her mom was cognitively impaired<\/a> and had been living in a secure unit in the residence for less than a year.<\/p>\nIn a report released Monday, coroner Jean-Fran\u00e7ois Bertrand concluded that Jean died of hypothermia and outlined several security and training issues in the residence.\u00a0<\/p>\n
Not only was the balcony door \u2014 accessible from the hallway \u2014 supposed to be locked, says the coroner, but the surveillance system failed.<\/p>\n
Orderly saw Jean \u2018confused\u2019 just before she wandered<\/p>\n
The orderly on call the night of the incident also failed to properly monitor Jean throughout the night, according to the report.\u00a0<\/p>\n
Before Jean wandered onto the balcony late Feb. 29, 2024, she was found by an orderly in the corridor \u201cslumped\u201d against the balcony door.<\/p>\n
The orderly reportedly realized that the door was not locked and escorted Jean back to her room \u2014 noting that she was \u201cconfused and was not responding to him.\u201d<\/p>\n
\u201cHe then tried to find the key to lock the [balcony] door, but didn\u2019t find it,\u201d wrote the coroner.\u00a0<\/p>\n
\u201cHe failed to flag the situation to his superior and took no further steps.\u201d<\/p>\n
Exactly 10 minutes after the orderly escorted Jean to her room, the cameras captured Jean \u2014 barefoot with a blanket over her shoulders \u2014 heading in the direction of the balcony.<\/p>\n
Staff only realized Jean was missing from her room the next morning at around 5:20 a.m., according to the report. They found the senior a few minutes later on the balcony unresponsive and in cardiac arrest. <\/p>\n
Staff attempted life-saving efforts but she was transported to hospital by emergency personnel and declared dead at 6:25 a.m.<\/p>\n
Surveillance system not \u2018up to standard\u2019<\/p>\n
In the report, the coroner says the orderly specified that he didn’t know how to consult residents\u2019 files and said he was unfamiliar with night procedures and the required frequency of resident room checks.<\/p>\n
According to policy at the time, room checks were supposed to be performed every hour.\u00a0 Jean was not checked on for more than five hours.<\/p>\n
The coroner also found that the surveillance system was \u201cneither functional nor up to standard,\u201d especially considering Jean was in the section of housing for residents with neurocognitive disorders and wandering behaviours.\u00a0\u00a0\u00a0\u00a0<\/p>\n
WATCH | How to balance safety and autonomy in seniors’ homes:![\"\"](\"https:\/\/www.newsbeep.com\/ca\/wp-content\/uploads\/2026\/01\/1769196435_822_default.jpg\")
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Balancing safety and autonomy in seniors\u2019 residences after 3 cold-weather deaths<\/p>\n
After three Quebec seniors passed away in the cold in the last week, the owner of a seniors\u2019 residence says there are measures private homes can take to ensure the safety of their tenants. A seniors’ advocacy expert says there is a fine line between providing autonomy and safety for the elderly in the wintertime. <\/p>\n
Correction: A previous version of this story said the level of safety was at the discretion of each residence. In fact, certain RPAs (depending on their categories) were required to install anti-wandering security systems by July 2025.<\/p>\n
Bertrand noted that several cameras and surveillance equipment \u201cthat could have allowed for the sighting of Ms. Jean had been out of order for several weeks.\u201d<\/p>\n
\u201cNo alarm notified the RPA staff when the cameras were activated by movement,\u201d wrote Bertrand.<\/p>\n
\u201cIt appears clear that Ms. Jean’s death could have been avoided if the RPA’s security cameras had been monitored and if the door leading to the balcony had been equipped with a device to promptly alert staff.\u201d<\/p>\n
Quebec\u2019s regulation respecting the certification of private seniors’ residences \u2014 in place since July 2025 \u2014 requires the installation of security devices on every exit to alert staff in certain RPAs.<\/p>\n
But Bertrand noted the regulation doesn\u2019t apply to intermediate resource sections, also known as RIs, such as the one that housed Jean. <\/p>\n
RIs are designed for residents with some loss of either physical or cognitive autonomy and are overseen by regional health authorities. <\/p>\n
\u201cWhy are RI users not entitled to the same safety standards as those in RPAs?\u201d questioned Bertrand.\u00a0<\/p>\n
\u201cUsers presenting with neurocognitive disorders are found in both RPAs and RIs; therefore, they must be able to benefit from the same services and the same safety standards.\u201d<\/p>\n
‘Profoundly sad incident,’ says director of RPA<\/p>\n
Bertrand said it is \u201cvital\u201d to raise awareness on the importance of complying with the requirements. He recommended the CISSS Chaudi\u00e8re-Appalaches remind staff in RIs of the importance of properly controlling all exits in its facilities.<\/p>\n
In an emailed statement, the integrated health and social services centre for the Chaudi\u00e8re-Appalaches region said it has taken note of the recommendations issued in the report and will ensure it’s following up with the \u201cnecessary seriousness it deserves.\u201d<\/p>\n
The coroner recommended the private seniors\u2019 home install security devices on doors and an intervention procedure for when an alert is triggered. He also recommended for the home to ensure continuous monitoring of its cameras.\u00a0<\/p>\n
The seniors\u2019 home takes the coroner\u2019s report very seriously, says Xavier Houdot, the director of the R\u00e9sidence Saint-Antoine.\u00a0<\/p>\n
\u201cAbove all, our thoughts are with the family and loved ones of Ms. Jean. This is a profoundly sad incident,\u201d wrote Houdot, in an emailed statement.\u00a0<\/p>\n
\u201cFollowing this incident, concrete measures have been put into place at the R\u00e9sidence Saint-Antoine to reinforce security and prevent this kind of situation from happening again.\u201d\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"Listen to this article Estimated 5 minutes The audio version of this article is generated by AI-based technology.…\n","protected":false},"author":2,"featured_media":428656,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[22],"tags":[49,48,295,66],"class_list":{"0":"post-428655","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-environment","8":"tag-ca","9":"tag-canada","10":"tag-environment","11":"tag-science"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts\/428655","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/comments?post=428655"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts\/428655\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/media\/428656"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/media?parent=428655"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/categories?post=428655"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/tags?post=428655"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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