'Our hearts were broken, just shattered': recalling deadly mix-up at former Sudbury hospital

After months of complicatedtestimony and finger pointing, in the spring of 1974, the inquest into 23 patients who may have been killed by mixed up gas lines at the former Sudbury General Hospital, narrowed it down to nine.

JacquelineDupuiswas relieved to see her sister Suzanne's name on the list.

The 16-year-old had triedto kill herself in June, 1973by taking too many of her dad's pain pills. She then had second thoughts and asked her mother to take her to the hospital.

She never walked out.

During the inquest it had been argued that she died of a drug overdose and not due to a deadly blend of nitrous oxide and oxygen in the mask that was applied to her face.

"The thought of her dying because she committed suicide was more than we could bear," said JacquelineDupuis, now 64. "Because we knew her as such a wonderful person. I couldn't take it."

Jacqueline Dupuis said her sister had found out she was pregnant and feared how her strict father, who worked at the Copper Cliff smelter, would react.

Her parents and six other brothers and sisters never fully recovered from Suzanne's death and are stalked by addictions to this day, Dupuis said.

"Our hearts were broken, just shattered."

She married the same year as the inquest, and in 1975, returned to the general hospital to give birth to her daughter.

"I was totally petrified that they were going to kill me too," Dupuis remembered.

"I kept saying to my husband 'don't let them put any masks on me. Don't leave my side. Don't leave the baby's side.'

"I knew it was probably not going to happen again," she continued. "But they killed my sister. And that's how I look at it. I don't look at it as an accident. I look at it as neglect and negligence."

Dupuis said she thinks of her sister often, especiallynow that's living with terminal cancer.

"She's going to be at the gates waiting for me. I can't wait to see her, but I'll wait," she laughed, who, despite her diagnosis, is planning to get married next summer.

Morning North5:39The Folo: remembering the deadly gas line mix-up at a Sudbury hospital

Sudbury's Jacqueline Dupuis remembers her 16-year-old sister Suzanne, who was one of 9 people killed by mixed-up gas lines at the Sudbury General Hospital in 1973.

What happened?

A new wing at the hospital was added over the winter of 1972-73, with the first patients being admitted to the new emergency rooms in May, 1973.

Over the next five months, there were 23 suspicious deaths that would eventually be the subject of a coroner's inquest.

It was called following the death of Catherine Dominic, 6, in September, 1973. The Dowling, Ont. girl broke her arm falling off a swing, but died on the operating table after an oxygen mask was put on her face.

Over three long months of testimony, the hospital's lawyers argued that most of the cases were not related to the improperly installed gas lines.

Some blamed the hospital, others pointed the finger at doctors and nurses who didn't test the gas before hand, but most of the focus was on the contractor and architect hired for the $6 million project andthe flawed schematics for the gas system that werefollowed during the construction.

In the end, no specific fault was assigned.

"It is safe to say that many of those involved only gave 75 per cent. Which was not enough," coroner Ross Bennett said at the inquest.

The inquest jury concluded that at least nine of the deaths were directly connected to the gas problem:

• RichardLagrandeur, 3, ofGarson,near drowning.
• Andrew Solomon, 54,Wikwemikong, cardiac arrest
• GervaisAlbert, 75, Sudbury, stroke
• Catherine Dominic, 6,Dowling, broken arm
• SuzanneDupuis, 16, drug overdose
• AnnaBihum, 68,Sudbury, cardiac arrest
• HilmaLehto, 72
• AlinaJacobson, 55,Walden,shortness of breath
• RandolpheFreake, 16,Agincourt, cut his leg during visitto Sudbury

The CBC television program Newsmagazine, hosted by Lloyd Robertson, did an episode on the Sudbury inquest. It aired in March, 1974, before the jury had ruled and the lawyers for the hospital argued they should be barred from watching it.

The coroner said he didn't have the power to enforce that kind of restriction on them.

Here is the audio from that program:

Morning North18:08Archival Tape: deadly gas line mix-up at Sudbury General Hospital

The audio from the CBC TV Newsmagazine in March 1974, hosted by Lloyd Robertson, covering the deadly gas line mix-up at the hospital and the months long inquest into the deaths of 23 people.