The 93-year-old died on Jan. 20 after walking out of her Montreal seniors’ residence in the middle of the night during a winter storm.
The report notes that she had been staying at the Résidences Lux Gouverneur for just over a year.
“Despite her age, she had all her cognitive functions and did not suffer from any health problems, other than the start of hearing difficulties,” coroner Géhane Kamel wrote.
The residence has three towers, all linked by common areas. Rowley Hotte Duceppe lived in Tower 3.
At 4:12 a.m., an alarm went off in Tower 2 due to a potential carbon monoxide leak in the common area. At 4:55 a.m., a general alarm in all three buildings was accidentally activated but stopped five minutes later as firefighters signalled residents from towers 1 and 3 that they could return.
WATCH: Marguerite Blais expresses sympathy for Gilles Duceppe and family
Rowley Hotte Duceppe, the report finds, had already made her way outside. When she tried to re-enter her building, the doors were locked and her access card did not work. There was neither a bell nor an intercom.
“At this moment, it was snowing heavily. With the wind, the temperature felt like -35 C,” Kamel wrote.
“The minutes and the hours passed, and she still could not enter the building. She was found by a staff member at 11:40 a.m., but it was too late. She had died of hypothermia a few minutes earlier.”
Her death, an accident, was the result of a series of unfortunate events that could have been avoided if the residence’s employees had done something different before and after the alarms went off, Kamel states in the report.
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The coroner suggests the Résidences Lux Gouverneur put in place several measures to prevent such an event from happening again:
- Equip the residence’s six emergency exit doors with an intercom system that has a bell
- Connect the six emergency doors to an electrical panel independent of the fire alarm panel to signal any irregularities
- Do a visual inspection in the staircases and outside the buildings each time an alarm goes off
- Have a written procedure in the emergency plan to ensure that after a fire alarm, all residents in the three towers are accounted for as they return to their buildings
- Designate one person whose job is to make sure the areas are safe while also watching surveillance footage
- Inform residents once they rent an apartment of the restrictions of the motion detectors
- Make sure that all residents’ medical charts reflect their actual situation so they are coded correctly
The Quebec government confirmed its support of the coroner’s report recommendations.
“My thoughts are with Mrs. Rowley Hotte Duceppe’s family,” said Marguerite Blais, Quebec minister responsible for seniors and informal caregivers.
“We are taking the coroner’s report seriously… We support the coroner’s recommendations to avoid the recurrence of such an unfortunate event.”
The report concludes that following Rowley Hotte Duceppe’s death, representatives from the residence have already started modifying the facility’s emergency protocol plan and that “they warmly welcomed the coroner’s recommendations and are ready to put them in place as soon as possible.”