'Every medical professional seemed to fail my father,' son says

The night Donald Darrell Mesheau’s heart failed seven hours into his wait to see a Fredericton ER doctor, all the tasks in triage fell to one nurse, plus anyone who could be spared to help.

The Horizon Health Network manager responsible that night said these are “battles” fought daily in New Brunswick’s health-care system, beset with a nursing shortage and delays in finding long-term care for patients.

His son says “every medical professional” failed his father, and he’d be alive if he’d been seen before his heart had already stopped.

Over two days this week, a coroner’s inquest heard that Mesheau, 78, was taken to Dr. Everett Chalmers Regional Hospital in Fredericton just after 9:30 p.m. on July 11, 2022, and was found found unresponsive in the waiting room just before 4:30 a.m. the next morning. The five-person jury declared he died of natural causes, with the cause of death listed as heart failure.

Mesheau’s death was followed by a public outcry and the firing of Horizon CEO Dr. John Dornan, plus the dismissal of then-Health Minister Dorothy Shephard from her cabinet post and the boards of both the Horizon and Vitalite health networks. Fredericton police determined there was “no criminality” in January.

Darrell Mesheau, seen left in an obituary photo, was a world traveller who really loved New Brunswick and was active in the community, says son Ryan Mesheau.

Mesheau’s son, Ryan Mesheau, said it’s been a “long two years,” but that it was important the public be made aware of the details of his father’s death to “make sure it never happens again.”

“The bottom line is that Horizon Health made mistakes. Every medical professional seemed to fail my father the night of his death by not following their own standards and protocols,” he said.

He said that Canadian Triage and Acuity System standards weren’t followed from the beginning, saying he was “supposed to see a doctor in 30 minutes, and he didn’t see one until he was dead, seven hours later.”

The jury recommended that “all stakeholders” should “collaborate and take ownership” of hospital capacity issues. It called for the findings of Horizon’s post-incident review to be “fully implemented, funded and staffed” and recommended a change to the way patient vitals are monitored in the waiting room.

“We wish to extend our deepest condolences to Mr. Mesheau’s family, friends and loved ones,” said Margaret Melanson, interim president of Horizon, who said they will review each recommendation “closely.” Since Mesheau’s death, she said Horizon has implemented new measures “enhancing access and the delivery of patient care” in the emergency rooms at its hospitals.

“These measures have included increasing staffing levels to monitor the well-being of patients in our waiting rooms, who are regularly checking vital signs, and providing comfort and support to patients while they wait,” Melanson said in a statement.

‘A battle every day’

On Monday and Tuesday at the Fredericton Inn, the jury heard from 11 witnesses, including registered nurse Neil Gabriel who said the ER was short-staffed that day, but not “dangerously so,” and to him, “staffing wasn’t the real problem” at that time, but not being able to move patients on from the ER, which he described as “bed blocking.”

Susan McCarron, who is Horizon’s clinical director responsible for emergency care in the region, said that the hospital had been over-capacity due to patients waiting for long-term care placements. That means that ER patients who have been admitted to the hospital have nowhere to go but the acute care beds.

Since Mesheau’s death, McCarron told the inquest a “flow centre” staffed by physicians’ assistants who “decant” cases less urgent than Mesheau’s out of the waiting room, as well as co-ordinators to help facilitate discharges from the hospital have helped relieve pressure on ER spaces.

“It’s a battle every day. Some days we do really well. Some days it doesn’t go so well,” she said, saying nurses make “good decisions” about who goes into the waiting room.

There were 17 admissions at the Dr. Everett Chalmers Regional Hospital emergency room on the night of July 11, 2022, a coroner’s inquest heard Monday in Fredericton.

Gabriel, who was on shift earlier that day, testified that the ER had 17 admitted patients waiting that day, with only two of the 26 emergency beds held open in case of an ambulance.

Gabriel said the triage unit, which would usually have five people in daytime hours and two for the night shift, was down to just one person that night because they were missing a nurse. That one person would be responsible for triaging patients, communicating with ambulances for offloading and checking waiting room patients, Gabriel said.

On arrival, Gabriel said a person triaged at level 3 would have had their vitals checked and then sent to the waiting room, if safe to do so. Gabriel said the triage nurse should visually check every hour and check vitals every “couple of hours,” but “it’s not humanly possible with everything they’re encompassed to do.”

Danielle Othen, a registered nurse in charge of triage that night, said she had been working for 12 hours, and had no chance to take breaks.

“You just go to work,” she said. “You do your triage, and you just take the next person in line.”

Othen agreed with Wilbur that she was also responsible for the waiting room, but had no time or opportunity to do so. When asked, McCarron called that the “daily experience” of an ER staffer.

Seven-hour wait

Ashley Guptill, a primary care paramedic with Ambulance New Brunswick, testified that she was called to Mesheau’s downtown Fredericton apartment at 8:56 p.m., where he said he’d had a cold for a week and complained of “weakness.”

Guptill said Mesheau was short of breath while exerting himself, but his heart readings didn’t show the signs of a heart attack. When they got to the hospital at 9:33 p.m., she brought him to the waiting room in a wheelchair until a nurse could see him. She said now, a paramedic would have waited with the patient, which could take one to 10 hours of “offload delay.”

Mesheau was triaged by Othen at 10:44 p.m. and around 15 minutes later April Knowles, a licensed practical nurse, told the inquest she helped wheel him to the bathroom. She said she was watching patients in the psych unit that night but had time to assist in the ER waiting room.

When Knowles brought him back to the waiting room at 11:18, she said his vitals were “normal” for a man his age and he was not in distress.

A screenshot of surveillance footage from the night Darrell Mesheau was taken to Dr. Everett Chalmers Regional Hospital in Fredericton shows nurse April Knowles with Mesheau in the emergency waiting room just after 11 p.m., when his vitals were ‘normal.’ A coroner’s jury found he died of heart failure after being found unresponsive hours later.

A security guard, Bertus Scholten, testified that he saw Mesheau outside just before 2 a.m. getting a “little air,” saying Mesheau was a “nice guy” who was “talking well.”

Knowles said she had done a 2:03 a.m. vitals check, with similar results, and visually observed him around 3:30 or 3:45.

Security footage played at the inquest from 4:03 a.m. that morning onwards shows Mesheau slumped motionless in a wheelchair, head propped on his arm, as other patients walk past and watch TV. Community coroner Peter Kervin said the security footage shows that between 2:03 and 4:28, nobody had physically interacted with Mesheau or stopped to speak with him.

At 4:28 a.m., Knowles said she asked a passing ER nurse to look in on Mesheau, and the nurse said “he didn’t look so good,” so Knowles came to check. She said she found him unresponsive with a “very faint” pulse and signalled for a “code blue” at 4:33 a.m. taking him to the ER.

Dr. Shawn Tiller, the ER physician, said in recorded testimony that Mesheau was flatlined when he arrived, and was “cool” to the touch, indicating no blood flow for “quite a while.” After CPR was unsuccessful, he pronounced Mesheau dead at 4:44 a.m.

Sen Rang Yan, head of the pathology department at Chalmers, said the evidence from the autopsy was “extremely consistent” with heart failure. The physician who performed the autopsy, who wasn’t available to appear, found that hypertension issues that had led to a previous heart bypass surgery caused a lack of oxygen to the heart, Yan said.

What’s next

Ryan Mesheau said the coroner’s office had worked closely with the family, and knew much of the information. He told reporters he hadn’t seen the security footage, which was “awful” to watch.

“It may be too late for my dad, but it’s not too late for other New Brunswickers,” he said, calling health care a “system that nobody wants to fix.”

In a letter, McCarron said Horizon’s post-incident review included eight recommendations involving making sure the CTAS guidelines are followed, standardize patient transfer from ambulances and facilitate transfer of non-urgent admissions. On the witness stand, she went through each, agreeing that they were “basically” completed.

Horizon now has funding for personal care attendants to ensure each ER has monitoring, but “offload delay” from ambulances is still a factor, she said. She said that staffing issues are still a “daily occurrence,” saying they hired travel nurses to account for this, which are nurses which contract in from an agency.

While nurse vacancies were once 65 per cent, she said they’re now between 45 and 47 per cent, adding it’s improving but still a “work in progress.”

Ryan Mesheau told Brunswick News “it’s a good thing” that the jury recommended Horizon’s recommendations be fully funded and staffed. He said the province wants to “ride it out” regarding health care, saying it would be a ballot box issue for him if he lived in the province.

“The system seems to be underfunded, and that’s what everyone says,” he told reporters. “But it’s much more about money. What are you going to do about money? You have a system that nobody wants to fix.”

Andrew Bates, Local Journalism Initiative Reporter, Telegraph-Journal