Intervention Reports

Between December 13 and 23, 2010, that is, in fewer than 10 working days, 60 seniors with decreasing independence, most of them from Hôpital Pierre-Le Gardeur, were transferred to the Centre multivocationnel Claude-David’s transitional unit.

The incident as reported to the Québec Ombudsman concerned:

• the context of the emergency transfer of particularly vulnerable users and the risks associated with the changes they were also subjected to;
• living conditions in the users’ new environment that were cobbled together hastily;
• the substantial number of deaths in the weeks following the transfer.

The Québec Ombudsman made recommendations to the CSSS du Sud de Lanaudière, the Agence de la santé et des services sociaux de Lanaudière, and the Ministère de la Santé et des services sociaux (MSSS). They mainly concern follow-up on the CSSS’s existing action plan to improve service quality. On a broader basis, the Québec Ombudsman also examines the pressure on institutions to unclog emergency services, which was what was behind the transfers: the solutions contemplated regionally and by MSSS must first and foremost respect users’ safety and well-being.

The authorities concerned assured the Québec Ombudsman of their complete collaboration in implementing the required solutions, some of which, they pointed out, had already been applied.

Intervention report

The situation reported concerns the problems encountered by a person who asked the adoption and reunion service of Centre jeunesse de Québec – Institut universitaire to search for her birth father, i.e. the processing times and the improper disclosure of information regarding her request (results, location of her parent).

The Québec Ombudsman's recommendations to the youth centre are aimed at:

• ensuring that users are more properly informed about the standard processing times for this type of request;
• better controlling the disclosure of information regarding the progress in searching for a birth parent;
• ensuring that user dissatisfaction with services received is addressed more effectively and that any complaint or dissatisfaction expressed in writing to an employee of the youth centre or to the local service quality and complaints commissioner is treated with greater confidentiality.

Intervention report

A community organization in the Québec City region asked the Québec Ombudsman to examine an Agence de la santé et des services sociaux de la Capitale-Nationale decision that did not appear to comply with the Politique de reconnaissance et de soutien des organismes communautaires de la région de Québec and the Programme de soutien aux organismes communautaires of the Ministère de la Santé et des Services sociaux. The organization argues that the Agency does not correctly interpret the definitions used to categorize the different kinds of community organizations, which affects subsidy amounts.

Following the Québec Ombudsman's intervention, the Agency admitted that not everyone understands or interprets the criteria for determining community organization typology the same way. It therefore committed to discussing this issue with the representatives of the region's Regroupement des organismes communautaires.

Intervention report

A report was made because a user:

• had been removed from his living environment, Résidence Monchénou, by Centre Notre-Dame de l'Enfant;
• had been transferred to another residence under the institution's responsibility;
• had been subjected to this change under circumstances that ran counter to some of his rights.

The Québec Ombudsman recommended that Centre Notre-Dame de l'Enfant henceforth obtain the informed consent of users with an intellectual disability in all situations involving a significant change in their life project.

Intervention report

The facts: A report was received, criticizing the living environment and the quality of the services offered by the residence. The principal grounds for dissatisfaction were the poor food service, the fact that residents were not represented on the institution's board of directors, and management's failure to listen to and respect the residents.

The Québec Ombudsman's recommendations were intended variously for the residence's authorities, the Health and Social Services Agency and the Société d'habitation du Québec, according to their missions. The goal of the recommendations was to improve service quality through:

• the addition of external resources;
• follow-up to the dissatisfaction expressed in the report;
• the identification and implementation of solutions;
• a more attentive response to complaints; and
• the introduction of mechanisms allowing residents to be involved in decisions affecting their daily lives.

The Québec Ombudsman has asked the three parties concerned to inform it of the measures implemented in the wake of its recommendations.

Intervention report (french version)

The facts: Three babies were victims of violence or family negligence.

The Québec Ombudsman's recommendations were to:

• improve the quality of the services available to vulnerable and neglected children, in every region of Québec;
• introduce new practices in and between the institutions when serious incidents such as this occur.

Intervention report (summary) (french version)

Intervention report (french version)

The facts: A report criticized the poor quality of services and care in a seniors' residence, including:

• non-invasive care given by non-professional staff and acts reserved for nursing staff;
• basic care and personal assistance;
• lack of security and protection for residents;
• the method used to administer and distribute medication;
• the poor quality of the food; and
• poorly adapted, poorly maintained premises.

The Québec Ombudsman's recommendations concerned improvements to the layout and maintenance of the premises.

Intervention report (french version)

The facts: A report was received to the effect that a resident had died as a result of serious burns (accidentally fell into a bath full of overly hot water and remained there for an extended period).

The Québec Ombudsman's recommendations were intended for the Ministère de la Santé et des Services sociaux, the Agence de santé et de services sociaux de Montréal, the CHUM (Hôtel-Dieu) and the Manoir-de-l'Ouest-de-l'Île Residential and Long-term Care Centre. Their purpose was to ensure that appropriate remedies and measures were introduced to avoid any repetition of the incident.

Intervention report (french version)

A petition was sent to the Québec Ombudsman, demanding the removal of the residence's board of directors. The petition had been drawn up by Manoir des Pommiers residents and was signed by 200 people. According to its authors:

• some residents were bullied and harassed to such an extent that they no longer wanted to leave their rooms;
• the police were called regularly to the residence; and
• several complaints of assault had been made.

The Québec Ombudsman's recommendations were intended for the Manoir des Pommiers, the Agence de la santé et des services sociaux du Bas-Saint-Laurent and the Société d'habitation du Québec. They included the introduction of various measures to solve internal conflicts, ensure better management of the residence and the services provided, and implementation of follow-up actions.

Intervention report (french version)

The facts: A report questioned the quality of the services available to users.

The Québec Ombudsman's recommendations were to:

• hold an administrative investigation of the facts reported;
• temporarily relocate the residents in order to provide them with appropriate conditions; and
• assess the health of the residents to identify any shortcomings requiring medical follow-up.

Intervention letter (french version)

Visit report (french version)

Intervention report (french version)

The facts: A report was received to the effect that a person had been kept in the hospital against his will. The report also mentioned a failure to respect deadlines for preventive custody, the use of isolation without valid grounds, bribery to obtain personal clothing, the right to leave the hospital, and exclusion of the person from the process of identifying the care required.

The Québec Ombudsman's recommendations concerned the introduction of various measures to ensure that users' rights were upheld: reminders for personnel, training sessions, stringent application of current legislation and standards, administrative adjustments and a review of the institution's code of ethics.

Intervention report (french version)

The facts: A report criticized the conditions of admission to the Jean-Talon Hospital emergency room for people with mental health disorders:

• clients confined to rooms that were permanently locked;
• different client groups housed together for long periods, regardless of the type of problem from which they suffered, without the necessary psychiatric services;
• lack of care personnel in the locked rooms (hygiene, supervision);
• lack of access to physical health care for these clients; and
• the need for a reorganization of the premises set aside for these people.

The Québec Ombudsman found that the problems identified had been addressed in a satisfactory manner, and no recommendations were made.

Letter of conclusion (french version)

The facts: A report criticized the poor quality of care and services given to three residents in the Manoir Saint-Amand transitional unit.

The Québec Ombudsman's recommendations concerned better oversight of residents: appropriate reminders for personnel, training, tighter controls on residents' safety, especially with respect to movements and medication, a more rigorous process to establish treatment plans, and better supervision of clinical practices.

Intervention report (french version)

The facts: A report mentioned numerous deficiencies in the care and services given to residents.

The Québec Ombudsman concluded that some of the allegations were founded. Its recommendations concerned the introduction of measures to improve the quality of the staff-resident relationship, better compliance with standards of professional ethics, more staff training, better supervision of clinical acts and greater attention to clients' needs when planning meals.

Intervention report (french version)

The facts: A report alleged that people with intellectual disabilities were often victims of discrimination based on their handicap, during end-of-life care.

The Québec Ombudsman's investigation did not find evidence to support the facts as reported, and no recommendations were made.

Intervention report (french version)

The facts: The author of a report feared that some of the Centre's clients were being badly treated, and also alleged over-use of containment and overmedication.

The Québec Ombudsman's investigation did not confirm the facts, and no recommendations were made.

Intervention report (french version)