Family says coroner's report offers few answers on why woman was found dead on floor of a Montreal ER

The day after his mother's funeral March 8, 2021, Emmanuel Macarine walked into the emergency room at Lakeshore Hospital and asked to see where her body had been found. 

He was initially turned down but Macarine insisted and was finally allowed to see the negative pressure room where Candida Macarine died on the floor, about half an hour before her body was discovered by staff on Feb. 27, 2021. 

The morning of her burial, CBC News had revealed the 86-year-old woman had been found on the floor, a detail the hospital omitted when informing the family of her death. 

"Our emotions were going from sadness to anger, restlessness," Placido Macarine, Candida Macarine's other son, said at the time.

In the more than 18 months since Candida Macarine died at Lakeshore, her family says they have met constant roadblocks when trying to seek information on the circumstances of her death. 

They say a recently released coroner's report has not helped much. 

"[Emmanuel's] reaction to the report is one of deep disappointment and anger," said Fo Niemi, the director of the Center for Research Action on Race Relations, who has been representing the Macarine family. 

The three-page report by coroner Amélie Lavigne says Macarine likely died naturally of a heart attack, and makes one recommendation to improve the surveillance of visual and auditory alerts of patient-monitoring systems at the hospital.

"No element suggests possible negligence or abandonment on the part of the nursing staff," Lavigne said.

But Niemi says the report failed to dig deeper into some of the family's concerns about the events leading up to Macarine's death.

For example, Lavigne noted that a system to monitor a patient's cardiac activity was available in Macarine's room, but does not question whether it was used at all, or whether staff members did not hear — or simply did not respond to — an alarm indicating her distress. 

"According to the information gathered, it seems that staff did not notice or hear the alarm at the nursing station," the coroner wrote.

Lavigne also wrote that a blood test conducted on Macarine at 10:26 p.m., hours before she died, displayed "elevated risk" of heart attack, due to a high level of the protein troponin in her blood. 

After another test at 2:11 a.m. revealed troponin levels "significantly" increased, staff did not check on Macarine again for nearly 20 minutes, according to Lavigne.