Crown didn’t charge nurses in care-home death despite investigator’s belief they were negligent, document reveals

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This article was published 22/03/2024 (585 days ago), so information in it may no longer be current.

Prosecutors declined to charge two nurses who Winnipeg police believed were criminally negligent in the death of a long-term care home resident with dementia who was asphyxiated after getting tangled in a curtain.

Irene Fontaine, a resident of Beacon Hill Lodge on Fort Street, who had been diagnosed with dementia at age 60, died on Jan. 11 last year — her 63rd birthday.

Her family has filed a lawsuit alleging negligence against the care home’s operators: Revera Inc., which managed the facility at the time, and Extendicare, which purchased the home last August.

Fontaine became tangled in the curtain of an unoccupied room down the hall from hers, on the fifth floor of the downtown care home where she’d lived for four years. Earlier that morning, she was seen carrying a birthday balloon.

A staffer discovered her with the curtain wrapped around her neck at about 11:50 a.m. and called a code blue to alert others to a crisis, but Fontaine was already dead.

Winnipeg Police Service major crimes detectives soon collected evidence that led them to believe two nurses were criminally negligent in the frail and ill woman’s death.

But WPS spokesman Const. Claude Chancy told the Free Press that the Crown attorneys’ office decided not to proceed with charges last year.

“Ultimately, the matter was sent for Crown opinion in April of 2023, with a response returned to investigators in November 2023 advising no charges were authorized,” said Chancy.

However, a court document filed by Winnipeg police to assist their investigation shed further light on the circumstances of Fontaine’s death.

A police detective alleged in the court document, filed to obtain a production order for Fontaine’s medical records, that the nurses took Fontaine, who had a tendency to wander, to the room just before 11 a.m. and closed the door, which was faulty.

She was unsupervised for about 50 minutes and likely unable to open the door, while police found no evidence anyone checked on her.

Video surveillance showed Fontaine trying to take a binder from the fifth-floor nursing station at 10:24 a.m., but a staffer stopped her.

Fifteen minutes later, after she was seen walking in and out of the dining room several times, Fontaine was spotted leaving with a clipboard.

At 10:44 a.m., a staffer put her in a chair near the nursing station, before Fontaine got up and left the camera’s view a minute later. Later, at 10:54 a.m., Fontaine is seen taking another resident’s walker, before a nurse moves it, takes her by the hand and speaks with her before Fontaine wanders off again.

Then the nurse, joined by another nurse, took Fontaine to the room where she was found dead. The two nurses left seconds later and one of them forcefully closed the door.

At about 11:45 a.m., the staffer who discovered her went to feed Fontaine lunch. Video showed her going to the room Fontaine was found in, appearing to use her shoulder to force open the door, said police.

Fontaine’s common-law husband told police she liked to play with curtains and wrap herself in them, but police said it was unclear if staff at the home knew that.

Police thought the two nurses then tampered with medical records.

Fontaine’s medical chart indicated she had been seen walking 15 minutes before the staffer found her and that her blood pressure was taken 10 minutes prior, but the surveillance tape suggested otherwise, a detective wrote in the court document.

“I believe that staff of Beacon Hill Lodge care home, particularly (the two nurses) did falsify records of Ms. Fontaine to cover up their inaction of care,” Const. Clint Peters wrote.

But a source who worked at Beacon Hill Lodge at the time said Friday the nurses were not the only ones to blame.

“Multiple staff have been complaining that they’re overburdened with people and we’ve become essentially a psych hospital, and the nurses are saying, ‘It’s too much, it’s too much,’ but they just accept anyone and everyone,” said the source, who spoke on the condition of anonymity out of confidentiality obligations.

“The people that are coming into the home are beyond the capabilities of the staff… but management refuses to listen.”

She said the staff are crying out for help.

“They’re saying, ‘Stop, stop giving us people who are over our limits,’ and it’s not listened to, who’s to blame?… and we know this isn’t the first time a person has been put in a room to prevent them from wandering,” the source told the Free Press.

“The management system is failing the nurses.”

The Protection of Persons in Care Office, an arms-length office that probes allegations of abuse and neglect in health-care facilities, launched an investigation into Fontaine’s death that is still underway, Health Minister Uzoma Asagwara said Friday.

“My thoughts are with the family at this time,” the minister said in a statement to the Free Press.

The PPCO is currently investigating and I am waiting on the results of a departmental review. That review is expected to be completed and made public soon.”

The province’s previous Progressive Conservative justice minister announced last July that office would be disbanded and replaced with a new independent investigator that would report directly to the legislature, after the province’s auditor general released a scathing report detailing failings in the PPCO.

A government spokesman noted legislation governing the proposed new office that was poised to be introduced was stalled, so the persons in care office remains active.

Fontaine’s family, with Martin Pollock of Winnipeg law firm Pollock & Company acting on their behalf, filed the lawsuit against the care home’s operators in Court of King’s Bench last week.

The family is seeking $110,000 in damages under the Fatal Accidents Act and special damages, including funeral expenses, plus court costs and interest.

A spokesperson for Extendicare said Friday neither of the nurses who were investigated are still working at the home. They weren’t employed by Extendicare, the spokesperson noted, as the death occurred prior to the company’s purchase.

Revera previously declined comment while the lawsuit is before the court.

erik.pindera@freepress.mb.ca