baby care

Death of a baby from Manawan: a report highlights the shortcomings of a nurse

Death of a baby from Manawan: a report highlights the shortcomings of a nurse

These faults are mainly related to the management of his nursing notes, can we read in the report obtained by Indigenous Spaces. She had already received verbal notices and an official letter of reprimand for failing to document her medical procedures on several occasions. A disciplinary letter had even been addressed to him on this subject.

The internal investigation carried out by the Masko-siwin Health Services investigation committee tried to really understand what had happened at the time of the events, since after having read the nursing documentation, several questions remained unanswered.

According to the report, the nurse concerned did not document the consultations or the physical examination and therefore failed to record important information on the clinical situation of the child. Nursing documentation makes it possible, in particular, to provide evidence of care and to ensure its continuity.

Since the events, the nurse, who has more than 35 years of service and worked for the Atikamekw community of Manawan for more than three years, has been suspended.

Too long delays in receiving adequate care

In early April, a baby in convulsions waited hours before being evacuated by ambulance from the community of Manawan north of Joliette.

The baby, who was suffering from meningitis, finally died at the CHU Sainte-Justine in Montreal, after an initial diagnosis questioned by the family and long delays in ambulance transport.

Coroner Géhane Kamel had concluded that the child had died bacterial meningitis following emergency care received too late. It took more than 8:30 hours between the initial call and the arrival of the seven-month-old baby at the CHU Sainte-Justine.

If in these recommendations, the coroner had mainly focused on the ambulance delays and therefore the child’s arrival in a hospital, she had also issued a recommendation to the health centre.

The Masko-Siwin center must ensure that the clinical assessment of the patient is carried out taking into account the level of priority granted and that the right means of transport is preferred in order to reduce transfer times, if the transfer of the latter is required to an establishment of health due to the urgency of the situationshe recommends.

A report that highlights several malpractices

The report of the administrative investigation of the Masko-Siwin health center obtained by Indigenous Spaces focuses on the work of the nurse who first took care of the child in Manawan, before his transfer.

He specifies from the outset that it is necessary to make a difference between the quality of the act and the quality of the documentation. Investigation demonstrates that the nurse has committed several professional misconducts contravening several articles of the Code of ethics of nurses.

Among other things, the nurse would have written a medical consultation note following a telephone conversation she would have had with an outside doctor on duty. According to the report, this note was written after the baby died.

This demonstrates that the nurse did not take reasonable steps to ensure continuity of care and treatment. »

A quote from Masko-Siwin Health Services Inquiry Report

Moreover, although she was worried about the child’s condition, the nurse would not have called the doctor on call, but rather would have text to inform him of the situation, without having received an answer from him.

Then, the child was transferred by ambulance, with the paramedics, without the presence of the nurse.

Finally, the nurse allegedly made false statements as part of the investigation process. The inquiry committee talks about lack of transparency and honesty on the part of the nurse.


The report also reveals that the nurse was already being followed up for breaches in the performance of her duties.

In February, she received a disciplinary letter for incidents of professional negligence in the management of medical records.

The nurse then had to take online training and complete an online self-assessment. However, the health center says it did not have the proof that she made them.

The nurse did it again, again demonstrating professional negligence in the management of medical records. »

A quote from Investigation report

The case would have been submitted to the Order of Nurses of Quebec and an investigation is underway.

For its part, the OIIQ can neither confirm nor deny it, stating that it is strictly confidential.

This information only becomes public when the syndic lodges a complaint with the Disciplinary Council of the OIIQ. However, to date, specifies the Order, no nurse responding on behalf of the one concerned has been the subject of a complaint filed with the Disciplinary Council and no decision has been rendered by it.

According to several sources, this event has greatly shaken the nursing service of Manawan.

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