"Nurse expresses shock over severe injury: 'Never witnessed such extent of damage in my professional experience'"
Witness Testifies to Grievous Wound – Death by Neglect?
In a shocking testimony, Ecaterina Clefas, a nurse, describes a wound of unprecedented size she encountered during the care of Normand Meunier, a 66-year-old tetraplegic man who passed away in 2024. The tragic incident, underscored by the devastating loss of his buttocks, was the focus of the first public hearing examining his death.
The investigation, led by coroner MDave Kimpton, strives to trace the sequence of events involving the healthcare professionals involved and offer recommendations to avoid such incidents in the future. The saddening account was shared by Sylvie Brosseau, Meunier's wife, who tearfully recounted, "He had no buttocks left, there was nothing left."
Two months before his death, Meunier developed a wound on his coccyx that progressed to the bone due to an inadequate hospital gurney. The wound became infected, making it incurable, ultimately triggering his death.
What is a Pressure Ulcer?
A pressure ulcer, or pressure wound, as it is medically referred, forms when prolonged pressure is exerted on a body area, typically over bony prominences such as heels, buttocks, or hips. Its formation is caused by the suppression of blood circulation in the affected area.
Pressure ulcers are classified into four stages according to their severity. Prevention strategies include regular repositioning (every 2 hours for bedbound patients, hourly for chair-bound individuals) to alleviate pressure, specialized support surfaces, daily skin inspections for early signs of redness, adequate hydration and protein intake, and rigorous adherence to these measures for patients in understaffed care settings or those with advanced dementia.
Untangling the Tangled Web of Treatment
Caroline Joly, the head of rehabilitation at the Institut de réadaptation Gingras-Lindsay-de-Montréal, revealed that Meunier's numerous health complications, such as sleep apnea, renal failure, obesity, and shoulder pain, made it challenging to treat him properly. Ideally, he should have been lying on his side in bed, but his shoulder pain prohibited this arrangement.
Nurse Nathalie Forget from CLSC Lafontaine emphasized the need to focus on the mobility of patients with wounds, recommending that they be turned every two hours in their bed. She found the photos of Meunier's wounds heart-wrenching, as she had provided care for him alongside her colleagues.
Six or seven out of thirteen nurses were on sick leave during the period when Meunier was receiving home care in November 2023, according to Clefas, who is also a home care nurse at CLSC Lafontaine. She testified, "I have never seen a wound of such magnitude in my entire career."
Public Perplexity, Search for Responsibility
Walter Zelaya, spokesperson for the organization Moelle épinière et motricité Québec (MEMO-Qc), indicated that a lack of awareness among certain actors is a key issue. He emphasized the importance of everyone recognizing that a pressure wound can lead to death. During the public hearings, several people in wheelchairs were present, adding to the somber atmosphere.
Sylvie Brosseau spoke candidly about the poor communication between healthcare departments that cared for her partner. Referring to the situation, she stated, "Reading Normand's file is far too long. I was told, 'Summarize it for us!' But I'm not a nurse, I'm a chef. It ended up being me who had to explain things."
In Brosseau's opinion, the issue seems to be systemic. "Yes, it's organizational, a lot of it. It's a shame, because when you go to the hospital, it's to get treated, but if no one talks to each other, it's complicated," she confided to La Presse.
Health Minister Christian Dubé has initiated an independent investigation into Meunier's death, following a family call for a more comprehensive probe. Three weeks of hearings will take place, starting on May 5th, with a total of 36 witnesses set to testify. The initial investigation by the CISSS des Laurentides was deemed insufficient by the family, prompting this further examination.
- The coroner, MDave Kimpton, is investigating the death of Normand Meunier, a 66-year-old tetraplegic man who passed away in 2024, to trace the sequence of events that led to his death.
- Ecaterina Clefas, a nurse, testified about a wound of unprecedented size she encountered while caring for Meunier, remarking that she had never seen a wound of such magnitude in her entire career.
- The wound on Meunier's coccyx, which worsened due to an inadequate hospital gurney, eventually led to his death, as it became infected and progressed to the bone.
- Pressure ulcers, medically referred to as pressure wounds, form when prolonged pressure is exerted on a body area, causing blood circulation suppression and eventual tissue damage.
- Prevention strategies for pressure ulcers include regular repositioning, specialized support surfaces, daily skin inspections, adequate hydration and protein intake, and rigorous adherence to these measures for patients in understaffed care settings or those with advanced dementia.
- Caroline Joly, the head of rehabilitation at the Institut de réadaptation Gingras-Lindsay-de-Montreal, acknowledged that Meunier's numerous health complications, such as sleep apnea, renal failure, obesity, and shoulder pain, made his treatment challenging.
- Nathalie Forget, a nurse from CLSC Lafontaine, recommended that patients with wounds be turned every two hours in their bed to alleviate pressure.
- During the period when Meunier was receiving home care in November 2023, six or seven out of thirteen nurses were on sick leave, according to Clefas.
- Walter Zelaya, spokesperson for the organization Moelle épinière et motricité Québec (MEMO-Qc), pinpointed a lack of awareness among certain actors as a key issue, emphasizing the importance of recognizing that a pressure wound can lead to death.
- Sylvie Brosseau, Meunier's wife, expressed her frustration over the poor communication between healthcare departments that cared for her partner, stating that reading Normand's file was far too long and complicated.
- Brosseau believes the issue is systemic, as when one goes to the hospital, it's to get treated, but if no one talks to each other, it's difficult.
- Health Minister Christian Dubé initiated an independent investigation into Meunier's death following a family call for a more comprehensive probe, with 36 witnesses set to testify in three weeks, starting on May 5th.
- The initial investigation by the CISSS des Laurentides was deemed insufficient by the family, prompting this further examination, which will cover aspects of workplace-wellness, general-news, crime-and-justice, education-and-self-development, personal-growth, mental-health, fitness-and-exercise, nutrition, cbd, skin-care, skin-conditions, health-and-wellness, medical-conditions, chronic-diseases, chronic-kidney-disease, respiratory-conditions, eye-health, science, therapies-and-treatments, and workplace-wellness.
