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The Quebec coroner’s office has released a report outlining a number of changes in progress after examining the death of a four-year-old girl from Gatineau earlier this year.
In March, Chloé Bélanger died in the days after she was seen at the Gatineau Hospital for an asthma attack.
At the time, her mother Alexandra Desjardins-Gunville said that while her daughter was seen by respiratory therapists and a doctor, the family was left alone for extended periods of time.
She said they felt like they had to “beg” for further help until Bélanger went into what she was later told was cardio-respiratory arrest.
She was transferred to Ottawa and died a few days later.
The coroner’s report from the Quebec coroner’s office is dated Oct. 14 and, in French, goes over the approximately eight hours between the girl arriving at the Gatineau Hospital emergency room and leaving with a medical team for Ottawa.
It outlines 14 changes being made by local health authority Santé Québec Outaouais (SQO).
They include reviewing the plan for moderate to severe child asthma and clarifying roles and responsibilities of staff in the pediatric department.
Medical staff are also being told to emphasize parent concerns in clinical evaluations and to supervise and document parent participation in the administration of treatments.
The report says changes should be in place this autumn and it will start checking they’re in place in December. The office does not have the legal mandate to assign blame or analyze the quality of health-care worker actions.
Saddened measures weren’t in place
In a statement to Radio-Canada, Desjardins-Gunville said she is saddened by the long list of changes.
“I am tired of a system that tends to correct things after a tragedy takes place,” said the mother’s French statement.
She still said she hopes they will prevent similar instances from happening in the future.
“We miss [Chloé] every second,” Desjardins-Gunville said. “I wouldn’t even wish it on my worst enemy.”
WATCH | Treatment under review after girl’s death:
Health authority investigating 4-year-old girl’s death after she visited Gatineau Hospital for asthma attack
The public health authority for the Outaouais is reviewing the case of a child patient who died in the days after she was seen at Gatineau Hospital for an asthma attack. CBC’s Liam Baker spoke with the girl’s mother.
The Quebec coroner’s office declined further comment and directed Radio-Canada to the Ontario coroner’s office, which is leading the investigation on the case.
CBC News reached out to the Ontario coroner’s office, but was told it could not provide its own report, nor comment on the case, citing provincial laws.
In a statement to Radio-Canada, the health authority said it could not comment on the details of the situation to respect the confidentiality of personal information.
SQO said following Bélanger’s experience, the organization “quickly undertook a thorough review that led to the implementation of an improvement plan aimed at strengthening the quality and safety of care and services.”