When Deputy Chief Coroner Emily Caissy read her opening remarks, she said Darrell Mesheau was found lifeless in the waiting room of the Dr. Everett Chalmers Regional Hopsital ER waiting room after going there for care on July 11, 2022.
An inquest began on Monday and five jurors were selected.
Mesheau called an ambulance at 8:56 p.m. on July 11. He was transported to hospital in what paramedic Ashley Guptill said was normal oxygen and glucose levels.
When they arrived, she said he was taken to triage and ultimately put in the waiting room. Guptill said it was a “collaboration” on deciding where a patient may end up when it comes to the ER.
In Mesheau’s case, Guptill walked Mesheau out of the waiting area.
She testified there was nothing within assessment to say that he needed one-on-one engagement with the paramedic.
Seated in the waiting room
At 11 p.m., licensed practical nurse April Knowles checked on Mesheau and took his vitals. She did not record those vitals into the records management system until four hours later, she testified.
It wasn’t until 2:03 a.m. that his vitals were checked again, Knowles said, adding that two-hour vitals checks are now protocol for patients triaged level 3 under the CTAS scale.
“He was within normal limits,” she said, adding they’d shared a joke at that time.
Knowles testified Mesheau described being tired and wanting to go home while he waited.
She then told jurors she asked a coworker who was getting another patient from the waiting room to check on Mesheau, who came back to tell her she was concerned, which was around 3:40, according to Knowles.
At 4:28 a.m., Knowles checked on Mesheau and said he was non-responsive and his pulse was weak. A code blue was called a short time later.
In her testimony, Knowles was grilled about why she didn’t log his 11 p.m. vitals earlier and about the timeline of events leading up to the discovery of Mesheau as non-responsive.
“I am more diligent now,” she said. “It wasn’t on purpose.”
In later testimony, Peter Kiervin, the coroner assigned to investigate the death, said a review of the footage of the hospital security cameras showed no one physically interacted with Mesheau between the first vitals check at 2:03 a.m. and the final grim discovery at 4:28 a.m.
He said he did recommend to the chief coroner that there be an inquest into the death.
“We have no reason for this gentleman to pass away in the hospital,” he said in his testimony. “Under the circumstances, we should have an inquest because it is in the best interest of the public.”
Staffing issues and high admissions
Nurse manager Neil Gabriel testified to the ongoing issues with in the ER at the time of Mesheau’s death.
He said at the time of Mesheau’s death there was only one team lead and triage nurse – who are the same person after 11:30 p.m.
There were 17 patients admitted the ER when Mesheau arrived by ambulance — meaning there was no beds available, known to hospital staff as bedlock.
He testified when beds are filled that way, it can be very difficult to see patients who need to be in a bed to be assessed by a physician.
There are different triage levels, which should be seen by a doctor in a certain amount of time, and at the time of Mesheau deaths, Gabriel said this about standard of care wait times:
“At times, it’s completely unrealistic. It is impossible.”
Gabriel said while staffing was likely an issue on the night Mesheau died, the 17 admissions to the ER were the real problem.
Other units at capacity are largely due to long-term care patients waiting for nursing home beds.
“Horizon has done a lot of initiatives to improve this but, at the end of the day, they have no control over nursing homes,” he said in his testimony.
The political backlash
In the aftermath of Mesheau’s death, Premier Blaine Higgs fired then-Health Minister Dorothy Shephard and Horizon Health Network CEO Dr. John Dornan.
At the time, he pointed blame at the management.
“It’s not up to me to run the health-care authorities or health-care authorities but it is up to me to ensure that the right people are in the position to do so and it starts at the top,” he said at the time.
“I believe it is a management issue, I believe there was no coordination of activity and that’s what I’m trying to drive home here. If we don’t get better management results in our hospitals, we won’t get better health care.”
Some changes within the system
Horizon Health Network implemented some changes as well, including ER waiting room monitors and patient flow clinics, to help ease the burden.
Gabriel also testified they hired two admissions coordinators to help facilitate discharged patients in a more timely manner.
Knowles testified that while at the time there was not set protocol to test vitals at certain times, that has now been developed for each level of triage.
Loved life, and lived it
Meshau’s obituary begins with, “Darrell loved life, and lived it.”
Mesheau was a diplomat in the Canadian Foreign Service posted in Canadian Embassies in Rome and Tel Aviv, according to his obituary.
“Darrell was a gentleman; warm, caring, funny, and intelligent, with an infectious spirit. He was a bright light wherever he went,” it goes on to say.
“He was a world traveler with a map collection to rival Rand McNally; a story teller, a reader, a conversationalist, a linguist.”
It finishes with “we loved him and we will miss him.”
In the testimony of several witnesses on Monday, they shared that Mesheau was a nice and sweet man.
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