Report on deaths in CHSLDs: the coroner flays Daniel Paré and the CISSS

A Radio-Canada investigation in the spring of 2020 revealed that several cases of abuse and unsanitary conditions had been taking place for several years at Manoir Liverpool, a RPAprivate residence for seniors of Lévis which was then under the control of the CISSSIntegrated Health and Social Services Center of Chaudière-Appalaches.

The CEO at the time, Daniel Paré, reiterated that he was never made aware of the physical and organizational abuse that was rampant at Liverpool Manor. An independent investigation would conclude that there was a “break in communication” that could explain this ignorance on the part of the managers of the residence.

The Liverpool Manor, in the summer of 2020 (archives)

Photo: Radio-Canada / Guillaume Croteau-Langevin

But in her 200-page investigation report into deaths in residential settings during the first wave of COVID-19, coroner Géhane Kamel casts doubt on the version of events of Daniel Paré and the CISSSIntegrated Health and Social Services Center.

It is also hard to believe that this situation took them by surprise and that no systemic controls were put in place.she wrote. How is it possible that no one knew?

Coroner Géhane Kamel (archives)

Photo: Radio-Canada / Daniel Coulombe

She blames the ex-CEOCEO to have delayed in intervening despite repeated requests for help from the owners of the residence, which endangered the safety of the residents. Moreover, she also believes that the CISSSIntegrated Health and Social Services Center did not take the appropriate measures given the urgency of the situation.

It is therefore surprising to hear the CEOCEO who was in office at that time [M. Paré] endorse accompanying and support measures over such a long period without being aware of the seriousness of the alleged measureswrites the coroner.

Daniel Paré was appointed director of the provincial COVID-19 vaccination campaign in the winter of 2020, before his appointment as deputy minister in March 2022.

Photo: Radio-Canada / Ivanoh Demers

Without the Radio-Canada report, the situation could have continued, she believes.

Remember that the Liverpool Manor was recently bought by a new owner and has since changed its name.

the CISSSIntegrated Health and Social Services Center de Chaudière-Appalaches would not comment on the case before the official presentation of the coroner’s report, which should take place later this week.

Coroner Géhane Kamel, Minister of Health Christian Dubé and the Ministry of Health and Social Services refused our interview requests.

preventable death

The coroner also concludes that the death of Jacques Levesque at the Manoir Liverpool, in Lévis in April 2020, could have been avoided.

Jacques Levesque died suddenly in unclear circumstances at Manoir Liverpool a few days after this photo.

Photo: Isabelle Levesque

Mr. Levesque died of oropharyngeal suffocation in the private residence for seniors in Lévis.

Géhane Kamel indicates that Mr. Levesque could have been saved from certain death if the nursing staff had applied the appropriate measures, in particular the Heimlich maneuver followed by adequate cardiac massage.

The coroner also believes that this death could have been easily avoidedsince his death took place in front of the staff, who should have known how to react in such a situation.

In particular, she recommends a clear and well-taught protocol at Liverpool Manor. She also recommends better training, since the investigation shows that many beneficiary attendants had no general training.

With information from Alexandre Duval, Félix Morrissette-Beaulieu and Audrey Paris.