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Staff at the nursing home where Violet Lucas was found dead, with her head wedged between her mattress and a guardrail, moved her body before the coroner arrived.
The investigating coroner could not view Lucas’s body as it was found at Extendicare Laurier Manor on Montreal Road and could not rely on photographs, either, because the staff didn’t take any before moving her body.
The coroner has ruled that Lucas died a natural death after suffering cardiac arrest. Although the report sheds light on some of the circumstances surrounding her death, it also raises new questions and highlights discrepancies between what staff reported after finding Lucas dead and the official report into her death.
Derek Lucas is the son of the late Violet Lucas, who died under mysterious circumstances in a nursing home. Julie Oliver
When this newspaper first reported on the April 7, 2017 death of the single mother of seven, her family was still in the dark about the circumstances surrounding her death. They knew that she had been found dead in a precarious position and it was suspicious for several reasons. She couldn’t move around on her own, yet she was found half out of bed. And her bed alarm, the one that alerts staff if a resident is out of bed or moving to do so, wasn’t working because the batteries were faulty.
Lucas was last seen alive at 10 p.m. on April 7, 2017. Staff checked on her 30 minutes later and found her dead. They didn’t try to revive her because she had a Do Not Resuscitate order.
Staff called the coroner 15 minutes later and the initial call sounded like a natural death. But the following morning, on April 8, 2017, a nursing home doctor interviewed overnight staff who reported that Lucas had been found with her head wedged between the mattress and guardrail. This was immediately deemed suspicious because Lucas needed help to move around, and there were concerns about the guardrails.
The coroner also noted that it was unusual behaviour because Lucas had no history of trying to get out of bed.
Because of the way she was found, there were fears that she died of asphyxiation. An autopsy showed no signs of trauma or strangulation, rather cardiac disease.
The coroner had initially called in the Ottawa Police to investigate. They concluded there was nothing criminal about the death.
At the time of her death, staff told authorities that Lucas’s bed alarm was working but in fact a test showed that the batteries were faulty so staff would not have heard any distress call.
A government inspector did a re-enactment involving staff that concluded Lucas was not in fact found wedged between the mattress and guardrail, rather her chin was touching the guardrail and her hip and legs were outside of the side of the bed, according to the coroner’s report.
It is not known if the government inspector used the same staff members who discovered Lucas to re-enact the positioning of the body two weeks later. That finding is at odds with a staff account given to a nursing home doctor.
Lucas’s death comes at a time when the quality of care at nursing homes in Ottawa is under scrutiny.
And a spotlight is what Lucas’s family wants.
There were two safety alarms in her room, both designed to alert nursing staff if a resident is out of bed or has been removed from bed, or has somehow fallen from bed in the night.
But both alarm systems were useless because they weren’t being used properly: they weren’t mounted properly and the wrong batteries had been used, according to an inspection report.
The circumstances leading to her death have left her family heartbroken, and in the name of his mother, Derek Lucas wants a full airing of how she was failed.
“People in nursing homes are our mothers, fathers, uncles, aunts, grandmothers, and grandfathers. They aren’t numbers on a balance sheet, They are people, and people deserve to be treated with the care and respect we expect others to treat us,” Derek Lucas said in 2017.
He said the staff seemed considerate and caring, but now he wonders how competent they were if they couldn’t even figure out which batteries to use.
He says he can’t help but wonder whether his mother struggled to breathe, or if she called out for help. He wonders if staff could have intervened in time if the alarms were working.
The coroner’s investigation is not yet formally complete.
Chris Smith, administrator at Extendicare’s Laurier Manor, said in a statement:
“While we cannot discuss specifics of this matter due to the privacy obligations we owe to our residents, we can let you know that at Extendicare the quality of care and dignity of our residents is of utmost importance.”
查看原文...
The investigating coroner could not view Lucas’s body as it was found at Extendicare Laurier Manor on Montreal Road and could not rely on photographs, either, because the staff didn’t take any before moving her body.
The coroner has ruled that Lucas died a natural death after suffering cardiac arrest. Although the report sheds light on some of the circumstances surrounding her death, it also raises new questions and highlights discrepancies between what staff reported after finding Lucas dead and the official report into her death.
Derek Lucas is the son of the late Violet Lucas, who died under mysterious circumstances in a nursing home. Julie Oliver
When this newspaper first reported on the April 7, 2017 death of the single mother of seven, her family was still in the dark about the circumstances surrounding her death. They knew that she had been found dead in a precarious position and it was suspicious for several reasons. She couldn’t move around on her own, yet she was found half out of bed. And her bed alarm, the one that alerts staff if a resident is out of bed or moving to do so, wasn’t working because the batteries were faulty.
Lucas was last seen alive at 10 p.m. on April 7, 2017. Staff checked on her 30 minutes later and found her dead. They didn’t try to revive her because she had a Do Not Resuscitate order.
Staff called the coroner 15 minutes later and the initial call sounded like a natural death. But the following morning, on April 8, 2017, a nursing home doctor interviewed overnight staff who reported that Lucas had been found with her head wedged between the mattress and guardrail. This was immediately deemed suspicious because Lucas needed help to move around, and there were concerns about the guardrails.
The coroner also noted that it was unusual behaviour because Lucas had no history of trying to get out of bed.
Because of the way she was found, there were fears that she died of asphyxiation. An autopsy showed no signs of trauma or strangulation, rather cardiac disease.
The coroner had initially called in the Ottawa Police to investigate. They concluded there was nothing criminal about the death.
At the time of her death, staff told authorities that Lucas’s bed alarm was working but in fact a test showed that the batteries were faulty so staff would not have heard any distress call.
A government inspector did a re-enactment involving staff that concluded Lucas was not in fact found wedged between the mattress and guardrail, rather her chin was touching the guardrail and her hip and legs were outside of the side of the bed, according to the coroner’s report.
It is not known if the government inspector used the same staff members who discovered Lucas to re-enact the positioning of the body two weeks later. That finding is at odds with a staff account given to a nursing home doctor.
Lucas’s death comes at a time when the quality of care at nursing homes in Ottawa is under scrutiny.
And a spotlight is what Lucas’s family wants.
There were two safety alarms in her room, both designed to alert nursing staff if a resident is out of bed or has been removed from bed, or has somehow fallen from bed in the night.
But both alarm systems were useless because they weren’t being used properly: they weren’t mounted properly and the wrong batteries had been used, according to an inspection report.
The circumstances leading to her death have left her family heartbroken, and in the name of his mother, Derek Lucas wants a full airing of how she was failed.
“People in nursing homes are our mothers, fathers, uncles, aunts, grandmothers, and grandfathers. They aren’t numbers on a balance sheet, They are people, and people deserve to be treated with the care and respect we expect others to treat us,” Derek Lucas said in 2017.
He said the staff seemed considerate and caring, but now he wonders how competent they were if they couldn’t even figure out which batteries to use.
He says he can’t help but wonder whether his mother struggled to breathe, or if she called out for help. He wonders if staff could have intervened in time if the alarms were working.
The coroner’s investigation is not yet formally complete.
Chris Smith, administrator at Extendicare’s Laurier Manor, said in a statement:
“While we cannot discuss specifics of this matter due to the privacy obligations we owe to our residents, we can let you know that at Extendicare the quality of care and dignity of our residents is of utmost importance.”
查看原文...
