‘My mother was let down’: The failings behind the unexplained death of Violet Lucas

On April 7, 2017, Violet Lucas was found dead with her head wedged between her mattress and her bed railing, her body slumped down on the floor. Son Derek Lucas is still waiting for answers. JEAN LEVAC / POSTMEDIA NEWS


Violet Lucas conquered more than her fair share of hardship. After escaping an abusive husband, she raised seven children on her own.

She had only a Grade 10 education and when her children were old enough, she learned a trade and got a job in a factory. She stretched a dollar, shopped from the dented-tin bin, sewed and knitted what she could and made all the birthday cakes.

She sacrificed, and made sure her kids, all seven of them, had what they needed — even hockey and her famous roast beef.

But her best life lesson was instilling in her children the value of a good, formal education — something she never had. She didn’t want them to struggle like she had.

She carved a good family life out of a hard path. And Lucas tried her best to never let anyone down, even when she, herself, was down on her luck. Everyone else came first.

It was this remarkable single mother who spent the last moments of her life in the most awful way at Extendicare Laurier Manor on Montreal Road.

On April 7, 2017, Lucas was found dead with her head wedged between her mattress and her bed railing, her body slumped down on the floor.

Lucas, 79, suffered from diabetes and had a history of strokes. She used a wheelchair and was not strong enough to get out of bed without assistance.

How she died remains unclear and unexplained.

The long-term care home and the Ministry of Health and Long-Term Care that oversees the home have little to say. Her family is in the dark and has been provided few details. Months after her death, they await the results of a coroner’s investigation.

Lucas’s death comes at a time when the quality of care at nursing homes in Ottawa is under scrutiny. Following Citizen reports of abuse and neglect at three of the four homes operated by the City of Ottawa, investigations and reviews of city-run homes were launched. But Lucas died in a privately-run facility, which will not fall under the scope of the city’s investigations. Extendicare Laurier Manor is one of 23 other homes in Ottawa not run by the city — and not under a spotlight.

And a spotlight is what Lucas’s family wants. Because while it might be unclear how she died, what is clear is that she was failed, not by her family, but by those paid to look after her. A series of failings by the home, detailed in provincial inspection reports, reveal, in part, what went wrong the night of her death.

It was sometime after 10 p.m., when Lucas found herself in distress.

There were two safety alarms in her room, both designed to alert nursing staff if a resident is out of bed or has been removed from bed, or has somehow fallen from bed in the night.

On April 7, 2017, Violet Lucas was found dead with her head wedged between her mattress and her bed railing, her body slumped down on the floor. Son Derek Lucas is still waiting for answers. JEAN LEVAC / POSTMEDIA NEWS

But both alarm systems were useless because staff didn’t use them properly. The alarm systems weren’t mounted properly and the wrong batteries had been used, according to an inspection report.

Another failing revealed in the inspection report is that patients in beds with railings weren’t evaluated beforehand to assess and “minimize risk.”

On the night Lucas died, nursing staff wouldn’t have been alerted because the alarms weren’t working, she hadn’t been evaluated for a railing bed, and staff had failed to ensure her plan of care was fully up to date, according to the report. (Lucas also had a new mattress that had not been tested for use with a bed-railing system.)

After Lucas died, inspectors examined the bed rails used by 50 residents at the facility and found that 13 of them had to be tightened.

The circumstances leading to her death have left her family heartbroken, and in the name of his mother, Derek Lucas wants a full airing of how she was failed.

“People in nursing homes are our mothers, fathers, uncles, aunts, grandmothers, and grandfathers. They aren’t numbers on a balance sheet, They are people, and people deserve to be treated with the care and respect we expect others to treat us,” Derek Lucas said.

“My mother was let down, I was let down, and as her primary responsible caregiver, I feel I let her down.”

He said the staff seemed considerate and caring, but now he wonders how competent they were if they couldn’t even figure out which batteries to use.

“While the staff made it feel like things were going so well over the years, I had no idea that, in the background, there were systematic issues with simple things like making sure batteries were replaced in critical aids like bed alarms,” he said.

He says he can’t help but wonder whether his mother struggled to breathe, or if she called out for help. He wonders if staff could have intervened in time if the alarms were working. It was a personal support worker who found Lucas and alerted nursing staff.

Nobody wanted to put Lucas in a nursing home, but after she stopped taking her medication, it was required. She had several ailments and it was the right place for her, at least at the time.

When her family first visited her, she’d be waiting for them at the front door hoping they’d come to take her home.

They did everything possible to make her laugh and always brought her a decent cup of coffee and made the best of it. They fed the squirrels birdseed in the garden. Lucas couldn’t really put words together at the time, but the look on her face was priceless, recalled her daughter-in-law, Donna Lucas.

The odd Big Mac helped, too.

But there was no getting away from the sadness of seeing this proud and dignified woman, once filled with laughter, now in a home, quiet and ailing, and no longer cheering on her beloved Green Bay Packers.

“Each time I visited her I could see her declining more and more and it broke my heart each time,” Lucas’s youngest daughter, Patricia Sweet, said.

Derek and his ex-wife, Donna, last visited Lucas on April 7, just hours before she died. As usual, they brought coffee but Lucas didn’t seem to be herself that day. Staff were getting ready to get her out of bed for supper and they didn’t want to be in the way, so they said goodbye, and said they’d be back the following day. And they hoped she’d be better. Derek got the call that night.

He, like the rest of the family, is waiting for the coroner’s investigation to conclude with the hopes of learning more details about his mother’s death.

The family has been told that she likely died of cardiac arrest but has not been given more details, notably whether she went into cardiac arrest before or after her head became wedged between the mattress and bed railing.

The Ministry of Health and Long-Term Care said that beyond its inspection report, it will not comment on Lucas’s case.

Extendicare Laurier Manor also said it couldn’t comment on the case.

“At Extendicare Laurier Manor, the safety of our residents is of paramount importance to us. In this case, due to privacy regulations, we are not able to discuss the specifics of this case,” Jennifer Cummins, the home’s administrator, said in a statement.

Lucas’s death is not the first incident that has prompted ministry inspectors to examine the facility.

A Citizen review of ministry inspection reports over the five-year period from 2012 to 2016 at Extendicare Laurier Manor reveals the home has been found non-compliant 83 times. That number leaps to 108 when available data from 2017 are included. 

A facility can be found non-compliant for a number of reasons, ranging from a mild infraction — a failure to offer patients a snack in the afternoon and evening, for example — to something much more serious, like a failure to prevent staff-on-patient abuse. 

When it comes to abuse, the Citizen’s audit shows that since 2012 there have been at least 15 incidents of reported neglect or patient abuse — either sexual, physical or verbal —  that have led to a non-compliance order being issued against the facility. 

At city-run facilities — which officials have said may face systemic problems — there are far fewer incidents of non-compliance or patient abuse. In fact, when compared with the Citizen’s audit of city-run facilities, Extendicare Laurier Manor has dozens more non-compliance citations than any single city-run home. And the city’s four long-term care homes only had four more instances of patient abuse than Extendicare Laurier Manor had on its own.  

Of the 15 incidents, nine involved reported staff-to-resident abuse while five involved resident-on-resident abuse.

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