Confusion and Indecision about how to Deal with "untouchable" Doctor
"Despite significant and documented complaints of serious disruptive behaviour problems and infrastructure of the Hospital Policies and bylaws by Dr. Daniel in the Spring of 20054, there seemed to be much confusion and indecision as to how to deal with this physician." (Coroner's Jury Recommendations, p. 2)
Long History of Disruptive Workplace Violence not considered in his re-appointment
"Relevant behaviour issues and complaints were not identified during Dr. Daniel's re-appointment process at the hospital. There were multiple complaints from the nurses regarding Dr. Daniel's disruptive behaviour starting in 2000 which included damage to equipment, fracture of a nurse's left ring finger, verbal abuse unprofessional behaviour in front of patients and refusal to work with a specific nurse." (Coroner's Jury Recommendations, p. 3)
Assessment of doctor's readiness to return to work based solely on his own word
"Marc Daniel returned to work following the assessments of the PHP (Physician Health Programme) and his treating clinicians. Their letters of recommendation to return to work were based only on their interviews with Marc Daniel. There was no documentation of consultation by PHP with any of the OR nurses, the Hospital Administration or Lori Dupont." (Coroner's Jury Recommendations, p. 5)
Confusion about how to file a complaint or to address the situation
"It seemed like several people approached their supervisors or talked amongst themselves at the hospital regarding Lori's situation, as well as other incidents of Marc Daniel's abuse and harassment. However, it seems that several people were uncertain how to go about filing a complaint or addressing the situation effectively within the realms of the workplace code of conduct." (Coroner's Jury Recommendations, p. 6)
Depression not viewed as a lethal risk factor for Lori Dupont
"Dr. Daniel's depression did not appear to be viewed as a lethal risk factor for Lori Dupont. Through the evidence presented, the jury has learned that mal depression can be a high risk factor for domestic homicide. There seemed to be a focus on treating and managing Marc Daniel's mood and depression without dealing with his attitudes about women, relationships and abusive behaviours. (Coroner's Jury Recommendations, p.7)"
Doctor's drug theft/misuse goes unchecked
"The evidence presented through Ms Iovino-Hopper regarding Lori's discovery of drugs and syringes in Marc's car, the responding EMS workers' discovery of drugs and syringes at Marc's final suicide attempt, Lori's mother's evidence regarding drugs and syringes found at Marc's first suicide attempt, and head of security's discovery of 30 syringes in Dr. Daniel's locker after his death."