Pearl Malamud Mendelsohn, 90, was living at the Lev-Tov seniors' residence in the Montreal neighbourhood of NDG at the time of her death.
She died Jan. 23 after receiving second- and third-degree burns to 10 per cent of her body when she fell onto the heater and couldn't get up.
She was barely conscious when she was discovered by residence staff. Mendelsohn was taken to Hotel-Dieu hospital, where she died a few hours later.
Coroner Paul G. Dionne, who filed his report this week, criticized staff for moving her bed closer to the heater just days before her death.
Mendelsohn's son, Lawrence Mendelsohn, said they moved the bed to make it easier to care for the patient. The space between the bed and the wall was about 10 centimetres.
"Once that happened, she was wedged in. There's no way she could have [escaped]. She didn't have the strength to lift herself up at all," he said.
Mendelsohn said that when Lev-Tov staff moved her bed, they also moved her away from the emergency call button.
In his report, Dionne suggested moving the bed to keep Mendelsohn from repeatedly falling out of it was "not the best way to protect her."
Resident needed long-term care
Lev-Tov falls under the jurisdiction of Montreal's Maimonides Geriatric Centre. The centre rents out space at two seniors' residences for elderly people who don't need as much medical attention as those in long-term care facilities like Maimonides operates in Côte St-Luc.
The coroner's report said Mendelsohn should have been moved into a long-term-care facility weeks before her fall. It also recommended the Maimonides Geriatric Centre do more to ensure that the residences it operates are safe.
Amy Fish, director of quality and multidisciplinary services at the Maimonides Geriatric Centre, would not comment on specific cases, but says the coroner's recommendations are being taken very seriously.
"In general, any time we receive recommendations from an outside body, we take them very seriously and any recommendations are immediately implemented," she said.