Posted at 12:00 a.m.
The McGill University Health Center (MUHC) was ordered to pay $15,000 in moral damages to the parents of Jonathan Fontaine-Duval, a 33-year-old man who died of a diabetic coma, in January 2016, following errors and omissions in monitoring his cancer medication.
In a decision handed down on January 7, Judge Stéphane Davignon, of the Small Claims Division, concluded that “the MUHC has failed in its primary mission, namely to provide [à Jonathan Fontaine-Duval] the diagnostic services appropriate to the evolution of his condition and [de] ensure that his needs are assessed on time”, while he was receiving chemotherapy treatments.
Could this tragic end have been avoided and should it have been by the MUHC? At the end of the investigation, the Tribunal concludes that yes.
Excerpt from the decision of judge Stéphane Davignon
Judge Davignon indicated that he had “no hesitation” in awarding Robert Duval and Francine Fontaine the maximum amount of damages that can be awarded in this instance, wishing that they “can now embark on another path of mourning for Jonathan more than six years after his death.
No health problems
When he consulted an MUHC doctor in June 2015, complaining of fatigue and pain in the lower back, abdomen and neck, Jonathan Fontaine-Duval had “never had a health problem”. He is a burly young man of 1.93 m and 100 kg, kinesiologist by profession, who runs marathons, who has made many trips and who is a baseball coach. A biopsy confirms that he has Hodgkin’s lymphoma.
From July to November, he goes through four cycles of chemotherapy treatment, an aggressive approach advocated due to the advancement of the cancer, which is at stage 4.
The treatment seems to be working wonderfully. On November 23, 2015, Jonathan no longer showed any trace of Hodgkin’s lymphoma.
The complete treatment plan, however, provides for two other cycles of chemotherapy “to increase the chances of stopping a recurrence”. Among the drugs he receives in high doses is dexamethasone. This drug has the property of increasing the patient’s blood sugar by increasing the production of glucose by the liver, while reducing the effectiveness of the insulin produced naturally by the pancreas.
signs of diabetes
Until the end of November, indicates the judgment, “the results of his blood counts do not show anything abnormal”. But things will quickly get complicated from there.
On December 18, a few weeks after Jonathan Fontaine-Duval began his fifth round of treatment, blood tests showed that triglyceride and glucose levels were well above normal levels.
On December 24, the patient begins his sixth cycle of chemotherapy, again with high doses of dexamethasone. He complains of fatigue. A nurse notes it in the file as a major side effect of the treatments, but “no intervention is done”.
The patient receives the second treatment of his sixth and final cycle on January 8, 2016, and must continue to take dexamethasone for the next three days. At the trial, in Small Claims Court, a doctor will point out that in blood tests taken on January 7, the day before this last treatment, there are not even results for blood sugar.
On January 13, 2016, Jonathan Fontaine-Duval was found dead at home, in his bed, by a friend who was worried about not having heard from him. His death, the pathologist concluded, dated back to the day before.
diabetic coma
But his death, says Judge Davignon, “is in no way linked to the illness that brought him to the MUHC, namely Hodgkin’s lymphoma”. A coroner’s report concludes, several months later, that Jonathan Fontaine-Duval died of a diabetic coma, stemming from diabetes that developed in the fall of 2015 while receiving treatment at the MUHC, but who was neither taken care of nor treated by his care team.
An amicable agreement had already been reached between Jonathan’s family and his doctor, but the parents wanted to have the hospital’s responsibility also recognized in the death of their son.
There was an obvious slack in the follow-up care given to Jonathan and in his case the consequences were tragic. It is obviously impossible to say that his death would necessarily have been avoided, but the means to achieve this had to be put forward. They weren’t.
Excerpt from the decision of judge Stéphane Davignon
A spokeswoman for the establishment wrote to The Press that “the MUHC is analyzing the court’s decision and will not comment”.