Villa des Brises

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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Villa des Brises gets near failing grade on inspection

Local Journalism Initiative / / / , , , , , , ,

By Trevor Greenway

An inspection by Quebec’s investigation department has found that Villa des Brises long-term care home, where Masham resident Aline Maisonneuve was found unconscious in her room and died two days later in April 2024, failed nearly half of its operational measures mandated by the province, including having a faulty call-for-help system for patients. 

According to the January 2024 inspection report by the Direction des Inspections et des Enquêtes, the Villa des Brises care home facility in Gatineau was non-compliant in 18 out of 37 categories. The report was obtained through an access-to-information request. 

Among the biggest infractions cited by the report were a faulty call-for-help system, which was connected to care staff’s cellphones rather than a central line in the home. Several patients of Villa des Brises the Low Down spoke with reported pulling the alarm systems for help, only for their pleas to go unanswered. 

Maisonneuve, a Masham senior, was a patient at the home in 2024. She died in the Hull Hospital on April 14, 2024, after fellow patients reported that her screams for help went unanswered throughout the night two days earlier at Villa des Brises. Doctors found bedsores on her back and torso and a coroner is now investigating her death. 

According to the inspection report, the home also got a failing grade for its fire safety plan, as its resident list was not up to date. The home also failed under the “risk of wandering” category, as it does not feature an alarm system to alert staff if patients wander out of the building. 

The inspection also revealed that staff regularly left hazardous products around the home unattended.

“Presence of a bottle of odoriferating solution concentrated in the fifth floor residents’ bedroom. Cart containing several household products left unattended,” the report stated. At the time of the report, the home also had issues with its liability insurance and had no collaboration or cooperation agreements with intensive care units or prescription drug providers. 

A second inspection in June 2024 revealed the home was still non compliant in six categories, including the faulty call-for-help system, the home’s fire safety plan, as well as a risk of wandering. 

Maisonneuve’s son, Guy, and her daughter-in-law, Shelley Langlois, have been trying to get justice for their loved one for over a year and say the inspection shows just how bad things were at Villa des Brises while Maisonneuve stayed there.

“It puts into perspective just how bad things were at the Villa des Brises/CISSS de l’Outaouais residence,” said Langlois. “Many of the serious problems were documented as far back as January 2024 and yet patients kept being placed there.”

A coroner’s report into Maisonneuve’s death is expected to be released sometime this June. 

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Masham senior was ‘victim of abuse’ at Gatineau care home

Local Journalism Initiative / / / , , , , , ,

By Trevor Greenway

Aline Maisonneuve wasn’t given a bath for over two weeks while under the care of nurses at the Villa des Brises long-term care home in Gatineau, a report by Quebec’s complaint commission suggests. 

Quebec’s Commissioner for Complaints and Quality of Services found that the Masham senior, who died April 14, 2024, two days after being found unresponsive in her long-term care room in Gatineau, 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. 

Before she was taken to the Hull Hospital, witnesses reported hearing her scream throughout the night – screams that went unanswered. She was then found unconscious and taken to hospital, where she later died two days later. Doctors at the Hull Hospital found bed sores on her back and torso. A coroner is now investigating the circumstances of her death. 

While the details around how her mother-in-law was treated at the home are devastating to read, Shelley Langlois told the Low Down that after waiting for answers for over a year, she and her husband, Guy, feel that someone is finally listening to their heartbreaking story. 

“We feel validated,” said Langlois, flipping through the commissioner’s report. “Validated that our concerns were warranted. None of this felt right from the beginning.”

In his report, Commissioner John Benoit noted that on the day Maisonneuve was found unconscious, paramedics discovered a “clean bandage” on her arm, indicating that she had recent bloodwork done. But medical records showed that she had only received bloodwork on March 27, 2024 – 16 days before she was found unresponsive in her care home room. 

“They asked the staff about this, and they had no record of [Aline] having had bloodwork. We can only deduce that the bandage is from bloodwork that would have been taken during a hospitalization at Hull Hospital on March 27, 16 days ago,” Benoit wrote in his report. “As the bandage was clean, it indicates that [Aline] had not likely been bathed in over two weeks. 

The report referred to Maisonneuve’s treatment plan at the care home between Feb. 27 and March 31, 2024, and noted that, while she received personal hygiene assistance almost every day, “she never received a full bath in the bathtub/shower over the same period” according to her treatment plan. 

“I therefore find that there were shortcomings, not only in terms of assistance with hygiene care by VDB [Villa des Brises] staff, but also in terms of the clinical follow-up provided by the nurses of the home support clinical team working at VDB.”

The report went on to note that Aline was also “fully dressed” upon her arrival at the Hull Hospital, which Benoit wrote, “suggested to us that either she had slept in her clothing or someone dressed an unconscious woman prior to sending her by ambulance. Either scenario is deeply upsetting.” Benoit also noted that he has “doubts about the assistance offered” to Maisonneuve between April 1 and 12, 2024, as the care home has yet to submit her treatment plan for that timeframe, “despite several attempts to obtain it.” 

Staff failed to follow ‘rule of care’

Nurses at the care home noted in their file on April 9, 2024, a few days before Maisonneuve was transferred to hospital, that no pressure ulcers were found on her body, according to the report. However, the report referenced a “lack of detailed notes” on Maisonneuve’s file, especially in the days leading up to her admission to the hospital. Benoit wrote in his report that the discrepancies make it impossible to explain the bedsores found by doctors at the Hull Hospital. 

The report stated that notes from a triage nurse at the emergency room at the Hull Hospital did not indicate wounds found on Maisonneuve when she arrived on April 12, 2024. However, a complete physical examination was not performed in the emergency room. It wasn’t until 9:30 p.m. that night when a doctor and a charge nurse discovered bruises and a pressure sore on her tailbone and back. 

“I am concerned about the health condition observed by the nursing and medical team at the Hull Hospital when your mother was admitted on April 12,” wrote Benoit. “The incomplete record-keeping, the absence of the treatment plan for the period from April 1 to 12, the inadequate use of various documentation and follow-up tools, such as the assessment of the risk of falling and the risk of developing pressure ulcers, and the lack of follow-up on care protocols (e.g. post-falls) demonstrate major shortcomings in the care provided to your mother during her stay at the Résidence Villa des Brises.” The report also described four separate instances when Maisonneuve fell at the care home, and each time staff failed to follow the “rule of care,” which involves post-fall assessments and documentation. According to the report, these post-fall assessments were either “absent or incomplete” and documentation was “very limited.”

The report came with a lengthy list of recommendations and an action plan for Villa des Brises to follow. These include implementing assessment and follow-ups for users who have fallen, ensuring nursing staff are trained in delirium detection, ensuring that nurses include prevention-related clinical guidelines when the risk of pressure sores is identified and several other measures. According to the report, many of these recommendations have been implemented since last summer. 

‘We read it and were just bawling’

Langlois told the Low Down that she and her husband had felt abandoned by the system: nurses and staff at Villa des Brises; executives within the CISSS de l’Outaouais; and their own MNA, Robert Bussière, who has yet to contact the family personally. 

They said they’ve waited more than a year for any movement on their file. 

But now that their complaints have been validated, they said they feel confident that justice for their grandmama, mother and mother-in-law will eventually be served. 

Langlois said when she and Guy read in the report that Maisonneuve was “the victim of physical and organizational abuse through negligence on the part of the VDB and SAD care staff during her stay,” they began to weep.

“I highlighted it. We read it and were just bawling,” said Langlois. “What we were looking for was someone to say, ‘You’re not crazy. This place was a shithole.’ And then to follow up with the action plan.”

Langlois praised Quebec’s complaint commission and said that she hopes her and Guy’s story will give others the confidence to push for justice when they feel they or their family have been wronged. 

Guy said he still struggles with the fact that he couldn’t save his mother from neglect at the care home. 

“We knew something was wrong with that place, but we couldn’t do anything about it,” he said, fighting back tears. “We couldn’t save her.” 

MNA Bussière refused to comment on the case, citing that it was a confidential matter. 

A coroner’s report into Maisonneuve’s death is expected to be finalized in June.

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