It is “very likely” that the death of a seven-month-old girl from Manawan at the CHU Sainte-Justine last April could have been avoided if she had not received emergency care “too late”, notes coroner Géhane Kamel in an investigation report released today.
In a five-page document, the coroner analyzes in detail the circumstances that led to the death of Niteïyah Chilton on April 4, who then shook the Atikamekw community of Manawan. An investigation was then quickly opened by the coroner’s office.
Three days before the baby’s death, the parents had contacted the nurse at the Manawan dispensary, in the Lanaudière region, because the girl was showing flu-like symptoms. “Acetaminophen was then suggested to be administered, but no visit was made to the child,” the report said.
The next day, the child has febrile convulsions and has difficulty breathing. The parents, “extremely worried”, then demanded hospital transport. Manawan’s nurse instead asks them to bring the baby to the dispensary, “which they do”.
The nurse finally calls for hospital transport from the Manawan ambulance teams at 8:59 p.m., but receives no response from them, as they are “overwhelmed”. A call is then made two minutes later to the teams of Saint-Michel-des-Saints, a village of 2,500 souls in the MRC of Matawinie. A team of ambulances from this sector set off almost six minutes later, “despite priority 1”.
It will take 1 hour 48 minutes for the paramedics to arrive at the dispensary. They then leave for Joliette with the child 33 minutes later. Thus, the little girl arrived at the Joliette hospital at 2:30 a.m. on April 3, “i.e. 5:30 a.m. after the initial call to 911”, explains Géhane Kamel.
Due to the “precarious” condition of the little girl, who was suffering from bacterial meningitis, a request was made at 3:18 a.m. to transfer her to the CHU Sainte-Justine. The property is approximately an hour’s drive from Joliette Hospital. However, due to various delays, the infant arrived at the Montreal hospital at 5:32 a.m., “8:30 a.m. after the initial call” to the emergency services, noted the coroner.
“Despite the efforts of the CHU Sainte-Justine medical team, the neurological prognosis is poor. It is agreed with the parents to stop the active treatments, ”details the report. The death of the girl will then be noted on April 4 at 8:50 a.m. by a doctor from the hospital center.
Three recommendations
“In this context, and given the initial medical assessment, it seems to me very likely that delays of this magnitude have had an impact on the survival of the child and deserve consideration of ways to reduce them. and thus prevent this from happening again, ”says Géhane Kamel. She comes to the conclusion that the little girl died of bacterial meningitis “following emergency care received too late”.
To prevent such a tragedy from happening again in the future, the coroner is issuing three recommendations. It first urges the Ministry of Health and Social Services to set in motion its vast project to transform pre-hospital emergency services, on which it claims to be working, in order to be able to implement “as soon as possible” services medical evacuation by helicopter for patients “in critical condition” who are “in remote areas”.
Such a recommendation had been made in 2009 by coroner Jean Brochu following the death by drowning of a two-year-old child from the community, Jaylia Jacob. The Atikamekw community has also begun discussions with Airmedic in recent months to have a heliport and offer medical transportation services by air, notes the leader of the Atikamekw community of Manawan, Sipi Flamand, in an interview with the To have to tuesday.
According to him, if the seven-month-old girl had been able to have quick access to a helicopter after her parents had alerted the emergency services, “it could have been a game-changer. »
In order to make up for the lack of manpower in ambulance services in remote regions, the Ministry of Higher Education should for its part “evaluate the possibility of setting up college cohorts of Aboriginal origin in pre-care hospitable, ”we can read. A recommendation that the Manawan dispensary should also implement, indicates the coroner.
Because, “currently, they are not able to respond [à la demande] given that there is a lack of human resources”, notes Sipi Flamand, in reference to the paramedics of Manawan. The community has only had one ambulance for several years.