Human error to blame for fatal oxygen mishap at Charles-Le Moyne ICU last June

MONTREAL – Oxygen was accidentally cut off for nine COVID-19 patients for nearly a minute in the Charles-Le Moyne Hospital intensive care unit, on Montreal’s south shore, last June, resulting in the death of one patient.

The CISSS de la Montérégie-Centre, the health authority overseeing the hospital, says it happened June 5, 2020, just after 8 a.m., due to work on the medical gas network.

A spokesperson says the oxygen cut-off was the result of “human error.”

It affected nine patients in the COVID-ICU set up in the hospital.

“Following the cut-off of the medical gases, the users were quickly taken care of by the workers present on the unit,” said Martine Lessage, spokesperson for the CISSS de la Montérégie-Centre.

“Respiratory therapists, nurses, and intensivists quickly mobilized to provide care and provide the respiratory assistance required by users, that is to say, either by mask or nasal cannula connected to an oxygen cylinder already in place or using manual ventilation.”

“You need your oxygen level at a maximum so even for these patients even a minute is really a long time. And it could have really catastrophic consequences,” said Dr. Hoang Duong, president of Internal Medicine Specialists of Quebec.

For eight of the patients, their situations were restored without serious consequences, but for 71-year-old COVID patient Maurice Leblanc, the event proved to be fatal.

According to LaPresse, the Canadian armed forces veteran had been hospitalized and intubated on May 16.

He died less than one hour after the incident, unable to recover from the lack of oxygen.

“The sickest patients are already on a respirator, but this respirator needs oxygen. And if the oxygen source is cut, you could have all the machines you want, but you lack this very important component, which is oxygen,” said Duong.

The local health authority says they’ve analyzed the situation and made recommendations to prevent such an event from happening again.

“I never heard of that before, on this scale, where it affects the whole ICU. I never saw it and fortunately so. Most hospitals, they offer secure treatment and if you’re sick, you’re better off in hospital than not,” said Duong.