Coroner outlines series of mistakes that led to Gilles Duceppe's mother being found dead in snow

Hlne Rowley Hotte Duceppe, who died of hypothermiaoutside the emergency exit of herseniors' residence last January, was stuck outdoorsin plain view of a security camera that no one bothered to check for six hours, a coroner has concluded.

The report, published Tuesday, describes that and a number of other mistakes made by staff atthe residence where the 93-year-old womanlived. Rowley Hotte Duceppe's son, Gilles Duceppe, is the former head of the Bloc Qubcois.

It felt like-35 with the windchill, according to the report, with strong winds and blowing snow, when Duceppe's motherslipped outjust before 5 a.m. last Jan. 20, in response to an alarm that went offin her building complex.

Her access card would not allowher back inside viathe emergency exit.

An alarm went off as a result of her using the emergency door, but an employee turned it off 20 minutes laterwithout checking to see if someone was outside, Coroner Ghane Kamel said at a news conference at which the report was presented.

• Gilles Duceppe's mother, 93, found dead of hypothermia outside Montreal seniors' residence

Family considering legal action

The Duceppe family is now considering legal action against the residence, according to their lawyer, Marc-Antoine Cloutier.Cloutier said the residence, LuxGouverneur in Montreal's east end, has never apologized for what happened.

Kamel wrote in the report that Rowley HotteDuceppelived at the residence for about a year. The coroner said she had beennervous about moving in, but her family was supportive andpresent.

She was rarely alone because one of her two daughters stayed with her five nights a week. Rowley Hotte Duceppe had a "visceral" fear of fires, a daughter told the coroner.

The general alarm had gone off at 4:55 a.m., the coroner said. Sheconcluded that Rowley Hotte Duceppedied just minutes before her bodywas foundby an employee at 11:04 a.m.

The unitthe woman lived in had beenequipped with a motion detector, but that alarmfailed togo off when she went outside, according to the report.

Preventable death

Kamel concluded that Rowley Hotte Duceppe's death could have been prevented, recommending a series of measures that theresidence where she livedshould take to avoid similar situations in the future.

She said an intercom and doorbells should be installed at each of the residence's six emergency exits, as well as an indicator panel whichwould connect all six exits and show when there's an anomaly.

Her other recommendations include:

• Checking stairways and touring outdoor exits after any alarm is triggered;
• Conducting a head count of residents in each of the residence's three towers after an alarm sounds and coming up with a written emergency procedurefor reintegrating residents after an alarm goes off.
• Designating one staff member to be in charge of the residence'ssafety and to monitor surveillance cameras.
• Making sure residents' medical files reflect their current situations [and are "coded" as such].

A spokesperson for the coroner's office said Kamel metthe management of the Lux Gouverneur, and the residence had already been in the midst of updating the buildings' emergency procedure.

In a separate news release, Lux Gouverneur said it isimplementing the coroner's recommendations. It highlighted a line the report pointing out thatcontrol of the building is turned overto the Montreal fire serviceonce an alarm goes off.

Staff were shaken by what happened, it said, and the safety and well-being of residents are a priority.

Quebec PremierFranois Legaultsaid he was saddened by the death.

"We can't imagine something like that happening to our mother or grandmother," Legault said.

He said he had read the report, concludingthe government wasn't a target of the coroner's findings.

Just the same, he said, Quebec's minister in charge of seniors, Marguerite Blais, is working on new safety procedures for seniors' homes in the province, "sothat never again will this sort of terrible accident happen."