Medical error contributed to death of Gatineau man at Hull Hospital in 2021: Coroner

Hull Hospital in Gatineau, Que. (Google Streetview)

A 28-year-old Gatineau man, who died at the Hull Hospital in November 2021, was given five times the prescribed dose of lorazepam before his death, according to a coroner's report.

Benoit Lauzon, who had Down syndrome, was living in supportive housing in Gatineau when, on Nov. 2, 2021, he began to experience breathing problems. He was taken to the Hull Hospital, arriving at 11:18 p.m., where he was diagnosed with sepsis secondary to pneumonia.

At around 7:40 a.m. Nov. 4, Lauzon became agitated and was prescribed 1 mg of Ativan (lorazepam) to be administered intravenously, but he was actually given 5 mg, the coroner found.

Lauzon began hyperventilating, had a rapid heartbeat and became comatose. His mother was called and he died a short time later.

According to Le Droit, there was no autopsy at the time of Lauzon's death. His mother submitted concerns to the Outaouais public health unit, the CISSSO, which brought it to the attention of coroner Francine Danais, who agreed to launch an investigation. This investigation revealed the medical error in the hours before Lauzon passed away.

CTV News Ottawa obtained the report, written in French, from the coroner's office.

Danais said in her report that while she could not definitively say whether the overdose of lorazepam caused Lauzon's death, it was certainly a contributor. She ruled the death accidental.

The coroner recommended to the CISSSO the following:

• Verify compliance of nursing practice of the preparation of medications in syringes;
• Ensure that all syringes containing medication are identical with a label; and
• Remind all nursing staff that saline pre-filled syringes are not designed for drug administration.