Quebec, Ontario hospitals need to improve information sharing, coroner says

Hospitals along the Quebec-Ontario border need to develop a real-time system to communicate a patient’s information in emergency situations, according to a report from an Outaouais coroner. 

The recommendation comes from an investigation into the death of Falone Kathayi, who sought treatment at Ottawa’s Montfort Hospital and was discharged before she was taken by ambulance to the Hull Hospital in Gatineau, Que., where she died on May 13, 2021.

Francine Danais, a Quebec coroner for the Outaouais, said in her report the border region sees patients cross the river in both directions for medical treatment and better communication is needed.

“It’s not that there isn’t any collaboration, but the system is slow. In certain cases, like the case of Ms. Kathayi, a life-and-death emergency, every minute counts,” Danais said in a French interview with Radio-Canada.

However, the coroner did qualify her statements, saying it may not have changed the outcome in the particular situation.

“I can’t say if they had the information in real time that the life of Ms. Kathayi could’ve been saved. I can’t make that statement, but maybe we could’ve improved her chance of survival,” Danais said.

In her report, she said given the amount of time since the first appearance of symptoms, Kathayi’s condition had likely become irreversible by the time she arrived at the Hull Hospital.

Coroner investigates

Kathayi first sought treatment for severe abdominal pain, diarrhea and vomiting at the Montfort after feeling symptoms on May 12, according to the report.

After receiving tests, medication and being able to hold down some juice and water, Kathayi was told she was experiencing some form of gastroenteritis or food poisoning.

About seven hours after being discharged on May 13, Kathayi began experiencing abdominal pains again and was taken to the Hull Hospital by ambulance.

When she arrived she began experiencing heart failure and a code blue was declared.

She was intubated, given cardiac massage and a transfusion protocol was initiated.

After 81 minutes, staff ceased their efforts and she was declared dead.

The report said the autopsy showed she suffered an intestinal blockage, which has similar symptoms to the earlier diagnosis of gastroenteritis or food poisoning.

The coroner doesn’t suggest there may have been negligence at either hospital. Danais said it’s not the job of coroner’s to find fault or assign responsibility for a death.

Digital records differ

Quebec patients have a digital profile that includes their test results, prescriptions and pre-existing conditions and which follows them between health care providers within the province.

The Ottawa Hospital system launched its own real-time medical information system in 2019 so patients’ information could easily be shared between major eastern Ontario health care providers.

Danais said neither systems can be consulted by physicians in the other province.

She said when Kathayi arrived at the Hull Hospital, staff began re-administering the same tests that had been completed at the Montfort earlier that day.

She added that the files they requested from Ontario didn’t arrive until it was too late.

Despite Montfort being outside the jurisdiction of a Quebec coroner, Danais said she provided a copy of the report to the hospital.

Her report noted Monfort’s own review of the case found care met the hospital’s standards, but also included recommendations on file management, pain evaluations and giving verbal instructions to improve care.

The Montfort Hospital said in a statement it accepts the recommendations in the report and offered condolences to the family and loved ones of Kathayi.

Quebec’s Ministry of Health and Social Services said it will provide an update on how it will address the coroner’s recommendations in three months.

CBC