifically salaries for nurses in Quebec, when compared to Ontario.

According to the Fédération interprofessionnelle de la santé du Québec, nurses in Quebec with a bachelor’s degree have the lowest starting salary in the country, at $53,000 a year. It’s a significant difference in Ontario, where starting salaries for nurses are $74,000 – a staggering 40 per cent more than their Quebec counterparts. This is sending nursing staff to Ontario in droves. And the lack of nurses in operating rooms in the Outaouais means more medical technicians are leaving, including the region’s only vascular surgeon, says Hennessey.

“We’ve lost four out of six plastic surgeons. We’ve lost a general surgeon. We’ve lost gynecologists with operating room time and lack of equipment,” said Hennessey. “We’ve lost urologists, and – most recently and the big one – we’ll be losing our last and only vascular surgeon for the entire region.”

He continued: “That is a major, major impact for the care of the population. Very sick patients will have to go to Montreal, and emergency cases will have to be transferred further to Ottawa. But when you’ve got a rupture [abdominal aortic aneurysm], every single minute counts. People with major surgeries, such as brain cancers, are going to need to wait significant periods of time.”

Hennessey noted that CISSSO nurses are “phenomenal, but boy, they’re getting tired.”

Doctors facing ‘moral distress’

Hennessey wanted to be clear that surgeons are not leaving the area solely to find work and make money, but many have left the region over what he calls “moral distress,” as doctors feel they can’t follow their duty of care in the Outaouais.

“They feel like they can’t provide the care to the patients that they need and this is causing such distress that they need to actually leave our area to go elsewhere,” he said. “Some people feel the surgeons are leaving because they want to make money. That’s not the sole reason. They are unable to provide care and are getting phone calls week after week from patients desperate for care and they can’t provide it to them.”

He said that occupancy levels in the region in 2014 and 2017 were at 93 per cent and 90 per cent, respectively. Within 10 years, those levels dropped below 50 per cent “due to a shortage of nurses and other staff.”

A consequence of chronic underfunding

SOS Outaouais president Jean Pigeon said the latest news about reduced operating rooms is just a consequence of the region’s chronic underfunding over the last 10 years.

According to the Observatoire de développement de l’Outaouais, it has estimated that the Outaouais region faces a funding shortfall of $180 million compared to other regions in Quebec.

Pigeon has the same argument as many doctors and health advocates: The situation won’t improve until there is an alignment of nurse and medical technicians’ pay with those of their Ontario counterparts.

“This is just going to slowly hurt our region more and more because nothing’s being done about it, right?” he said. “We’re the region in Quebec that has the fewest nurses per capita because … most of them are tempted to go and work elsewhere, especially in Ottawa.” Staff retention has been a constant struggle in the Outaouais region. In 2022, the Outaouais had the lowest number of nurses per resident in the province, with less than five nurses caring for every 1,000 people.

Gatineau MNA Robert Bussière did not respond to the Low Down’s call for comment.

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