The government of Quebec needs to ensure the role of the public health director is independent and without any "political constraint" and allow at least two caregivers to visit a loved one during a health crisis, a Quebec coroner has recommended in a final report.

Coroner Géhane Kamel's long-awaited report into the deaths of seniors in CHSLDs during the first wave of the pandemic was released Monday, with 22 recommendations targeting quality of care and emergency preparedness, among other areas.

It said seniors were severely overlooked in the province's early response to the rise of COVID-19 at the beginning of 2020.

The report looked into 53 deaths between March 12 and May 1, 2020 and includes testimony from 220 witnesses, some of whom reported "deplorable" and "shocking" treatment of the elderly when the pandemic first hit. Forty-seven of those deaths happened at the CHSLD Herron, one of the worst-hit residences by the pandemic's first wave.

"The COVID-19 crisis illustrates decades of failing public policies concerning CHSLD that were already known," wrote Kamel in her report, which is more than 200 pages long.

The hearings heard of inadequate staff, poor infection control policies, families being banned from seeing their loved ones for several days amid the outbreak, and residents being malnourished for days at a time in care homes that have been described as "war zones."

"The storm that hit us only highlighted the structural weaknesses of the network, which had

already run out of steam, and had done so for too long," wrote Kamel, warning that an aging population in Quebec will need a health-care system that can handle the demand in the near future.

She issued several recommendations for the Ministry of Health and Social Services, including "greater accountability" for long-term care home managers for the care of frail elderly people and to ensure there's an adequate supply of personal protective equipment at all times.

She also calls for the training of nursing assistants to be reviewed so that they can perform basic tasks, such as respiratory care and use of ventilators.

The lengthy report also takes aim at the provincial government in its early response to the coronavirus, saying the Ministry of Health and Social Services chose to put residents in CHSLDs "in the blind spot of preparations for the pandemic" even though officials were warned they were the most vulnerable population.

The health department met on Jan. 22, 2020 with no mention of special attention for long-term care residents. It wasn't until March 12 when a guide was sent to CHSLDs, but by then it was already 10 days after the first case of COVID-19 was detected in a care home.

"This situation alone is troubling and obviously late," wrote Kamel.

Once the virus infected residents in CHSLDs, the lack of adequate staff was a recipe for disaster and despite best efforts by staff to contain the spread, the depleted health network couldn't cope.

"During the health crisis, this glaring lack of staff (particularly beneficiary attendants and nursing assistants) and inadequate remuneration in private CHSLDs exacerbated this latent situation," the report noted. "All it took was a single breach to set the house on fire."

The fallout from not being prepared spilled outside the walls of the long-term care homes. Visits were banned except for end-of-life residents and their loved ones were kept in the dark about basic information about their health situations.

The information they did receive was often outdated and misleading.

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"It seems that at least on a few occasions these have unfortunately been deliberately misleading with the intention of hiding the horror in an attempt to induce false reassurance from concerned loved ones," Kamel's inquiry was told.

Kamel is scheduled to shed more light on her conclusions at a press conference on Thursday.


Sylvie Morin, a retired nurse who worked for 29 years in CHSLDs, testified in front of Coroner Kamel about her experience working at the Sainte- Dorothée care home, which was mentioned in the report. She said seeing the report come out on Monday made her relive the horrors she saw.

She said she raised problems with staffing levels with management, but her concerns fell on deaf ears.

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"It really makes me sad. It's something that could have been prevented … there weren't [enough] staff to take care of the people there that were dying of COVID. It was a pretty bad … I think that the decision was taken that old people would pay for that. It makes me mad," she said. "When you have to FaceTime with the family and the patient is dying there, it's really hurtful."

Other key recommendations in the coroner's report include:

  • Converting all private CHSLDs to state-run CHSLDs
  • Improving home care for seniors
  • Implement safe, professional caregiver-to-resident ratios in CHSLDs
  • Hire more managers to ensure all shifts are covered
  • Consider creating a voluntary emergency civic service under the authority of the public safety ministry to respond to situations similar to natural disasters
  • Ensure thereCHSLD management includes a manager in charge, a nursing director and a medical director
  • Ensure pandemic responses are planned every three years
  • Review the medical practices of doctors at CHSLDs Herron, des Moulins, and Sainte-Dorothée with regard to their decision to continue telemedicine despite the need for support and the high number of deaths.