MONTREAL -- There was tension over who was in charge at the privately owned Residence Herron care home as a COVID-19 outbreak worsened last year, with residents and their families left on the sidelines, a Quebec coroner's inquest heard Thursday.

Coroner Gehane Kamel heard from Herron staffers that managers from the regional health authority and the residence weren't on the same page as they tried to address staffing issues, building access and a lack of equipment.

Kamel said the testimony was creating the impression "that Herron people stayed in their offices, that the (regional health authority) remained in their offices and that in the middle of all that, while there are small procedural tussles, that there are people who are dying."

Regional health officials arrived at Herron on March 29, 2020, after requests for help and equipment, but the question of who was in charge over the next two weeks has remained up in the air.

Tina Pettinicchi, who was responsible for sales at Herron before the pandemic hit, ended up helping management wherever she could as the situation became dire.

The first confirmed COVID-19 case in the home was on March 27. Front-line staff quickly began to fall ill, and replacement staff were hard to find because of pressure across the network.

Some Herron workers confided to Pettinicchi that they were afraid, and many had been told to quarantine for 14 days. One of the health authority officials who came to help on March 29, Dr. Nadine Larente, was asked to speak to kitchen staff who were afraid to distribute food trays to patients.

Pettinicchi said she distributed trays that evening to several residents herself, but said she didn't note sticky floors and soiled patients as other witnesses have testified. "I didn't see anything that was like what was described in the media," Pettinicchi said.

Kamel wondered about the differing views of the situation, noting that Larente considered the situation bad enough that she called her husband and children to help.

"The perception of what is happening in this establishment is like night and day, it's like two completely different realities," Kamel said.

Pettinicchi would stay on until April 10, and she said there were a lot of communication issues -- the care home's three doctors had trouble reaching nurses, and families often complained they couldn't get any information. She was told no information or messages could be sent to families without health authority approval.

"The families were extremely worried. Some were angry about not having information. They were living these emotions," Pettinicchi said, recounting a visit to a dying resident after the family asked her to say goodbye for them.

"There were a million things happening at the same time," Pettinicchi said. "I was overwhelmed by everything that was going on." She said she didn't feel the health authority had a plan for Herron.

Earlier Thursday, the last of the three doctors who cared for residents at Herron testified that she stayed away from the residence until April 11 because of a provincial directive to favour telemedicine for long-term care patients and because of a severe lack of protective equipment at the site.

Dr. Adriana Ionescu testified the situation was "madness" as she tried to manage patients in different facilities, all at a distance.

The three doctors at the facility entered Herron for the first time in the outbreak on the day after a media report detailed numerous deaths and poor conditions. She said it was when health officials took over that things started to turn around.

Ionescu described the period as the most difficult in her medical career.

Later, a health authority nurse who came to help manage Herron for a few weeks beginning on April 3 said she was unable to make schedules because the owners were having trouble finding personnel. Some of those sent by agencies to work as orderlies had no experience working in long-term care.

There were also difficulties in obtaining personal protective equipment and even keys to locked rooms at Herron, which she said ownership refused to relinquish until a health authority manager intervened.

The nurse, who cannot be named, choked up as she described how residents were deprived from seeing their loved ones, suggesting the government should have eased restrictions.

The coroner's mandate is to investigate 53 deaths at six long-term care homes and one seniors residence -- including 47 at Herron -- during the first wave of the COVID-19 pandemic.

This report by The Canadian Press was first published Sept. 16, 2021.