The body of Jeannine Benjamin, 85, was found by a maintenance worker at the Chartwell Oasis St. Jean on May 14, 2015. While she died of natural causes, the staff did not follow procedures when she didn't show up at meal time for several days.
Benjamin often skipped breakfast, but would eat her other meals in the cafeteria at the same table with the same people.
Workers are supposed to take attendance and inquire about a resident after three missed meals, but the coronerís report noted that attendance had not been taken.
Coroner Andre-H. Dandavino pointed out that a series of errors were made by the staff.
Dandavino noted that the last medication delivery was made on May 7, and that no medication was taken from that day forward.
A resident notified staff that Benjamin had not been in the cafeteria for several days, though her aide said she has no memory of the conversation.
On top of that, the receptionist noted that Benjamin picked up a newspaper every week, but the receptionist did not notify anyone when Benjamin did not do so.
Recommendations include ensuring they follow established rules
Coroner issues recommendations after body found a week after death in seniors' home | CTV Montreal News (external - login to view)