AN 88-year-old man choked to death in a North Vancouver seniors' home this January as an under-trained staff member fed him his breakfast, according to a damning B.C. Coroners Service report released this week.
Staff at Sunrise of Lynn Valley then went on to lie to investigators about Eldon Mooney's final moments, wrote Coroner Kate Corcoran. The deception only came to light because the man's daughter, Gail Nelson, 60, had secretly installed a video camera in the room.
"Initial statements from facility management indicated there were no problems or concerns at the time Mr. Mooney's morning meal," Corcoran wrote. "BCCS was told Mr. Mooney was comfortable prior to staff exiting his room; that staff returned shortly after to find the 88-year-old unresponsive and that when assistance arrived, given an existing 'Do Not Resuscitate' order, no actions to resuscitate were initiated."
However, after watching Nelson's video footage, Corcoran learned the real chain of events.
"Mr. Mooney's death was a choking incident during breakfast; an incident
not responded to in a safe, efficient and effective manner," she wrote. "The video confirms that some of SLV's staff members were less than forthcoming with the facts surrounding Mr. Mooney's final minutes, leaving management unaware of the correct circumstances."
The incident was made public this week in an investigative report by the Province newspaper.
A forensic pathologist who also watched the video said it showed a patient in distress, apparently trying to cough while being fed and then losing consciousness. A post mortem revealed a "massive amount of partially chewed food in the airways," extending all the way to the man's lungs. Smaller amounts of food found in his airways suggested this was not the first time Mooney had inhaled particles of food.
Corcoran noted that Mooney was deaf, had no teeth and had a clinical history of dementia. Sunrise staff had fast-tracked Mooney's admission to support his family, and were unprepared for his behavioural problems and feeding needs.
"Mr. Mooney was a challenging patient to care for, and staff was ill prepared and incapable of dealing with his issues - issues known to exist in the elderly and vulnerable population that facilities such as Sunrise of Lynn Valley cater to. If not for the video brought forward by the family, Mr. Mooney's accidental death would not have surfaced," she wrote.
A separate investigation by the province's Community Care Facilities Licensing branch found 23 violations of the law at Sunrise of Lynn Valley.
These include: inadequate patient monitoring; poor food preparation and service; a lack of training in safe feeding techniques, the handling of delirious patients and in emergency response; and inadequate admission screening and care plans.
However, since the investigation's findings were made available, Corcoran wrote that she is satisfied with Sunrise's "numerous and timely improvements," such as the introduction of 24-hour nursing supervision, enhanced staff training and "group discussions regarding ethics and the importance of full and honest incident reporting."
Sunrise Senior Living, a publicly traded company which operates more than 420 seniors homes across North America and Europe, released a statement describing the incident as "tragic" and "not at all representative of the care we give at Sunrise.
"We confront any shortcomings vigorously and respond proactively to help ensure we are providing our residents with the very best home," it stated.
They declined to comment further. Hours after the release of Corcoran's report, provincial Health Minister Mike de Jong publicly apologized to Mooney's family in the legislature.