Quebec and Ontario hospitals must improve information sharing, coroner says


Hospitals along the Quebec-Ontario border must develop a real-time system to communicate patient information in an emergency, according to a report from an Outaouais coroner.

The recommendation stems from an investigation into the death of Falone Kathayi, who sought treatment at Montfort Hospital in Ottawa and was discharged before being transported by ambulance to Hull Hospital in Gatineau, Quebec, where she died on May 13, 2021.

Francine Danais, Quebec coroner for the Outaouais, said in her report that the border region sees patients crossing the river back and forth for medical treatment and better communication is needed.

“It’s not that there is no collaboration, but the system is slow. In some cases, like the case of Ms. Kathayi, a life-threatening emergency, every minute counts,” Danais said in a French interview. at Radio -Canada.

However, the coroner qualified his statements, saying it may not have changed the outcome in the particular situation.

“I can’t say if they had real-time information that Ms. Kathayi’s life could have been saved. I can’t make that statement, but maybe we could have improved her chances of survival,” he said. declared Danais. .

In her report, she said that given the time that had elapsed since symptoms first appeared, Kathayi’s condition had likely become irreversible by the time she arrived at Hull hospital.

The coroner inquest

Kathayi first sought treatment for severe abdominal pain, diarrhea and vomiting at Montfort after experiencing symptoms on May 12, according to the report.

After receiving tests, medication, and being able to withhold juice and water, Kathayi learned that she was suffering from some form of gastroenteritis or food poisoning.

About seven hours after being discharged on May 13, Kathayi began to experience abdominal pain again and was transported to Hull hospital by ambulance.

Upon arrival, she began to suffer from heart failure and a code blue was declared.

She was intubated, received cardiac massage and a transfusion protocol was initiated.

After 81 minutes, the staff stopped their efforts and she was pronounced dead.

The report says the autopsy showed she was suffering from an intestinal blockage, which has symptoms similar to the previous diagnosis of gastroenteritis or food poisoning.

The coroner is not suggesting that there was negligence in either hospital. Danais said it was not the coroner’s job to find fault or assign responsibility for a death.

Digital recordings differ

Quebec patients have a digital profile that includes their test results, prescriptions and pre-existing conditions and tracks them between health care providers in the province.

The Ottawa Hospital System launched its own real-time medical information system in 2019 so patient information can easily be shared among major healthcare providers in Eastern Ontario .

Danais said none of the systems can be accessed by doctors in the other province.

She said when Kathayi arrived at Hull hospital, staff began to re-administer the same tests that had been done at Montfort earlier today.

She added that the files they requested from Ontario did not arrive until it was too late.

Although Montfort falls outside the jurisdiction of a Quebec coroner, Danais said he provided a copy of the report to the hospital.

Her report noted that Monfort’s own review of the case found that care met hospital standards, but also included recommendations on case management, pain assessments, and providing verbal instructions to improve. cares.

Hôpital Montfort said in a statement that it accepts the report’s recommendations and offered its condolences to Kathayi’s family and loved ones.

Quebec’s Ministry of Health and Social Services said it will provide an update on how it will deal with the coroner’s recommendations in three months.


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