The Coroner’s Inquest into the deaths of Lori Dupont and Marc Daniel was completed on December 11, 2007, when the Jury delivered its Verdict. Lori Dupont, a recovery room nurse at Hotel- Dieu Grace Hospital in Windsor, was murdered at the Hospital by Dr. Marc Daniel, an anaesthesiologist with privileges at the Hospital, who then took his own life. The Coroner’s Jury made 26 recommendations directed at public hospitals and other organizations that deal with issues including physician privileges, Hospital by-laws and governance, workplace safety and domestic violence.

The Jury’s final recommendation was that the Chief Coroner’s Office should provide a report in December 2008 publicly reporting on the status of implementation of the recommendations. Ontario public hospitals should therefore carefully review the recommendations, and the steps they have taken to implement the recommendations, in the near future.

A number of the Jury’s recommendations were directed specifically to Ontario public hospitals, which will require updating their policies, procedures and by-laws to address a number of issues.

In particular, the Jury recommended that hospitals should conduct a review of their by-laws to ensure that their Medical Staff Governance By-laws and other related policies are updated to reflect the priority of patient and staff safety. A number of specific recommendations address how the Jury envisions the changes to hospital governance that would achieve this goal. The principles and considerations identified as informing by-law reviews include:

  • patient and staff safety and quality of care;
  • progressive discipline principles, as outlined in the 2006 College of Physicians and Surgeons of Ontario working document from its Disruptive Physician Behaviour Initiative; and
  • clear codes of behaviour for physicians along with appropriate follow through and remedial/disciplinary action by hospitals.

The rationale for this key recommendation is to ensure that relevant behaviour issues and complaints are properly identified and managed by hospitals.

The Jury also made recommendations regarding the relationship of hospitals with the Physician Health Program; designing and implementing hospital policies to address domestic violence and abuse or harassment, including appointing a “diversity officer”; ensuring that hospital management of controlled substances is appropriately addressed; and ensuring that significant physician behaviour problems are reported immediately to the College of Physicians and Surgeons of Ontario.

It is important to note that failure to implement a jury recommendation sent to a hospital by the Coroner may be used in evidence against the hospital in the future should there be a criticism raised in a future legal proceeding. The expectation is that hospitals will pay close attention to jury recommendations on systemic issues that affect hospitals and that hospitals will exercise due diligence in implementing those recommendations.

In light of this and of the fact that the Coroner’s one-year report on the implementation of the Dupont/Daniel recommendations is fast approaching, we recommend that hospitals take the time to carefully scrutinize the recommendations to ensure that their policies, by-laws, codes of conduct and other systems reflect the recommendations of the Jury and if not, take reasonable steps to implement the recommendations. Note, however, that a number of the recommendations require amendments to the Public Hospitals Act which have not yet been enacted.

A full summary of the recommendations directed toward public hospitals is available on the Ontario Hospital Association’s website at: http://www.oha.com/Client/OHA/OHA_LP4W_LND_WebStation.nsf/resources/Dupont-Daniel+Inquest+Public/$file/Backgrounder+-+Implementation+of+Recommendations+_FORMATTED_.pdf