Ryan Mesheau thinks his father had died for about 40 minutes before anyone at the Dr. Everett Chalmers Regional Hospital emergency room realized.
Darrell Mesheau passed away in the waiting room seven hours after he came by ambulance the previous night on July 11, 2022.
“Horizon Health made errors,” he told reporters. “Every medical professional seemed to let my father down on the night of his passing.”
A two-day coroner’s inquest was held into Mesheau’s death and a jury of five people heard from 11 witnesses.
The timeline
Mesheau called for an ambulance at 8:56 p.m. on July 11. He was taken to the hospital with normal oxygen and glucose levels according to paramedic Ashley Guptill.
He arrived at the hospital and was seen on surveillance video being escorted to the waiting room by Guptill at 9:32 p.m. on the same day.
It would be about an hour later before licensed practical nurse April Knowles stated she took his vitals at 11 p.m. She is seen on camera at 11:23 p.m. Knowles said she didn’t log those vitals until four hours later and the sticky note they were documented on has since been destroyed.
She is not seen on surveillance video again until 2:03 a.m. when she again checks Mesheau’s vitals, saying in her testimony that he was within normal limits.
A video shown to the jury shows Mesheau slumped in a wheelchair from 4 a.m. until about 4:31 a.m. when he is finally wheeled into the emergency department.
Community coroner Peter Kiervin said no one physically interacted with Mesheau from 2:03 a.m. until around 4:28 a.m., which was supported by video surveillance, and contradicted earlier testimony by Knowles that she’d checked on him around 3:40 a.m.
Once Knowles noticed Mesheau was non-responsive at 4:31 a.m., a code blue was called and he was wheeled into the ER.
Dr. Shawn Tiller said on Tuesday. His first interaction with Mesheau was during resuscitation efforts — nearly seven hours after Mesheau arrived by ambulance.
He told the jury, in video testimony recorded March 28, that Mesheau was cold to the touch. Tiller explained it means Mesheau was without blood flow for a period of time, but couldn’t confidently say for how long.
A team worked to revive Mesheau for 10 minutes before he was pronounced dead at 4:44 a.m. by Tiller.
“If the heart is stopped, there is nothing further that can be done,” he said in the video. “Efforts are futile. You are torturing the individual unnecessarily.”
A pathologist with Horizon Health Network determined that the cause of death was heart failure.
Staffing issues persist
Registered nurse Danielle Othen said she was working alone in triage the night Mesheau was brought into the ER. She describes being short-staffed the entire weekend.
On a typical night shift, there should be three RNs in the acute area, two RNs in the ambulatory area and two LPNs, two registered nurses in triage. At that time, triage was also responsible for the waiting room area.
“We were short-staffed. We didn’t have the right amount we should have to work properly,” she later testified.
There were 52 patients in the ER that night. Only two beds were free in the acute care section, none in ambulatory, and one in the intensive care unit.
Also, there were no available beds in other units, such as cardiac care, medical, or surgery. A HHN official later said that each of these units was also taking on three more patients.
At 11:55 p.m. in July, there were 14 patients at CTAS level 2 and 21 patients at CTAS level 3.
Patients at CTAS level 3, like Mesheau, should be seen within 30 minutes. Earlier witnesses said that this is impossible under the current standards.
Othen later said that there have been no changes in the staffing levels. They have LPNs and personal care attendants for the waiting room area, but they are not always staffed.
Susan McCarron, the clinic director for area three for Horizon Health Network, said staffing problems continue, but she introduced the use of travel nurses, which has been helpful.
The travel nurse program is expected to finish in August, she said during testimony.
She said that some initiatives are showing results but are still being worked on, including wait times for CTAS level 3 patients.
“In February, the wait time was 230 minutes,” she said. “In March, 190 minutes. (It’s) a battle we fight every day. We are trying to decrease that time. The goal for this year: 120 minutes.”
The national standard is 30 minutes.
Jury recommendations
After about two hours of deliberations on Tuesday, the jury made three recommendations.
- All stakeholders should work together and take responsibility to resolve the bed-blocking issue. In particular, the backlog of social development patients contributes significantly to the efficiency of the emergency room operation.
- The eight recommendations of the quality-of-care committee should be fully put into effect, funded, and staffed.
- Staff should be provided with handheld electronic devices to record patient vitals.
While these recommendations are not mandatory, the coroner will bring them to the relevant organizations. They will also be included in the 2024 annual report.
As for Darrell Mesheau’s family, they feel like it's a system that no one wants to fix.
“It may be too late for my dad, but it’s not too late for other New Brunswickers,” said Ryan Mesheau.
