‘There was no one to see the big picture,’ says coroner in Herron’s investigation

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Coroner Géhane Kamel had slept poorly on Wednesday night, announced Thursday when he opened what was scheduled to be the last day of hearings on the 47 deaths at Résidence Herron during the first wave of the COVID-19 pandemic in 2020. .

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Disturbed by the conflicting testimony she has heard since the investigation into the deaths at the Dorval Private Long-Term Care Facility (CHSLD) began on September 7, she is adding three days of hearings, October 25-27, and removing at least four witnesses. . She did not name them, but wants to “challenge” them about the information they provided in their testimonies.

“I had the impression of leaving with many questions and half answers or answers that did not satisfy me,” he said. “If I were one of the families affected by this tragedy, I would leave with so many questions, and that is the opposite of what we should be doing. We must shed at least a minimum of light on all this for them. “

The role of a coroner’s investigation is not to seek “absolute responsibility on the part of one party or the other,” Kamel said. “What we are looking for is the truth.”

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And in Herron’s file, he is under the impression that “the truth is random” because the witness accounts of events often contradict each other.

When officials from the West Island health authority, CIUSSS de l’Ouest-de-l’Île-de-Montréal, entered Herron on March 29, having placed the facility under guardianship, they found many residents without food, dehydrated and lying in their own urine and feces.

Even before the pandemic, the facility, with about 140 residents, was understaffed. On the night of March 28, word spread among staff that “the virus was in the building” and that a resident had died in the hospital the day before and, according to some witnesses, employees left the Herron en masse. Kamel told the investigation Thursday that he will see video tapes from surveillance cameras at the Herron from March 27 to 29.

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Witnesses, including Samantha Chowieri from Groupe Katasa, the company that owned and operated Herron until it closed in November, described a chaotic scene in which staff were short and widespread confusion reigned.

“The government does not have clear rules when it puts a place under fiduciary administration,” he told the investigation on Thursday. “There has to be a person in charge,” he said. “A fiduciary administration should not be left in the hands of CIUSSS without a clearer structure.”

Kamel said more than once this week that there was “a black hole” in the Herron between March 29 and April 10. “Even from CIUSSS people, we get incomplete responses,” he said. “There was no one who saw the big picture.”

For Christiane Boucher, one of several children of Herron residents who died during that chaotic period and who addressed the investigation Thursday, “a system that was supposed to help my father kill my father.”

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There was “a disconnect with human care to the end.” The pandemic, he said, simply “exposed the fact that the system is broken.”

Before the pandemic, Denis Boucher was immobilized in his bed at night due to understaffing and over-medicated, he said.

For hearings to lead to change so that a dire situation like the Herron does not recur “would mean a complete overhaul” to introduce proper communication, accountability and a universal emergency plan that all branches adhere to. of the health care system, Boucher said.

All long-term care facilities must be nonprofit, he said, “and workers must be heard: they are at the center of the action.”

Tina Gurekas’ mother, Olga Maculediciu, was a grandmother and great-grandmother, someone who had a career in dietetics and lived a productive life, and when she died at the Herron, her belongings were sorted out or discarded.

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“We are angry and disappointed that the system did not take care of her,” Gurekas said, describing “a complete lack of communication and coordination” at Herron. He said staff communication with families ceased after visits stopped shortly after the pandemic was declared on March 11, 2020, and did not resume once CIUSSS took over.

The government needs better oversight of for-profit long-term care facilities, a partnership between hospitals and nursing homes, and a province-wide disaster plan, Gurekas said,

“After nearly three weeks of hearings, we don’t know what happened between the time our father entered Herron on March 27 and when he died on March 29,” said Peter Barrette. “No one seems to have seen it.

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“We know that the situation was chaotic. Why did they accept a new resident when they knew they couldn’t take over? “

Barrette said he and his family “deplore the fact that no criminal charges were brought” in connection with the deaths at CHSLD Herron.

As a means of care, a CHSLD must have rigorous and structured care, he said, with staff guaranteed a fixed number of hours to prevent them from going from one center to another.

Barrette favors the nationalization of all CHSLDs and the creation of “a public network that aims not to provide profit to owners, but to provide human care to people in the last days of their lives.”

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