Baby died of natural causes but Urgences-Santé needs to reassess services: Quebec coroner

A coroner’s report into the death of an eight-month-old from Shawinigan, Que., who was being treated at the Montreal Children’s Hospital, concludes the baby girl died of natural causes.

In his report signed Feb. 10, 2023, Quebec coroner Dr. Louis Normandin states the baby died of acute respiratory failure following pulmonary aspiration linked to gastroesophageal reflux.

Essentially, Normandin said it appears the baby vomited her breakfast and aspirated it while choking, despite a rapid intervention by the mother.

The child then went into respiratory distress and because of underlying health conditions and weak lungs, she quickly stopped breathing and went into cardiac arrest.

“She no longer had the strength to overcome such an ordeal and it is reasonable to think that any intervention, however diligent and competent, would not have changed the outcome,” Normandin wrote in French.

Despite concluding the baby died of natural causes, Normandin pointed to several issues following the mother’s 911 call from her hotel room at 9:07 a.m. on June 15, 2022.

In his report, Normandin urges Urgences-Santé to reassess its services and take the necessary measures to prevent such situations from happening again.

Normandin found that seven Urgences-Santé staff members out of 19 were missing on the day the baby died.

He goes on to explain that because of the context in which Urgences-Santé was operating, the 911 call was assigned to both the Centre de Communications Santé (CSS), which deals with health emergencies, and Montreal police.

The CCS call centre received an electronic summary describing the health emergency as being an eight-month-old baby with a high fever, coughing and with difficulty breathing. Normandin says attempts by a medical dispatcher 18 seconds later to reach the mother were unsuccessful.

Without additional information, the call was assigned a priority 3, with an ambulance wait time estimated at nine minutes 43 seconds.

Meanwhile, police officers who arrived on scene at 9:15 a.m. discovered the baby wasn’t breathing. They started CPR and at 9:17 and called for immediate ambulance assistance through a direct line where calls are not recorded.

Normandin says at this point, the priority of the call was bumped up to “absolute,” meaning first responders, paramedics and advanced care units were mobilized.

However, Normandin said the police report stated the dispatcher was unable to give an estimate on when an ambulance would arrive.

Faced with that uncertainty, the officers made the decision at 9:19 to head to the nearest hospital. They arrived at the Montreal General Hospital’s Emergency at 9:21, the same time first responders arrived at the hotel. Paramedics followed shortly after, arriving at the hotel at 9:23.

Normandin said the baby was transferred by ambulance to the Montreal Children’s Hospital and that CPR was maintained throughout. She arrived at 9:58 but efforts to revive the baby girl were unsuccessful and she died a few minutes later.

At the time, Urgences-Santé told Global News it was dealing with a high volume of calls and limited staff at its call centre.

In a statement to Global News on Wednesday, Urgences-Santé said it has taken note of the coroner’s report and has already taken action to remedy the situation following its own internal review last summer.

“As you know, all sectors of activity are experiencing labor challenges and the pre-hospital sector throughout Quebec is unfortunately no exception,” Urgences-Santé said Wednesday in a statement to Global News.

“The Corporation is actively pursuing its recruitment efforts. Since last summer, more than 50 paramedics and nearly 20 emergency medical dispatchers have been hired.”

Urgences-Santé added that it is also relying on solutions that aim to optimize resources and pointed to recent initiatives such as secondary triage and co-evaluation with nurses as examples.