Breaches but no blame for the death of a Matimekush baby

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Faults but no blame for the death of a baby by Matimekush

Matimekush–Lac John community (Archives)

The death of an 11-month-old toddler in Matimekush last May was of natural causes and does not warrant blame or recommendations, the coroner concluded. The sad event, however, highlights shortcomings in respecting the regulations in force at the community dispensary.

More specifically, the parents had to wait at least 20 minutes at the ;outside the dispensary with their inanimate child before a nurse arrived on site.

According to coroner Bernard Lefrançois, the analyses, carried out by the Laboratory of Forensic Sciences and of Forensic Medicine of Montreal, however, reveal a death of natural origin.

The probable cause of the child's death is viral pneumonia which developed with disconcerting rapidity from Saturday morning April 30, 2022 to Sunday morning May 1, 2022, the coroner's report states.

According to the coroner, no one is to blame for the toddler's death. Shortcomings were brought to light with regard to the care and measures in force at the Matimekush–Lac John dispensary. However, these failures did not necessarily cause the death of the baby.

The coroner further emphasizes that the parents acted responsibly and provided the care required by the toddler's state of health.

On weekends, the Matimekush dispensary– Lake John is closed. There is therefore no one on the scene, but a nurse on call remains available to respond to emergencies. A change of guard is also planned on Saturdays and Sundays to ensure a presence at the dispensary from 10 a.m. to 1 p.m.

The day before the toddler died, Saturday, April 30, the child's mother contacted the nurse on duty by phone. The report states that since the child did not have a fever at the time, the nurse advised the mother to give the baby Tylenol.

Since the mother did not have any at home, a medicine kit was prepared by the nurse and collected by the father from the clinic around 3 p.m. that day.

Despite this medication, the child's state of health would have deteriorated during the night. Early Sunday morning, the parents fed him before putting him back to bed. They discovered his lifeless body at 11 a.m. Sunday morning.

When the parents arrived at the clinic with the lifeless child at around 11:15 a.m., there should have been a changing of the nurses' guard. However, no one was on the scene.

Nearly 20 minutes passed between the emergency call made by neighbors of the dispensary and the arrival of a nurse. The coroner states in his report that according to our discussion with the person in charge of the dispensary, a maximum delay of 10 minutes is the acceptable standard and applied given the proximity in this community.

According the coroner, however, these two failings are not sufficient to lay blame on anyone for the death of the child.

The coroner finds that although they [the measures ] were not fully implemented that weekend, it cannot be said that if they had been, the child could have been saved.

Since the death of the toddler, a new measure has been implemented at the dispensary so that all situations concerning a child under the age of two are the subject of a consultation in person and not only by telephone.

No recommendations were made in the coroner's report.

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