Health minister calls the incident ‘unacceptable and disturbing’

A succession of errors led to a patient, who was still recovering from anesthesia and surgery, being abandoned on an empty floor without supervision or medical assistance for hours, Radio-Canada has learned.

The incident occured at Fleury Hospital, in Montreal’s north end, on the night of Feb. 3, several Radio-Canada sources learned.

The patient, a firefighter, was supposed to be sent to the eighth floor for overnight observation after an evening surgery. However, the orderly erroneously took him to the third floor ⁠— intended for day surgeries ⁠— which is closed at night.

According to sources, the orderly saw someone in the hallway and assumed it was a nurse, when it was in fact a maintenance worker. The worker didn’t see the patient and then closed the door on their way out.

For hours, none of the medical staff noticed the patient was missing. It wasn’t until his wife, who was waiting for him on the eighth floor, started asking questions around 1 a.m. that a staff member went to investigate.

A co-ordinator went to the operating room but was unable to find the patient there. Still, no one activated a code yellow to signal that the man was missing.

The patient, who was recovering from anesthesia, woke up about two hours later, around 3 a.m., with no one around. In a gown, without a cell phone, he found the strength to go to the nurses’ station, but no one was there.

He then picked up a phone and called security, who reportedly hung up on him.

The man then called his wife to come get him, and the couple decided to leave the hospital. The patient’s vital signs and pain were assessed before he was discharged, and he refused further treatment.

‘He could have died 100 times’

Hospital and health authority staff say the case raises concerns about the quality of care being provided. (Radio-Canada has agreed not to name them, as they are not authorized to speak to the media.)

“He could have died 100 times,” said a source who is not authorized to speak to the media.

“Everyone was shocked,” said another source. “It shouldn’t happen.”

The regional health authority, the CIUSSS du Nord-de-l’Île-de-Montréal, confirmed that a patient was taken to the wrong floor of Fleury Hospital on Feb. 3. It said that after realizing the patient had disappeared, the medical team called the patient, who was able to speak with his surgeon.

“Our priority was to continue caring for the patient at home,” said CIUSSS spokesperson Marie-Hélène Giguère.

What type of operation the patient underwent is not yet known, but the CIUSSS said the surgery was related to the upper body.

Paul Brunet, a patient advocate and president of the Conseil pour la protection des malades, says patients are usually in much more vulnerable positions, which could have made this case “much more serious.”

“It’s hard to believe that, once admitted, once registered, once operated, a patient is abandoned, as if he didn’t exist,” Brunet said. “He was literally written off. It sends shivers down the spine.”

Ongoing investigation and reinforced measures

The risk management team is currently investigating the incident with the patient’s co-operation, according to the CIUSSS.

“Labour relations are also involved in the investigation to understand the role and responsibilities of each of the employees and managers who intervened during this evening,” the regional health board said. “The teams have all been interviewed.”

“This type of incident hardly ever occurs and we will do everything necessary to prevent it from happening again,” Giguère said.

She said additional measures have already been put in place to correct the situation, such as indicating where the patient is headed in their file, as well as transmitting that information verbally to employees in charge of transfers. The day surgery unit will also receive more monitoring rounds, even outside its operating hours.

The CIUSSS confirms that this incident is considered a “sentinel event,” which the Health Ministry defines as an event that requires in-depth analysis, because it reveals flaws in a process that have led or could have led to serious consequences. Such incidents are announced to the entire health network.

Health Minister Christian Dubé said in a statement that the incident was “unacceptable and disturbing.”

“It does not in any way represent the care that Quebecers deserve, and that they must have,” Dubé said. “A situation like this should never happen.”