‘People passed the buck’ as seniors died at Herron CHSLD, coroner says

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Quebec broke its “moral and societal contract” with citizens by letting vulnerable seniors die in its long-term care centers during the pandemic’s first wave, a coroner said on Thursday.

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And at Dorval’s Herron CHSLD, where 47 people died in often appalling conditions, coroner Géhane Kamel said authorities at every level failed residents and their families.

“People failed. Be it the owners, the local health authority, or the ministry. That much for me is undeniable. People passed the buck,” Kamel said. “Everyone wrote to each other, there were a lot of emails exchanged. But during that time, people were dying.”

Kamel led the public coroner’s inquiry into the deaths inside Quebec’s long-term care centers, known as CHSLDs, during the COVID-19 pandemic’s first wave.

After releasing her 200-page report earlier this week, she detailed her findings during a news conference Thursday.

Overall, the inquiry focused on 53 deaths from four public long-term care centers, two private ones and a private seniors’ residence. It heard from more than 200 witnesses, including health professionals, ministers and family members of the deceased.

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Using what happened inside the homes as an example, Kamel painted the province’s health network as so weighed down by bureaucracy and disorganization that it was incapable of reacting with the flexibility needed when the pandemic struck.

And while it was well documented CHSLDs were facing staff shortages and other challenges long before the pandemic, Kamel said, the situation was never properly addressed.

Combined with the government deciding to focus on securing hospitals instead of CHSLDs early on, Kamel said the centers became an easy target for the virus.

“COVID-19 took these already fragile long-term care centers by assault,” Kamel said. “Our most vulnerable seniors were kept in our government’s blind spot.”

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Nearly 4,000 people died in Quebec’s long-term care homes during the first wave. In many cases, the report details, the situation became so hectic that deceased residents were left in their rooms for 24 hours before being brought to a funeral home.

On a personal level, Kamel said some of the testimony heard during the inquiry was so devastating, especially in terms of the lack of care provided to dying residents, that it was impossible for her not to be both saddened and angered by it.

Kamel said of the 53 deaths investigated, the ages of the deceased ranged between 60 and 95. But in her report, she explained, she purposely left out specific ages to fight back against how she feels society has downplayed the elderly dying throughout the pandemic.

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In speaking about the Herron, Kamel was also highly critical of Lynne McVey, chief executive of the regional health authority that covers western Montreal. The health authority has since announced McVey will be leaving her position this summer.

The coroner was also critical of Daniel Paré, who was the director of the regional health authority in Chaudière-Appalaches before later heading Quebec’s vaccination campaign.

Though alarming details about unsanitary conditions at a seniors’ residence on his territory were revealed, Paré told the inquiry he wasn’t aware of it.

Kamel stopped short of saying she thought Paré lied during the inquest, saying she trusts his testimony was in good faith. But she reiterated she believes it’s impossible he wasn’t aware of what was going on.

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In all, Kamel made 23 recommendations. Among them were that Quebec’s public health director be more independent, that the province increases at-home care for seniors, and improve staff-to-resident ratios in CHSLDs.

In a statement issued Thursday, Quebec Health Minister Christian Dubé and Seniors Minister Marguerite Blais said they welcome the report’s findings. The government noted it considers several of Kamel’s recommendations have already been implemented.

Asked whether she believes a public inquiry on Quebec’s handling of the first wave is necessary, as many have called for, Kamel said it wasn’t in her mandate to decide whether an inquiry should take place.

But she did say she hopes her report can spur change in the way Quebec treats its elderly moving forward — and, especially, that it will push the government to ensure a similar tragedy can never happen again.

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“Unfortunately,” Kamel said in closing, “history will remember that in Quebec, it was the elderly who paid the highest price during the first wave of COVID-19, an insidious disease with dramatic consequences.”

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