A 79-year-old woman’s tragic death due to hypothermia outside a seniors’ home in Quebec in 2024 could have been averted, as indicated by a recent coroner’s report. The deceased, Réjeanne Jean, was discovered on a balcony at the Résidence Saint-Antoine in Lévis, Que., on March 1, 2024. Jean’s daughter, Caroline Desrosiers, highlighted her mother’s cognitive impairment and recent relocation to a secure unit within the facility.
The coroner, Jean-François Bertrand, identified lapses in security and training within the residence that contributed to Jean’s untimely demise. The balcony door, accessible from the hallway, was supposed to be locked but was found unlocked. Additionally, the surveillance system failed to function as expected.
On the night of the incident, the attending orderly failed to adequately monitor Jean, who was later seen wandering onto the balcony barefoot with a blanket. Despite being discovered in a confused state by the orderly earlier, no further actions were taken to prevent the subsequent tragic outcome.
It wasn’t until the following morning that staff realized Jean was missing from her room. She was found unresponsive and in cardiac arrest on the balcony and subsequently pronounced dead at the hospital. The coroner emphasized shortcomings in staff training, room checks, and the malfunctioning surveillance system, which failed to detect Jean’s movements due to faulty equipment.
The coroner’s report underscored the importance of adhering to safety requirements and recommended the installation of security devices on exits and continuous monitoring of surveillance cameras. The director of the seniors’ home, Xavier Houdot, expressed deep regret over the incident and assured that corrective measures have been implemented to prevent such tragedies in the future.
