Quebec coroner finds senior’s death accidental, but care home employee reported for negligence

A Quebec coroner has concluded that the death of a 97-year-old woman following a fall at a seniors’ home in 2024 was accidental, but in her report, she raises numerous questions about how the fall happened and how staff allegedly responded.

Angelina Geraldi died at CHSLD LaSalle, a public long-term care facility in Montreal, on Dec. 18, 2024, less than a day after she fell out of bed.

Geraldi’s nursing care plan assessed her as being at high risk of falling. She was entirely dependent on staff to help her get in and out of bed or use the bathroom.

In coroner Geneviève Pépin’s report, which was released earlier this month, Pépin said the post-mortem examination revealed Geraldi had fractures in both hips as well as internal bleeding. The bleeding caused hypovolemic shock, which prevented the heart from pumping enough blood. This led to heart failure.

According to the details outlined in the report, a nursing assistant on duty at the time of Geraldi’s fall didn’t appear to follow protocol during the incident and her account of what happened changed during the investigation.

CHSLD LaSalle confirmed the nursing assistant, who was an employee, no longer works there. It also reported her to the Ordre des infirmières et infirmiers auxiliaires du Québec (OIIAQ) for negligence.

Geraldi’s granddaughter, Alice Costello, said she finds the lack of accountability disappointing.

“What is strange, or at least I don’t understand fully, is that they say it was not [the] fault of anyone. However, someone does not work there anymore,” said Costello.

“Those two things just don’t add up.”

The night of the incident, a resident in a neighbouring room reportedly heard Geraldi’s screams sometime between 3:30 a.m. and 4:30 a.m. According to the coroner, the resident saw Geraldi lying on the floor and banging on the walls for help.

The neighbour pressed his alarm button to alert staff. About 10 minutes later, an employee went to check on Geraldi.

Both Geraldi’s and the nearby resident’s doors were open, which allowed him to see what was going on. He testified that the employee seemed distraught and was unable to lift Geraldi. 

The resident wasn’t able to identify the employee, but reportedly saw them “dragging Ms. Geraldi across the floor by pulling her with both hands, while she was groaning.”

According to protocol, if a resident has fallen, it’s supposed to be reported to the head nurse before any attempt is made to lift them to avoid further injury.

At the time of the fall, Pépin said both the head nurse and an orderly were taking their breaks, but were available if needed. The only staff member on Geraldi’s floor was a nursing assistant, according to the report.

The head nurse testified she was not informed of the fall during her shift.

Later that morning, Geraldi called staff and asked to be moved into a seated position. But when the orderly tried to move Geraldi to her chair, she began to scream and told him her legs hurt.

During that visit, Geraldi reportedly told the orderly she had fallen. The orderly, or préposée aux bénéficiaires (PAB), told the coroner he found this surprising as Geraldi was in bed when he entered her room around 5 a.m., and she would have been unable to get up on her own if she had fallen.

Geraldi’s bed was also equipped with sensors, known as a SMART device. If Geraldi tried to get up or fell out of bed, an alarm would go off at the nurses’ station, in her room and in the hallway. The orderly told the coroner the device appeared to be working and did not indicate she had gotten out of bed.

The device also appeared to be working when the head nurse did her final rounds at 7 a.m.

The fact Geraldi had fallen was not recognized until 8:30 a.m., when the morning staff started. An incident report was then filled out — about four five hours after the fall. 

During this post-fall analysis, the sensors on Geraldi’s bed were tested and they were no longer working.

“There is therefore no way of knowing whether the SMART system was triggered or not during Ms. Geraldi’s fall,” Pépin states in her report.

Following Geraldi’s death, the nursing assistant on duty denied finding Geraldi on the floor, both during the police investigation, which was part of the coroner’s inquiry, and during the inquiry by CHSLD LaSalle.

This contradicted what she allegedly told the CHSLD’s manager the morning of Geraldi’s fall. The manager told Pépin the nursing assistant told her she hadn’t seen Geraldi fall, but found her on the floor.

“Subsequently, she denied to her employer having seen Ms. Geraldi on the floor and denied that any fall had occurred,” Pépin wrote in her report.

The coroner credits the “very credible” testimony of the neighbouring resident for bringing Geraldi’s fall to light.

“The totality of the fractures found during the post-mortem examination leaves no doubt that there was a fall. A person cannot inflict such fractures on themselves while lying in bed,” Pépin wrote.

Pépin did not make any recommendations in her report. She said she felt it was unnecessary because CHSLD LaSalle had trained all members of their care team on fall management and made a number of changes to help and reduce falls since Geraldi’s death.

According to Hélène Bergeron-Gamache, a spokesperson for the CIUSSS de l’Ouest-de-l’Île-de-Montréal, that includes intentional, personalized rounds to respond quickly to the needs of residents at high risk of falling.

The care home has also adopted standardized tools to better identify risk factors for falls.

Pépin also noted that orderlies must inspect equipment at the beginning and end of each shift to make sure it’s working properly. Staff is held accountable for whether this is completed.

The coroner herself confirms that many details remain unresolved, including why the nursing assistant did not report the fall to her colleagues, why she did not ask for help, and why she moved Geraldi, which is contrary to established protocol. 

However, Pépin says it is not within her mandate to examine competence, quality of care or rule on a person’s civil or criminal liability. Pépin’s report was forwarded to Quebec’s order of licensed practical nurses, the OIIAQ.

The OIIAQ confirmed it had received the coroner’s report, which was shared with its governing body. Any further consequences would only become public if it decides to file a complaint with its disciplinary committee.

Geraldi’s granddaughter, Alice Costello, understands mistakes happen and the employee may have panicked. Costello is trained as a patient care attendant and worked in a CHSLD herself.

While it’s upsetting to find someone may have been hurt during your shift, Costello said there are rules in place to prevent further harm.

“They’re not working at this one location, but do they still have their licence to practise?” she asked in reference to the nursing assistant.

“Are they still working in another facility? Were they put through retraining again?” 

Costello said she and her family are taking some time to reflect on the report before deciding whether they will sue.