The death of a diabetic man who choked while residing in an assisted-living facility could have been averted, said the coroner leading an inquest into the impact of the COVID-19 pandemic on Quebec care homes.

Coroner Géhane Kamel made the conclusion Wednesday after hearing from the auxiliary nurse who attended to Jacques Levesque the afternoon the 60-year-old died during a hypoglycemic episode at the Manoir Liverpool care home.

Ms. Kamel is reviewing events at seven care homes during the first wave of the pandemic, when more than 4,000 Quebeckers died in long-term care centres and retirement homes. This week the inquest is focusing on Manoir Liverpool, a private seniors’ home near Quebec City that also provided assisted living for people with physical impairments.

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Mr. Levesque didn’t have COVID-19, but his death took place at a time when care homes, already stretched by staff shortages, descended into further disarray because of the pandemic.

The auxiliary nurse was on duty on April 26, 2020, when she and an orderly dealt with Mr. Levesque’s low blood sugar. (Their names are under a publication ban.)

The nurse testified that she didn’t have time to read Mr. Levesque’s care plan, relying instead on past verbal instructions. She was also afraid of him because she had heard he could get aggressive when his blood sugar level dropped.

She and the orderly tried to perform chest compressions, following instructions from a 9-1-1 dispatcher they had called after Mr. Levesque turned pale and stopped breathing.

Other testimony at the inquest revealed that Mr. Levesque was still partially lying in his bed, so the two women didn’t have proper support under his chest while they did cardiopulmonary resuscitation (CPR).

“It’s a really sorry situation,” Ms. Kamel said at the end of the nurse’s testimony. “I hope you’ll find some inner peace because what I am left with is that as an auxiliary nurse, you don’t consult medical files, you didn’t know the protocol, you didn’t help someone who was agitated – you took CPR training and the manoeuvres were performed on a person who was half on a bed.”

The coroner added: “I am left with the clear feeling that this was a death that could have been avoided. And I find it very sad and distressing.”

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The nurse had testified that at the start of her shift, she tested Mr. Levesque’s blood sugar level and found a very low glycemic reading of 1.7 so rushed to get him some food – first a toast with peanut butter, then a banana, cheese, sweetened orange juice and some glucose.

Mr. Levesque’s condition got worse – he became agitated, his face went pale and he collapsed on his bed. He was later found to have died from choking on his food.

A nutritionist had previously testified that snacks with protein, such as peanut butter, should only be given after the glycemic level had been raised, otherwise it could impede the absorption of sugar.

Mr. Levesque often had hypoglycemic episodes and the protocol prescribed by his physician for those occasions was to administer glucose and, if the problem was severe, an injection of the hormone Glucagon.

The nurse didn’t consult the folder with Mr. Levesque’s care plan, she testified. “It happened too fast.”

Her written notes said she had given him Glucagon, but she testified she actually administered Insta-Glucose, a fast-acting sugar gel.

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She said she had heard from other staffers that Mr. Levesque could become erratic when he was hypoglycemic and apparently had once made a dent in a wall during one episode.

“I did the best I could … I was scared of him.”

The orderly confirmed that they started CPR while Mr. Levesque was in still in bed. It was the first time she had been in such an unnerving situation, she explained. “With someone so rattled next to me, I wasn’t thinking.”

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