Montreal family unsatisfied with coroner’s report into death of 86-year-old Filipino mother in hospital

A coroner’s report into the circumstances surrounding the death of 86-year-old Filipino mother and grandmother, Candida Macarine, at a Montreal hospital last year, has drawn little answers or comfort for her children.

Macarine was admitted to the Lakeshore General Hospital due to respiratory distress on Feb. 26, 2021, and was found dead on the floor by hospital staff in the early hours of the next morning. The coroner ruled she died of natural causes.

“We’re not questioning that my mom died of natural causes, given her age and medical history,” said Emmanuel Macarine, son of Candida. “But could she have received proper medical treatment? If she was found on the floor by the staff on time, maybe she’s still alive now?”

The family was initially told that Macarine had died of a cardiac arrest, only finding out more of the grim details through a news report more than a week later. Now, more than a year and a half later, the family says the unknowns of what happened that day still remain.

“How can our mother be at peace? How can we be reassured that our mother was properly cared for? Imagine how this question has been haunting us since her passing,” said Candida’s daughter, Gilda Macarine, back in March 2022.

READ MORE: ‘What really happened’: Family remains in the dark about grandmother’s death; report expected soon

On Sept. 14, a three-page report by coroner Amélie Lavigne was released. It says Macarine likely died naturally of a heart attack, stopping short of alleging neglect by staff.

“No element suggests possible negligence or abandonment on the part of the nursing staff,” Lavigne wrote. 

“It’s like mourning my mom’s death twice,” Emmanuel said. “After more than one year of waiting for this report, I thought she would have done a thorough investigation.”

For weeks after their mother’s passing, the Macarine children faced major problems accessing medical records at the hospital and other information surrounding their mother’s care during her stay at the hospital. 

The report found that, hours before she died, Macarine did a blood test that found she had a high risk of a heart attack, due to an elevated level of the protein troponin in her blood. 

At 2:11 a.m., another test found a more significant increase of troponin in her blood, yet staff did not check on her again for nearly 20 minutes, when she was found unconscious, according to the report. 

‘It’s not about how she died,’ said CRARR Executive Director, Fo Niemi. “She may have died of a heart attack, but what happened to the care that preceded her being found on the floor dead, ice cold? And more importantly, was she the only person who suffered this fate? Or there could have been other patients who could have gone to that same sort of B-24 section and who could have been possibly being neglected.”

“Bed 24 location, way in the back of the ER, it’s not mentioned in the report,” said Macarine’s daughter, Gilda. “Neither is the question as to whether bed 24 is equipped to handle my mom’s critical health condition.”

“By putting her in a room with low visibility from the nurses station, knowing full well that the state of my mother’s health was something to be closely monitoring, why would you do that?” asked Emmanuel.

The coroner questioned why Macarine wasn’t checked on sooner.

She noted that experts she consulted at the local health board, CIUSSS de l’Ouest-de-l’Île-de-Montréal, which oversees the Lakeshore Hospital, said it is normal for patients to have higher levels of troponin when they are already at risk of heart attack.

The Coroner’s report makes one recommendation surrounding the improvement of the surveillance of visual and auditory alerts of patient-monitoring systems at the hospital, since Lavigne said that a system to monitor a patient’s cardiac activity was available in Macarine’s room.

“It seems that staff did not notice or hear the alarm at the nursing station,” the coroner wrote.

“For a someone at the nursing station not to hear the alarm, visual and audio alarm, about Ms. Macarine’s state, that’s very serious,” said Niemi.

The CIUSSS tells CityNews in a statement: “[…] Tenders are in progress to improve the sound alarm system in place. Until a permanent solution is identified, a service assistant is on duty 24/7 in this emergency sector.”

RELATED: Family of Filipino woman found dead on hospital floor says it still doesn’t have answers

The Centre for Research-Action on Race Relations (CRARR) is accompanying the family through the process.

In a press release they say: “Two of the most serious questions, both entirely unaddressed in the report, are the time gaps during her stay at the ER where she was apparently left unsupervised, and contradictory information related to the time her body was found on the floor.” 

The family believes the coroner didn’t go far enough in the investigation and are calling for the case to be reopened.

Quebec’s Coroner’s office invites them to share their concerns in writing, adding in a statement: “The Act respecting the determination of the causes and circumstances of death prohibits the coroner from ruling, at the end of their investigation, on the civil or criminal liability of a person.”

“It was her birthday on September 20th, and that’s the day I received this report, and I thought finally I could go to her grave and say, ‘Mom, we finally have answers for you,'” said Emmanuel. “I thought we were getting answers finally, but I’m sorry, what do we have to do?”