In January, Heather Insley spent three excruciating days at Ottawa’s Montfort Hospital, watching her eldest son die.

Insley and her family mourned his death, honoured his wishes as an organ donor and agonized over funeral details.

Then, on the same day he was cremated, she received a text message from an unknown number. It was someone claiming to be her dead son and asking for money.

In disbelief, Insley called her husband Bill who assured her the text was just a “sick joke.”

We plannedthe funeral.I never knew what it would feel like to lose a child, and it was awful.– Heather Insley

Then, a few days later, she received another text. Insley dialled the number on her screen and asked for her son. Suddenly, a voice that sounded just like his came on the line.

“We were freaked,” Insley said.

But it was him, and in the days that followed, with the help of Ottawa police, the couple managed to track him down.

When he answered the door, Insley said she went numb.

“I thought, oh my God, your funeral’s tomorrow,” she recalled. “I thought, I’m so happy he’s alive, but I just went through all that mourning.”

But if her son was alive, who was the man in the hospital bed?

‘Lazarus Sean’

CBC spoke briefly by phone with Insley’s son Sean Cox, who confirmed details of this story.

The 43-year-old said he’d had no idea about the confusion at the hospital, and said learning about it from his parents sent chills down his spine.

Cox said he’s now determined to live a different kind of life.

“I feel like I’d been given a second chance,” he told CBC.

A man wearing a backwards hat and a blue polo shirt is shown in what appears to be a restaurant.
Sean Cox is shown in this photo his mother took several years ago. The 43-year-old said he feels as though he’s been given a second chance after he was misidentified as a patient who died at Ottawa’s Montfort Hospital in January. (Supplied by Heather Insley)

The miraculous reunion marked the first time in more than four years mother and son had seen each other. Insley said Cox struggles with addiction, frequently changes his address and only communicates with her sporadically.

The family had always feared receiving a call like the one they got from the hospital on New Year’s Day, but they never anticipated it would be a tragic mistake, or that they’d hold vigil at a stranger’s bedside.

Today, Insley lists her son as “Lazarus Sean” in her phone contacts — for her, a bit of dark humour in an attempt to cope emotionally with what happened.

Mistaken identity

Martin Sauvé, the Montfort’s director of communications, confirmed to CBC that officials were notified around Jan. 19 of the “misidentification of a patient” who had been in the hospital’s intensive care unit but died days after admission.

“True identity of the deceased patient has since been confirmed. The families involved have been informed,” Sauvé wrote in an email to CBC. “We offer our most sincere condolences to the loved ones of the deceased patient, and offer our apologies to both families involved for the distress caused by this situation.”

Sauvé said support is also being offered to hospital staff involved with the case. He said the hospital is taking the situation seriously and is coordinating a review into what happened.

He declined to answer follow-up questions about how the misidentification occurred or how the error was discovered, citing privacy concerns.

An older man and woman stand next to a hospital bed where a figure is surrounded by tubes and equipment. The patient's face is blurred to protect their privacy.
Heather Insley and her husband Bill stand by the bed of a patient they believed to be their 43-year-old son Sean Cox. (Supplied by Heather Insley)

Insley described the experience as an “emotionally traumatic nightmare.”

She said the family was told the man whose death they’d mourned had been found unresponsive outside the Ottawa Mission and had been on life support since Dec. 30. He never regained consciousness.

According to Insley, a nurse thought she recognized the man in the bed as Cox from an earlier hospital stay following an overdose two months earlier, and suggested staff try to reach his next of kin.

Similar features

On Jan. 1, Insley got a call from a doctor at the Montfort who told her a family member might be there in “grim condition.”

The doctor asked for her son’s birthdate and when she provided it, told her to get there as soon as possible, Insley said.

She drove the nearly four hours from her home in Picton, Ont., and entered the hospital room to find a man lying in bed, surrounded by medical machinery and wrapped in a thermal blanket. Ventilator tubes obscured the lower half of his face.

Insley said neither she nor the five other family members who visited the hospital room ever questioned whether the man in the bed was Cox.

“He had the same haircut, same thick hair, like my boy did — his long eyelashes.”

We stayed right with him, just as though he was our own son.– Heather Insley

At one point, she even noticed one of his feet had a distinctive, knobby big toe that was a genetic family trait.

Insley said she filled out paperwork for the man’s organ donation on Jan. 6.

“He was able to save three lives, two kidneys and the liver,” she explained, adding the family wasn’t asked to make any other medical decisions.

“We cried. We cried so much. It was just, it was devastating,” she said. “We planned the funeral. I never knew what it would feel like to lose a child, and it was awful.”

A woman in a red turtle neck stands next to a large window. A stained-glassed art piece spells out the word "love" below a pink and red heart.
Heather Insley is shown at her home in Picton, Ont., on Feb. 27, 2024. (Dan Taekema/CBC)

Looking back, she said there may have been clues that would have indicated it wasn’t her son in the hospital bed.

Cox has tattoos on both arms and a unique birth mark on his leg, but Insley said the other man’s limbs were concealed by the bedsheets, and no one at the hospital ever asked the family to confirm any identifying features.

“It was a grave mistake on their part and I blame myself for it … but I believed it was him without a shadow of a doubt,” she said.

‘Incredibly rare,’ says OHA

Jennifer Zelmer, CEO of independent charity Healthcare Excellence Canada, said determining a patient’s identity can sometimes present challenges, but is crucial to ensure they’re receiving the right medication, procedures or treatment.

“Identity is fundamental to safe care, making sure that you’re providing the right care to the right person at the right time,” she explained.

Zelmer said misidentification can and does happen, though she’s never heard of an experience like the one Insley went through. She stressed the need to learn from what happened to improve patient safety and ensure a similar mistake never happens again.

The Ontario Hospital Association said this type of incident is “incredibly rare.”

In a statement to CBC, the organization said it wants to “express sincere concern” for the man who died and the families involved.

A black ink hand print is shown on a phone. A woman is holding the phone.
Heather Insley looks at a handprint she asked for as a memento of her son. She said police later used the print to determine the actual identity of the man whose death she’d mourned. (Dan Taekema/CBC)

Insley said she’d asked staff at the funeral home to take hand prints of the man she believed was her son, planning to keep them as a memento.

After the misidentification was discovered, police used those prints to try to determine the true identity of the man who died, she said.

She believes the Montfort should take similar steps in the future — using fingerprints, blood work or dental records to confirm the identities of future John or Jane Does — and to save others the pain she and her family have endured

Insley said she hasn’t heard from the other man’s family and still doesn’t know who he was. With the help of Ontario’s chief coroner, she returned his belongings to the family: a lighter, an electric razor and a $10 bill.

“It was awful to think that I had lost my son, but at the same time, we showed love and everything to the other young man. We never left his side,” Insley said.

“We stayed right with him, just as though he was our own son.”

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