The circumstances surrounding the deaths of three St. Mary's Villa residents was the subject of a coroner's inquest held last week in Humboldt.
Roman Schneider, Getrude Lukan and Monica Washkosky all died within weeks of a carbon monoxide leak caused by a faulty boiler at St. Mary's Villa on Dec. 26, 2010.
The six-person jury ruled that Schneider and Washkosky's deaths were accidental; Schneider due to CO exposure, Washkosky of heart failure. The cause of Lukan's death was undetermined.
The jury also produced four recommendations: installing CO detectors at all Saskatoon Health Region facilities; monthly meetings at the health region; cross-training so maintenance workers know first aid and site managers understand the heating systems better; and improved communications policies by SaskEnergy.
Held in a small conference room at the Humboldt Uniplex March 3-7, the inquest was vaguely trial-like, even though inquest coroner Alma Wiebe was careful to point out that the purpose of it all was to seek truth, not assign blame.
Lawyers from the Saskatoon Health Region, SaskPower and SaskEnergy, along with coroner's counsel Jaimie MacLean, in her role as "prosecutor", heard from a parade of witnesses who described a night full of confusion and uncertainty.
It all began when residents in the facility's Dust Wing began to complain of nausea and headaches in the early morning hours of Dec. 26., 2010. The number of complaints was alarming to nurse Val Crone, who decided to call manager Sherry Gursky at home.
"She said something funny was going on," Gursky, the inquest's first witness, said of the conversation.
Crone, who was also called to testify, described a hectic night, with patient's buzzers going off every few minutes as a mysterious affliction swept through Dust Wing.
"It was very busy," Crone, who was visibly upset at times, said.
With no CO detectors in the building and no training to deal with such a situation, Crone and Gursky had no idea what was going on.
"I thought it might have been something viral, maybe the flu," Crone said, noting there had been a norovirus outbreak at St. Mary's only the week before.
It wasn't the flu, but that didn't become clear until maintenance supervisor Curtis Doepker arrived. Crone said it was about 4 a.m. when Doepker told her there was a CO leak. It had been about 90 minutes since Crone first called Gursky, who was anxiously waiting for someone from SaskEnergy to arrive and confirm what was going on.
According to Gursky, a SaskEnergy employee didn't arrive until about 5:20 a.m. It took about an hour to get there because the worker was coming from Watrous; Gursky mistakenly assumed someone would be coming from Humboldt. The SaskEnergy employee soon confirmed there was a CO leak, and a 911 call went out from St. Mary's Villa at 6 a.m. Many residents were sent to the hospital in Humboldt, including Schneider, who died that same night. Lukan and Washkosky died within weeks.
The CO leak originated in an aging boiler under Dust Wing's dining room. The combination of a back draft and a partially blocked vent caused a buildup of CO that spread to the ventilation system.
While the results were tragic, the need for upgrades to the boilers was well known at the time, and left some staff members very worried.
"This place is an accident waiting to happen," Crone remembered thinking in the weeks leading up to the incident.
The incident led to many changes in policy: CO detectors were installed in St. Mary's Villa the same day as the leak; CO exposure was added to the facility's Code Brown response system for hazardous spills or release; and staff were trained on the new procedures within three months of the incident. In July 2013, the Saskatoon Health Region was fined $154,000 and pleaded guilty to two charges under the province's Occupational Health and Safety Act in connection with the incident.
Nilesh Kavia, a spokesman for the Saskatoon Health Region, was also called to testify. He expressed remorse at the loss of life and the profound impact the incident had on so many people.
"On behalf of the region, and personally, I'd like to say we're really sorry about the incident," Kavia said. "When something like this happens, it's traumatic for everyone, the victims and their families as well as our staff."
Kavia stressed that the Health Region had learned from the event and had put in many new policies to ensure nothing of the sort happens again.
"We are on the right path to avoid these types of incidents in the future," he said.
Of everyone present at the inquest, perhaps no one had more personally invested than Veronica Dagenais, the daughter of Gertrude Lukan. Sandwiched in between the lawyers, Dagenais asked questions of most witnesses. Reached by phone after the inquest was over, Dagenais was comfortable with how things turned out.
"I think the jury did an excellent job," she said. "Under the circumstances the Health Region has already done a lot to correct some of the things that caused this incident. I give them credit for that."
Despite the official finding that the cause of her mother's death was undetermined, Dagenais wasn't convinced.
"I personally feel that carbon monoxide contributed to her death because of the way things happened after she was exposed," Dagenais said.
Dagenais and the other family members will never completely get over what happened that night, but the inquest did serve as a sort of final chapter to what's been a very dark story.
"As time passes, you have to come to terms with things or you'll beat yourself up about it," Dagenais said.
