MONTREAL -- Quebec Coroner Gehane Kamel, who is investigating the deaths at the Herron long-term care home (CHSLD) in Dorval during the first wave of COVID-19, was indignant Monday that no one thought to count the deaths at the time, as if "no one is accountable."

A form called SP-3 had to be filled out when a death occurred, and the death certificates were done remotely by the doctors, since they were no longer on site in Herron at the height of the crisis.

They made the report based on information given by the nurses who were on site.

These PS-3 forms were then either put in a binder, sent by e-mail or put in a pigeonhole.

The method varied, according to the testimony heard to date at the coroner's inquest. Hence the confusion about the number of deaths.

"It's as if SP-3 is nobody's business," the coroner said Monday. "No one's compiling it. It's just people dying."

Finally, on April 10, 2020, the number suddenly jumped from 13 to 31 deaths, after a survey was requested.

-- This report by The Canadian Press was first published in French on Sept. 20, 2021.