A coroner's report looking into the death of a seven-month-old baby from the Atikamekw community of Manawan, Que., says significant delays in receiving medical care likely played a role in the girl's death, as it took several hours to transport the child to a pediatric hospital.
The baby girl died April 4 at the Centre Hospitalier Universitaire Sainte-Justine in Montreal, from complications of meningitis and COVID-19, after first being diagnosed at the community's health centre as having a fever from teething.
When her parents sought emergency care after her condition worsened, the report says it took a total of eight and a half hours from the initial call for an ambulance to transport her to Sainte-Justine's.
Coroner Géhane Kamel says the child died of "bacterial meningitis following emergency care received too late."
Kamel made three recommendations, including implementing medical evacuation services by helicopter for patients in critical condition in remote regions.
This recommendation was made by another coroner 13 years ago following the death of a little girl in the same Atikamekw community, located 250 kilometres north of Montreal, in the province's Lanaudière region.
A long wait
On April 2, after the parents spent two days of treating the seven-month-old's fever with acetaminophen, she went into convulsions and was taken to the Centre de Santé Masko-Siwin de Manawan.
After seeing her, the nurse called for an ambulance as the child was suffering from "febrile seizures with breathing difficulties," according to the report.
The initial call was made for Manawan's only ambulance at around 9 p.m., but the vehicle was not available. The report says the team was overwhelmed and could not respond to the call. The head of operations for the Manawan area "did not communicate this break in service," the report says.
Another call was immediately made for an ambulance from Saint-Michel-des-Saints, Que., 90 kilometres away.
Despite the urgency of the situation, the ambulance set out nearly six minutes after the call was placed and took an hour and 48 minutes to arrive at the Atikamekw community's health centre. It left half an hour later with the baby and her mother for the closest hospital, the Centre hospitalier régional de Lanaudiére.
The baby arrived at the hospital at 2:30 a.m. — five and a half hours after the initial call. Considering her precarious medical situation, a request was made 48 minutes later to transport her to the CHU Sainte-Justine, where the baby arrived at 5:32 a.m. — more than eight and a half hours after the initial call.
"In this context, and given the initial medical assessment, it seems highly likely to me that delays of this magnitude had an impact on the child's survival," concluded Kamel.
'We have not changed,' says chief
The issue of ambulance delays and medical transfers from Manawan have been studied before.
After a toddler, who was also transferred from Saint-Michel-des-Saints to Montreal, died of drowning in 2009, a coroner recommended finding ways to reduce wait times for ambulances, including the possibility of establishing medevac services for patients in critical condition in remote regions.
"I can only agree with his concerns," said Kamel.
While private medical helicopter services exist, Quebec is one of the only provinces in Canada without an organized, pre-hospital emergency air ambulance system.
Sipi Flamand, the chief of the Atikamekw Council of Manawan, says it's unacceptable that Kamel has had to restate the recommendation about improving medical transfers.
"Knowing what happened in 2009, but also in 1998, we have not changed. Both at the level of Quebec and of the community, which remains underfunded to meet its needs," said Flamand in response to the report.
"It's shocking and sad," he said. "Cases like this baby should not have happened."
In 1998, another Quebec coroner looked into the respiratory failure of a 24-year-old man and ruled that if Manawan "was better equipped with medication [and] ambulance transport, and if the personnel were trained in the standard suggested by the regional board, it is likely that [the man] would still be alive today.
In the seven-month-old's case, Kamel believes the situation should "undoubtedly have required an initial assessment, which would have favoured transportation other than land."
Kamel is recommending that the Health Ministry undertake a project as soon as possible to revamp pre-hospital emergency services, including helicopter transport, so that patients in critical condition in remote regions can benefit from these services in the near future.
According to the coroner, the ministry is currently working on it.
For its part, Manawan began discussions with a private helicopter air ambulance company called Airmedic in May to have a heliport and offer medical transport services.
Flamand points out that he testified at the Viens Commission, a public inquiry into relations between Indigenous peoples and certain public services in Quebec, about the need for Manawan to have more than one ambulance. At the time, the community had none.
He thinks three would be better, plus the helipad.
Kamel is also recommending that the Manawan health centre ensure that the clinical assessment of a patient takes into account their priority level and that the right means of transportation is used to reduce transfer times when necessary.
"We must review practices, especially when the health of a child is at stake," said Flamand.
The coroner says the province also needs to explore out-of-the-box solutions.
One area that must be explored, she said, is the creation of a pre-hospital care unit specifically for First Nations patients, similar to how many of their communities have a dedicated police unit. She says the Ministry of Higher Education should evaluate this possibility and find ways to address labour shortages in remote regions.
Flamand says these three recommendations can realistically be implemented, but it takes participation from the government.