Quebec's ombudsman is urging the Montreal Children's Hospital to provide better pre- and post-surgical care, after looking into concerns raised about the cases of 16 patients, including one involving a four-month-old baby.
In a report made public Thursday, the ombudsman said there were several instances in which the level of care provided was "deficient."
The report said staff did not follow established protocols such as checking how much patients had urinated compared to what they had taken in, the regular monitoring of vital and neurological signs, and procedures to follow to safely discharge patients from hospital.
In the case of more than half of the patients whose files were examined, the way staff kept track of vital and neurological signs "did not correspond" with the hospital's guidelines, the report said.
Only a few of the patient files showed that vital signs were recorded at the time the patient was allowed to leave the hospital, the report said. In some files, there was no proof that vital signs had ever been taken.
In the case of the four-month-old, the ombudsman said a nurse failed to regularly check the baby's vital and neurological signs.
"If this had been done, the nurse would have seen that the baby's condition was deteriorating," the ombudsman wrote.
"When the nurse on the next shift took charge of the baby, she did a full reading of the vital signs, leading her to call for the medical staff immediately. The child was then transferred to the intensive care unit with septic shock."
In an interview with CBC News, Claude Dussault, the deputy ombudsman, said the baby was discharged more than a week later.
"Fortunately, there were no long-term consequences," Dussault said.
The nurse at fault has improved since then, the report said, and the incident was reviewed by other members of her team.
At the time, some staff said that "they felt uncomfortable about expressing concern about a patient under the care of a colleague."
"The members of the staff were therefore given means enabling them to do so in strictest confidence," the report said.
The ombudsman wants the hospital to create an action plan based on the report's findings.
The Montreal Children's Hospital is part of the McGill University Health Centre (MUHC). In a statement, an MUHC spokesperson said the hospital network had taken note of the ombudsman's report and had "already taken measures to correct the situation."