Hospital refuses to turn over medical records to family of Montreal woman found dead on the floor

The Lakeshore General Hospital in Montreal's West Island is refusing to hand over Candida Macarine's medical records to her family, after Macarine was found dead on the floor of her room in the ER in February.

The family has been fighting for months to get answers about the circumstances of their mother's death, and the hospital has already apologized to them for what it called "incomplete communications" when Macarine died.

The family was never told that the 86-year-old was found on the floor, and only learned of that fact in a CBC News story two weeks after she died.

The family made a request to the hospital's archive department to have access to their mother's complete medical file, but they were refused. All they received was a copy of Macarine's death certificate.

"This is stonewalling in its most unethical and inhuman form," Macarine's son, Emmanuel, told reporters during an online news conference Wednesday.

"We're calling for full disclosure of all the facts and the full disclosure of my mother's medical file," he said.

'Ignorant and Arrogant'

Candida Macarine was found dead Feb. 27, a few hours after being admitted to the hospital. She was discovered on the floor of a negative pressure room. Nurses had warned managers several times that it was next to impossible to see a patient in the room.

Staff at the hospital told the family their mother died of cardiac arrest, without mentioning she was found on the floor.

It wasn't until the family noticed a CBC News story two weeks later about a woman found "dead and ice cold" on the floor beside her bed that they realized that woman was their mother.

After her death the family made a formal request to the hospital's archives department to have access to her full medical file.

The hospital sent the family a copy of the death certificate, but refused to hand over the complete medical file, citing section 23 of Quebec's Health and Social Services Act.

That section states that heirs are indeed entitled to a deceased family member's medical records, but only "to the extent that such communication is necessary for the exercise of their rights in such capacity."

"This is so ignorant and arrogant on the part of the hospital," Paul Brunet, president of the Quebec Council for Patients' Rights, told CBC in an interview Wednesday.

Brunet said that hospitals often use this section to justify refusing to turn over records but he said there's a simple way around it.

He said if the family threatens the hospital in writing with legal action, the hospital is then obliged to turn over the whole file.

"The family is totally entitled to it, and it's so insulting that they don't tell the family how to do it," Brunet said.

This is just the latest setback in the family's search for answers.

It was only after the family held a news conference in March accusing the hospital of racism that the hospital asked the coroner's office investigate the death.

Then, the coroner who was assigned to the case stepped aside and a new coroner was assigned after the family held another news conference in May to point out a possible conflict of interest.

A piece of the puzzle

The family has been able to shed some light on what happened the night Macarine died, after receiving a portion of the medical record in a brown envelope from an anonymous source.

The documents with handwritten notes from staff working that night show that Candida Macarine appears to have last been in contact with hospital staff at 11:20 p.m. for a lab test. Sometime after that, she was moved to the COVID-19 isolation room in the ER.

The documents then show that she went into cardiac arrest at 2:45 a.m. when she was found on the floor.  Medical staff tried to revive her, performing CPR but she was pronounced dead at 3:04 a.m.

"This shows clearly there was a gap in the log, which means they might have not checked up on my mother," Emmanuel Macarine said.

Candida Macarine's daughter Gilda, who is a nurse herself, also spoke at the news conference.

"I can tell you that what I saw in the medical report is not right. The three-hour gap is most disturbing," she said.

Still no renovations to ER despite promise from hospital

The hospital ordered an internal investigation after Macarine's death and a coroner's investigation is also underway.

In May, the hospital promised to address some of the concerns raised by staff about the layout of the ER, including adding an employee dedicated to monitoring the three COVID isolation rooms in the ER, and renovations to improve the workspace.

The hospital said at the time that the renovations would begin "in the coming days" but a source who works at the hospital told CBC Wednesday none of that work has begun yet.

The source said the only change that has been made is the addition of a non-health-care professional to monitor patients in those rooms.

The West Island health agency, which oversees the Lakeshore, the CIUSSS de l'Ouest-de-l'Île-de-Montréal, told CBC in an emailed statement it couldn't comment due to the ongoing coroner's investigation.

"We reiterate, however, that we remain available to meet the family a second time if they so desire," Mélanie Araos, a spokesperson for the CIUSSS, said in an email.

Araos noted the addition of the staff member to monitor the negative pressure rooms, but didn't explain why the promised renovations have not yet begun.