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When Jimmy Lee Durocher, a 17-year-old in otherwise perfect health, went into the operating room Jan. 14 at a hospital in St-Charles-Borromee, Que., his family expected it would be a routine appendix removal. But less than four hours later, Durocher was in cardiac arrest, and he would never recover.

In a report to be made public Tuesday, the investigating coroner says the death was “highly preventable,” the result of a failure by hospital staff to provide proper follow-up care after Durocher was given morphine to treat post-operative pain.

Dr. Louis Normandin, the coroner, concluded staff failed to identify his worsening condition after the morphine until it was too late.

Durocher went into cardiopulmonary arrest. Efforts were made to resuscitate him, and his heart resumed beating, but after transfer to a Montreal hospital it was determined that he was brain dead.

Normandin noted that the death was accidental, and no one could have predicted Durocher’s reaction to receiving a five milligram dose of morphine.

“Because he had not received morphine before, Mr. Durocher deserved competent, professional attention,” Normandin wrote. “The nurse who administered the morphine did not respect the monitoring protocols.”

That nurse’s failure to follow procedure influenced two of her colleagues who neglected to independently verify Durocher’s condition, which included convulsions caused by a lack of oxygen to the brain.

The hospital staff also ignored a machine Durocher was hooked up to suggesting his vital signs and condition were worsening.

“So many signs warning of the catastrophe that were not noticed, except perhaps by his mother at his bedside, who twice reported the progressive slowing of her son’s heartbeat on the monitor,” Normandin wrote. She rang the bell to alert nurses but was told to wait during a midnight shift change.

A lawyer representing Durocher’s family said what happened to the teen, who began experiencing abdominal pain after a kick to the stomach during karate practice a few days before the operation, is rare.

“Usually those medications are provided following a protocol, and the protocol indicates what should be observed, what should be managed on the patient,” said Jean-Pierre Menard. “This is well-established procedure in hospitals across Quebec.”

Normandin is recommending hospitals follow protocols for the administration of narcotics.

“The strict, systematic and generalized application to the entire health network of a surveillance protocol specifically designed to detect and reverse the adverse effects of narcotics is essential if we are to avoid the recurrence of such a tragedy,” Normandin wrote.

Menard said the young man’s parents want to ensure similar lapses don’t happen in the future.

“The goal of the parents is to bring some change, to ensure everyone respects and complies with the protocols,” Menard said on Monday. “And to avoid a repetition of such a terrible event.”

The Lanaudiere regional health authority, which oversees the hospital, said numerous changes have been made since the death.

Spokeswoman Pascale Lamy said an internal investigation took place, shortcomings were identified and corrected and the health authority co-operated with the coroner’s investigation.

There were disciplinary measures for three staff members – one of whom was fired. “You will understand that because of the ongoing legal process, we can not comment further,” Lamy wrote in an e-mail.

The family has made a formal demand seeking compensation, and Menard said they are working to settle the case.

“It’s a sad story because those things normally should not happen,” said Menard. “It has happened here because the patient was not followed properly.”

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