Ryan Mesheau believes his father was dead for about 40 minutes before anyone at the Dr. Everett Chalmers Regional Hospital emergency department realized.
Darrell Mesheau died in the waiting room seven hours after he arrived by ambulance the night prior on July 11, 2022.
“The bottom line is Horizon Health made mistakes,” he said speaking to reporters. “Every medical professional seemed to fail my father on the night of his death.”
A two-day coroner’s inquest was held into Mesheau’s death and a jury of five people heard from 11 witnesses.
The timeline
Mesheau called an ambulance at 8:56 p.m. on July 11. He was transported to hospital with what paramedic Ashley Guptill said were normal oxygen and glucose levels.
He arrived at the hospital and was captured on surveillance video being escorted out to the waiting room by Guptill at 9:32 p.m. on the same day.
It would be about an hour later before licensed practical nurse April Knowles testified she took his vitals at 11 p.m. She is seen on camera at 11:23 p.m. Knowles said she didn’t log those vitals until four hours later and the sticky note they were documented on has since been destroyed.
She is not seen on surveillance video again until 2:03 a.m. when she again checks Mesheau’s vitals, saying in her testimony that he was within normal limits.
A video played for the jury shows Mesheau slumped in a wheelchair from 4 a.m. until about 4:31 a.m. when he is finally wheeled into the emergency department.
Community coroner Peter Kiervin testified no one physically interacted with Mesheau from 2:03 a.m. until around 4:28 a.m., which was supported by video surveillance, and contradicted earlier testimony by Knowles that she’d checked on him around 3:40 a.m.
Once Knowles noticed Mesheau was non-responsive at 4:31 a.m., a code blue was called and he was wheeled into the ER.
Dr. Shawn Tiller testified on Tuesday. His first interaction with Mesheau was during resuscitation efforts — nearly seven hours after Mesheau arrived by ambulance.
He told the jury, in video testimony recorded March 28, that Mesheau was cold to the touch. Tiller explained it means Mesheau was without blood flow for a period of time, but couldn’t confidently say for how long.
A team worked to resuscitate Mesheau for 10 minutes before he was pronounced dead at 4:44 a.m. by Tiller.
“There is nothing further that can be done if the heart is stopped,” he said in the video. “Efforts are futile. You are torturing the individual unnecessarily.”
A pathologist working with Horizon Health Network determined cause of death to be heart failure.
Staffing issues persistent
Registered nurse Danielle Othen said she was working alone in triage the night Mesheau was brought into the ER. She describes being short-staffed the whole weekend.
On a typical night shift, there should be three RNs in the acute area, two RNs in the ambulatory area and two LPNs, two registered nurses in triage. At that time, triage was also responsible for the waiting room area.
“We were short-staffed. We didn’t have the right amount we should have to work properly,” she later testified.
There were 52 patients in the ER on the night in question. There were only two beds available in the acute care section of the ER, none in ambulatory and one in the intensive care unit.
As well, there were no available beds in other units, like cardiac care, medical or surgery, which a HHN official later testified was also taking on three additional patients each.
At 11:55 p.m. on July, there were 14 patients at CTAS level 2, 21 patients CTAS level 3.
CTAS level 3 patients, which is what Mesheau was scored at, are recommended to be seen within 30 minutes — something earlier witnesses said is impossible under the current standards.
Othen later testified nothing has changed in terms of the staffing levels, adding that while there are now LPNs and personal care attendants for the waiting room area, they aren’t always staffed either.
Susan McCarron, the clinic director for area three for Horizon Health Network, said staffing issues continue to present problems, but she initiated the use of travel nurses — which has helped.
The travel nurse program is expected to end in August, she testified.
Some initiatives, she testified, are yielding results but continue to be worked on, including wait times for CTAS level 3 patients.
“In February, the wait time was 230 minutes,” she explained. “In March, 190 minutes. (It’s) a battle we fight every day. We are trying to decrease that time. The goal for this year: 120 minutes.”
The national standard is 30 minutes.
Jury recommendations
After about two hours of deliberations on Tuesday, the jury came forward with three recommendations.
- All shareholders should collaborate and show ownership in the resolution of the bed-blocking issue. In particular, the backlog of social development patients contributing significantly to the efficiency of operating the emergency room
- The eight recommendations of the quality-of-care committee are to be fully implemented, funded and staffed.
- Staff should be equipped with hand-held electronic devices to record patient vitals.
While those recommendations are not binding, the coroner will take them to the appropriate organizations. It will also be included in the annual report for 2024.
As for Darrell Mesheau’s family, they say it seems like a system no one wants to fix.
“It may be too late for my dad, but it’s not too late for other New Brunswickers,” said Ryan Mesheau.
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