MONTREAL -- A coroner hearing testimony about the situation at a suburban Montreal long-term care home where 47 people died during the first wave of the COVID-19 pandemic said Friday she was shocked at how long it took to get proper help to residents.

Gehane Kamel made the comments after hearing from a nurse who arrived at Residence Herron on April 9, 2020 with a team of a dozen nurses she'd recruited herself, nearly 10 days after regional health officials had seen the dire situation first-hand.

Before then, managers at the regional health authority serving western Montreal had been helping out at the severely understaffed private long-term care home, but only a few had formal nursing training.

Kamel questioned how it could have taken so long for qualified nurses to arrive at the Dorval, Que., home.

"I am feeling a little appalled," she said. "On April 9, it had been nearly 10 days that it was known that those people were slowly dying. As a society, we abandoned them."

Asked why it took so long to deploy frontline staff to the Herron facility, nurse Marie-Eve ​​Rompre said her bosses had told her they did not have the authority to formally manage the privately owned care home and fully take charge.

​​Rompre, a nurse from St. Mary's Hospital in Montreal who organized the team to help at Herron, was emotional on the stand, sometimes in tears.

She recounted that after only four hours at the site, several nurses wanted to leave and were completely demoralized. And some of the issues at Herron predated the pandemic.

She described one resident who came to her with dirty clothing, and when she suggested a bath, the resident asked if there would be a towel available. In consulting the files, Rompre found that every week since December 2019, a notation of "no towel available" was entered when the resident was supposed to take a bath.

Rompre also recounted seeing an unconscious, hypothermic resident in a room. At the same time, the room phone rang and it was the woman's husband. The nurse awakened the woman, who opened her eyes and started to cry when she recognized her husband's voice. The resident told her husband that she didn't think she would survive, and she was later transferred to the hospital where she died.

Later Friday, the head pharmacist for the regional health authority, Helene Paradis, described a disorganized pharmacy at the residence.

She had to clean it up because nurses who had been sent to help couldn't find the needed medications. Paradis said she found drugs from 2016 and 2017 and in one case, from 1994.

Paradis said she found vials of opened insulin and drugs that were encased in the frost of the freezer. Narcotics were improperly stored and there was no medication count.

"You are describing dangerous practices," said coroner Dr. Jacques Ramsay, who is assisting Kamel.

After cleaning up, Paradis said she had to get rid of the equivalent of a dozen large trash bags of medicine.

Kamel's probe is examining 53 deaths at six long-term care homes and one seniors residence during the pandemic's first wave.

-- This report by The Canadian Press was first published Sept. 10, 2021.