Donald Darrell Mesheau is identified in a news release issued by the Department of Justice and Public Safety on Tuesday as the patient who died while waiting for care on July 12, 2022.

The father of two and grandfather of one was about 78, according to his obituary.

No details about the patient, including his name, or the circumstances surrounding his death have previously been made public.

But witness John Staples told CBC the man, a senior, had been waiting alone in a wheelchair, in visible discomfort, for hours when he appeared to fall asleep. It was only during a routine check of people in the waiting room that a hospital employee realized the man had stopped breathing, Staples said.

Mesheau's death prompted a major shakeup of New Brunswick's health-care leadership. Premier Blaine Higgs fired Horizon president and CEO John Dornan, dropped Dorothy Shephard as health minister, replacing her with Bruce Fitch, and removed the boards of both Horizon and Vitalité, installing a trustee for each health network instead.

The inquest will be held May 29 through June 2 at the University of New Brunswick law School in Fredericton.

The presiding coroner and a jury will publicly hear evidence from witnesses to determine the facts surrounding Mesheau's death. The jury will have an opportunity to make recommendations aimed at preventing deaths under similar circumstances.

'Bright light' is missed

Mesheau was "was a bright light wherever he went," according to his obituary. "His pockets were never without treats for any dog that came his way, or without a crossword puzzle to enjoy over coffee with friends."

He is described as a world traveller and storyteller, an avid historian, lifelong learner and mentor.

Mesheau acted in plays and musicals all his life and was learning how to play the ukulele for an upcoming theatrical performance at the time of his death.

He was a diplomat in the Canadian foreign service posted in Canadian embassies in Rome and Tel Aviv, and was an executive civil servant in the Canadian Federal Immigration Department, assigned to offices in Buffalo, Ottawa, and Halifax, according to his obituary.

He served in the Canadian naval officer training program, and on the boards of several charitable organizations.

His family was his joy, it says. "We loved him and we will miss him."

Working to improve flow, patient experience

The Department of Health is aware the inquest has been called and will review the findings once it's concluded, said spokesperson Sean Hatchard.

"Over the past year, there has been increased effort by the regional health authorities (RHAs) and all health-care partners to work together to address the challenges facing our system and to improve services for New Brunswickers," he said in an emailed statement.

There were 17 admitted patients in the ER that night and 29 registered patients in the waiting room, according to documents obtained by CBC News through a right to information request. (Joe McDonald/CBC)

Horizon and Vitalité health networks are both working to "improve flow and the overall patient experience" in emergency departments, Hatchard said.

"Initiatives include the introduction of patient monitors and mental health and addictions social workers to emergency departments and a patient flow program. The Department of Health supports those efforts."

Asked for comment, Horizon spokesperson Kris McDavid replied, "Will reach back out if we have anything to add." Nothing was provided by the end of the work day.

Horizon review leads to 8 recommendations

Horizon has previously declined to comment on its internal review of Mesheau's death, which led to four "direct" recommendations and four "indirect" recommendations, which are defined as concerns "that would not have prevented the incident but are important for patient/staff safety."

The findings have been communicated directly to the patient's family, and Horizon "has nothing further to add," Steve Savoie, administrative director and co-lead of emergency services, has said.

Among the recommendations was to "identify and implement a strategy to ensure all waiting room patients are reassessed according to the [Canadian Triage and Acuity Scale] reassessment guidelines."

Nurses were doing double duty

The licensed practical nurses who were assigned to check on patients in the ER waiting room the night Mesheau died were also assigned to other tasks and "could not commit to regular checks," internal documents obtained by CBC News through a right-to-information request revealed.

The nurse-to-patient ratio the day Mesheau died was "alarmingly high and unquestionably … unsafe," according to local representatives of the New Brunswick Nurses Union.

There were 17 admitted patients in the ER and 29 registered patients in the waiting room, according to the 147 pages of Horizon Health Network documents.

Savoie, then-regional director of medical device reprocessing and patient flow improvement, outlined to interim CEO Margaret Melanson issues with monitoring patients in the ER waiting room.

"Due to short staff, ED staff will not be able to reassess and monitor patients at targeted interval times, causing risks if patients suddenly deteriorate," Savoie wrote.

Large hospitals should have two triage nurses per shift, but often operate with only one, increasing the likelihood that patients will wait longer to be triaged during peak times. "Not knowing the reason why patients are waiting is a significant safety risk."

The three other key recommendations from the Horizon review were to:

• Develop a regional policy to establish a standardized process for the triage of a patient who arrives via Ambulance New Brunswick, including times of hospital overcrowding.
• Create a standardized patient flow process to mitigate risk of health decline and facilitate [Canadian Triage and Acuity Scale] level 3 patients through the [emergency department] by enabling pre-investigation workup prior to seeing a health-care provider.
• Establish a regional policy that identifies the criteria and process to facilitate transfer of non-urgent admitted patients who are being "boarded" in the emergency department until an inpatient bed becomes available during ER overcrowding.

An inquest is a formal court proceeding that allows for the public presentation of all evidence relating to a death. The New Brunswick Coroner Service is an independent fact-finding agency that does not make any finding of legal responsibility.