Inquest into death of man in Fredericton ER waiting area ends with 3 recommendations

A coroner's inquest into the death of a patient in the waiting area of the Fredericton hospital's emergency department ended Tuesday with three recommendations aimed at improving ER services and preventing deaths under similar circumstances.

Darrell Mesheau, 78, spent about seven hours at the Dr. Everett Chalmers Regional Hospital ER before he was discovered unresponsive by a licensed practical nurse around4:30a.m.on July 12, 2022.

After deliberating for about two hours, the jury concluded he died at 4:44 a.m., when he was pronounced dead, as a result of heart failure, and that his death was due to natural causes.

The jury recommended all stakeholders"collaborate and show ownership in the resolution of the bed-blockage issue."

This was a reference to when patients who have been admitted to hospital have to remain in ER beds because there are no other beds available, largely because there are patients waiting in hospital for along-term care placement, such as a nursing home or special care home.

Seventeen of 29 available ER beds were occupied by admitted patients the day Mesheau died, the inquest heard.

The backlog of Social Development patients awaiting long-term care contributes "significantly to the efficiency of an operating emergency room," the jury said.

Eight recommendations that stemmed from an internal Horizon review following Mesheau's death should alsobe "fully implemented, funded and staffed," the jurors said.

In addition, staff should be equipped withhand-held electronic devices to record patient vitals.

Mesheau's family washappy with the recommendations, according to his son Ryan Mesheau.

"It may be too late for my dad, but it's not too late for other New Brunswickers," he said.

WATCH | 'It's not too late for other New Brunswickers'

Ryan Mesheau wants details surrounding his fathers death made public

5 months ago

Duration 2:34

At the inquest into the 2022 death of Darrell Mesheau at a Fredericton hospital, his son says its been a grim two years for his family, and he wants to see health care fixed.

The recommendations are not binding.

"It's in Horizon Health's hands now, so it's up to them," said Mesheau, who travelled from California to attend the proceedings.

He described himself as an optimistic person, but when asked whether he thinks the changes will be implemented, he replied, "probably not."

The family is "definitely" considering legal action, he added.

Horizon will review each of the recommendations closely, interim president and CEO Margaret Melanson said in an emailed statement.

"The safety and wellbeing of our patient is our foremost priority, and since this tragedy, Horizon has implemented several measures aimed at enhancing access and the delivery of patient care in our emergency departments.

"These measures have included increasing staffing levels to monitor the wellbeing of patients in our waiting rooms, who are regularly checking vital signs, and providing comfort and support to patients while they wait."

The chief coroner will forward the jury's recommendations to the appropriate agencies for consideration and response, said deputy chief coroner Emily Caissy.

The response will be included in the chief coroner's annual report for 2024 and in any subsequent reports, if necessary, she said.

Mesheau's death sparked outrage across the province and prompted amajor shakeup of New Brunswick's health-care leadershipthree days later.

During a news conference, Premier Blaine Higgs announced the firing of Horizon Health Network president and CEO John Dornan, replaced Dorothy Shephard as health minister and removed the boards of both Horizon and Vitalit.

Inquest hears from ER doctor

The inquest ended two days ahead of schedule. Caissyand thefive-member juryheard evidence from10 witnesses over two days and watched a portion of the ER security video from Mesheau'swaitto determine the facts surrounding his death.

ERDr. Shawn Tiller was among those who testified Tuesday. Hewas working alone on the overnight shift the day Mesheau died.

Mesheau, who had arrived at the ER by ambulance the night before, around9:33 p.m., was already cool to the touch when he was discovered unresponsive in the waiting area and rushedinto theemergency department shortly after 4:30 a.m., said Tiller.

That means he hadn't had any circulation in "quite a while,"Tiller testified via a prerecorded video.

He was "flat-lined," with no pulse, he said.

A designated "code blue" team immediately performed several rounds of CPR(cardiopulmonary resuscitation) and Tiller administered epinephrine to try to stimulate Mesheau's heart.

He then used an ultrasound to see if he could detect any faint cardiac activity that the monitor might not be picking up.

But "we weren't able to get any cardiac activity at all."

The head of pathologytestified Mesheau's cause of death was subsequently deemed to be heart failure.

The jury also heard from thetriage nurse Danielle Othen, who said she worked a 12-hour shift alone that night because they were short staffed and she was unable to monitor the vital signs of patients in the waiting room whom she had already triaged because she was too busy triaging new patients coming in.

Susan McCarron, clinical director of Horizon'semergency departments in the Fredericton region,told the jury about the internal review that resulted in eight recommendations, all of which she confirmed have been "basically approved and completed."