The coroner investigating the tragic blaze at a seniors’ home in L’Isle-Verte, killing 32 seniors just over a year ago, said he doesn’t understand why he’s been seeing the same problems for the past 20 years.

In his report released Thursday morning Coroner Cyrille Delage blamed inadequate fire prevention and a lack of staff for the deaths at the fire at the Residence Le Havre on Jan. 23, 2014. The blaze broke out just after midnight on a particularly cold night that saw firefighters' work hampered by strong winds.

Many of the occupants in the 52-unit building were over 85 and all but a handful had limited mobility, being confined to wheelchairs and walkers.

In the L'Isle-Verte blaze, the coroner concluded that there were several simultaneous problems that made for a chaotic rescue at the seniors’ home:

  • The building was not up to code;
  • There was not enough personnel to help dependent seniors;
  • Firefighters took too long to arrive and reinforcements did not arrive fast enough;
  • Questionable decisions by local firefighters;
  • Delays in transmitting alarms;
  • And there wasn't a proper evacuation plan.

Delage has investigated many fatal fires at seniors' homes in the past 20 years and he's made similar recommendations in the past.

Lack of training

“The night of the fire, [the seniors] were left on their own to escape,” remarked Delage in his report, “while the overnight employee went to wake up the co-owner of the residence, Mrs Irene Plante.”

Delage also said Plante "managed to get out very well, but the majority of residents did not have that chance.”

The coroner heard from over 50 witnesses during the inquest who testified about serious problems, including a lack of training from employees to deal with an emergency.

Roch Bernier, the other co-owner of the seniors' home, appeared at the inquiry and confirmed that the only employee working on the night of the fire didn't know the evacuation drill.

In another testimony, the coroner heard about how the doors to the seniors' home were locked from the inside as residents tried desperately to flee the smoke and flames.

Delage was also told by one witness that by the time he saw the first firefighter "it was already too late" for those in the residence.

Building not up to fire safety codes

During the coroner's inquest. the contractor who built the seniors' residence said it did not comply with building-code standards at the time of the fire.

The home's older wing, which was destroyed, was built in 1997 and did not have an automatic sprinkler system.


Coroner Delage included several recommendations in his report, saying it was imperative to improve fire safety to avoid future tragedies.

“I don’t think it’s asking for much,” said Delage.

He said he wants to see increased security with senior's homes up to safety codes, with better trained personnel, a quicker response time to alarms, and automatic sprinkler systems.

The recommendations mainly targeted the local health care agency for the Lower Saint-Lawrence region, saying they needed to improve their certification method for seniors’ residences, such as:

  • demanding proof from a certified architect that the building is up to building codes, which should be renewed every three years;
  • requesting an assessment by competent personnel of the autonomy of seniors in the home, in case any needed to be moved to quarters better suited to their mobility;
  • checking with local fire chiefs to make sure there’s a proper evacuation plan, along with fire drill exercises;
  • establishing norms for the number of staff on site;
  • demanding from owners proof their staff have proper training for emergencies.

He also advised the Ministry of Public Security to regroup firefighter services in urban and rural areas, so they can coordinate better when responding to emergencies.

The coroner also told the Building Code Board they should make automatic sprinklers obligatory in all buildings, whether new or old.

Delage also recommended the emergency call centre to change the way they respond to calls for fires. The coroner said at least one intervention team should immediately go to the scene when a fire is reported.

Government reaction

The provincial government said it will look at the report and its recommendations, but wants to give the families of the 32 people who died time to look over the report before taking action.

"One of the recommendations is the 911 centre take the call and they ask for the firefighter right now," said Lise Theriault, the Public Security Minister.

"Please just let the families read the report, take the notice, and be sure the government will come back as soon as possible with a response."

Report recommendations

-- That Quebec's public security and municipal affairs departments encourage rural and urban authorities to centralize fire services with the goal of having a co-ordinated action plan under a common leadership.

-- That the Quebec minister of public security require municipal leaders to regularly review emergency safety plans and to provide the ministry with regular review reports.

-- That the Quebec minister of public security declare null and void the "grandfather" clause allowing firefighters trained before a certain time to be exempt from new training.

-- That the agency that enforces the province's building code require all certified seniors' homes, old and new, to have automatic sprinkler systems.

-- That Quebec's emergency call centres be required to immediately dispatch at least one team of firefighters as soon as a fire signal is sent out to central alarm bureau.

-- That the regional health agency of the Bas-Saint-Laurent region, located on south shore of St. Lawrence River, have an architect certify that buildings are up to code and are being used according to their certification.

-- That the regional health agency order building certificates to be renewed every three years and ensure that buildings aren't being used for activities for which they aren't certified.

-- That the regional health agency also receive confirmation from a building's security personnel that emergency plans exist and that employees are properly trained.


The full report on the coroner's inquiry:

Coroner's Report Into L'Isle-Verte Fire at Seniors Residence by CTV_Montreal