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The Manoir Liverpool assisted-living facility had trouble following doctor-prescribed protocols for a diabetic resident who died during the first wave of COVID-19, according to testimony Tuesday at a coroner’s inquest into deaths in Quebec care homes during the pandemic.

Coroner Géhane Kamel is looking this week at Manoir Liverpool, near Quebec City, focusing on one representative case, the death of resident Jacques Levesque.

Mr. Levesque wasn’t getting the right dosage of insulin, and it is possible that on the day he died the attending staff didn’t follow the protocol to deal with his low blood sugar, his doctor testified Tuesday.

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The inquest also heard that many fear-stricken employees deserted the facility mid-shift when they learned that residents had tested positive to COVID-19. “Panic took over the personnel. People were extremely scared, what with all that was being reported in the media,” Micheline Beaupré, a supervisor, testified.

But even before the pandemic, the care was problematic, Mr. Levesque’s son told the inquest.

The 60-year-old Mr. Levesque suffered from many ailments, including diabetes and liver and kidney problems. His April 26 death was ruled to have been from choking on food but the inquest heard concerns about how Manoir Liverpool handled his diabetes.

Nicolas Verreault-Levesque said his father told him he once stopped an agency worker who was about to inject him with a wrong dose of insulin.

Mr. Levesque’s physician, Diane Cusson, testified that she spotted a discrepancy between the insulin scale she prescribed and Manoir Liverpool’s medical files, meaning that her patient was getting too much insulin.

Relatives were distressed by the numbers of times Mr. Levesque had hypoglycemic incidents. He would get agitated and unco-ordinated, once even breaking a leg. This problem never seemed to happen during his hospital stays.

Despite these issues, the family didn’t protest because they were in the process of getting Mr. Levesque transferred to a long-term care centre. “I didn’t want to file a complaint if I couldn’t follow up on it,” Mr. Verreault-Levesque said.

After the outbreak started on March 24, agencies didn’t want to send staffers because they couldn’t reassign them elsewhere after they had worked in a ward with COVID-19, Ms. Beaupré said. “So for sure, it was getting critical.”

A nutritionist testified that she found residents severely underfed and dehydrated after they had been confined to their rooms without help to eat their meals. She also learned that the kitchen’s food processor didn’t work well so they couldn’t serve properly puréed food.

She said one woman she was helping was so dehydrated she eagerly gulped down two glasses in front of her. “You rarely see that in an elderly person.”

Both the nutritionist, whose name is under a publication ban, and Dr. Cusson, questioned how Mr. Levesque’s hypoglycemia was handled before he died.

He wasn’t feeling well and had a low glycemic level so a staffer gave him the hormone glucagon, peanut butter on toast, orange juice and white cheese.

“That literally didn’t follow the protocol that we wrote down [if he had hypoglycemia],” Dr. Cusson testified. She said he was supposed to get Insta-Glucose, a fast-acting sugar.

The nutritionist said she left instructions that it was only after a resident’s glycemic level was back to a higher level that they should be given a combination of sugar and protein, for example milk and cookies or peanut butter and bread. “A toast with peanut butter would probably slow the process to increase the sugar level because of the interaction with the protein,” she said.

François Pinard-Thériault, a lawyer representing Manoir Liverpool owners Claude Talbot and Manon Belleau, said that an Insta-Glucose tube could be seen next to a photo of Mr. Levesque’s body, suggesting that he had been given the sugar gel.

The staffer who attended after Mr. Levesque that day is scheduled to testify Wednesday.

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