Quebec ombudsman finds ‘shortcomings’ in care at Montreal Children’s Hospital

Quebec’s ombudsman on Thursday released a series of recommendations to the Montreal Children’s Hospital after an investigation revealed numerous shortcomings at the facility, including infrequent monitoring of patients’ vital signs post-surgery.

The office of ombudsman Marc-André Dowd audited 16 medical files from the autumn of 2021. The probe, launched in response to “worrying” problems observed at the hospital, “confirmed various shortcomings,” the office said in a statement.

One example of insufficient monitoring, the ombudsman’s report said, involved a 16-year-old who was discharged with very low blood pressure. Another example involved a four-month-old baby whose vital and neurological signs weren’t taken frequently enough by a nurse in the post-anesthesia care unit. In consequence, that baby ended up in intensive care for septic shock.

The March 2022 report, released Thursday, included cases during which young patients weren’t properly monitored after they were given opiates such as morphine. The report says in 16 audited records, half the patients in care received opiates and only one was monitored correctly.

The ombudsman recommended that the hospital analyze the results of the investigation and properly train staff on the rules regarding pediatric opioid therapy, adding that the hospital has already taken some steps to address the problems.

A hospital spokesperson said in a statement Thursday it has acted on the recommendations outlined in the report.

“The Montreal Children’s Hospital has taken note of the Quebec Ombudsman’s recommendations concerning post-anesthesia care and has already taken measures to correct the situation,” Christine Bouthillier said in an email. “Audits are regularly conducted to maintain the quality of services.”