Achi news desk-
After about two hours of deliberations, the five jurors in the coroner’s inquest that investigated the death of Darrell Mesheau have ruled that he died of natural causes, and the cause was heart failure.
The 78-year-old former diplomat died after waiting almost seven hours in the waiting room of the emergency department of Ysbyty Dr. Everett Chalmers. He had arrived at the hospital in an ambulance, saying he was short of breath and weak, with little appetite.
Jurors heard he was triaged as a level three and moved to the waiting room, where his vitals were not regularly checked. Nurses working that night shared accounts of an overcrowded emergency department, where beds were completely full – mostly with patients who should have been in other parts of the hospital.
They were also understaffed, and said they did not have time to regularly check the vitals of those in the waiting room.
Jurors made three recommendations:
- That all health and government agencies cooperate and “show ownership in solving the bed blocking problem; in particular, the backlog of social development patients has a significant impact on the efficiency of an operational emergency department.”
- Staff should have handheld electronic sources to record patient vitals.
- And that eight recommendations found during Horizon Health’s internal investigation should be fully implemented, funded and delivered with appropriate staffing levels.
Some of those recommendations included employing certain healthcare workers specifically to monitor the well-being of patients in the waiting room, and that they have adequate equipment for real-time assessment and documentation of vital signs.
According to an exhibit from Horizon Health, that recommendation has been implemented, although Horizon’s clinical director confirmed during testimony that those positions can be difficult to fill.
The judges’ recommendations are not binding, but are sent to the appropriate agencies who have six months to respond.
