QUEBEC CITY -- Coroner Gehane Kamel is criticizing the fact that experts waited until March before informing the Quebec premier about the dangers of COVID-19.

Kamel is investigating the deaths that occurred in long-term care homes during the first wave. She said Wednesday she finds it disturbing that François Legault was left in the dark in January and February.

“What happened between January and March?” she asked. “And then, I'll allow myself to go a little further: (...) it's around March 9 (...) that we end up informing him of the kind of hemorrhage and that worries me.”

The coroner made the comments as she was finishing questioning the assistant deputy minister of seniors, Natalie Rosebush, for the second time.

Rosebush, who Kamel noted appeared “extremely nervous,” said that she knew as early as “late January, early February” that seniors were most vulnerable to the coronavirus.

But at that time, the concerns were mainly about the supply of protective equipment, health network preparations and the protocol for travellers returning home.

“I'm still hungry (for more details)," concluded Kamel. “No one has convinced me that the voice of the elders (...) has been heard. (...) It happened too little, too late.”

The coroner was surprised that they waited until March 12 to call the private long-term care homes to prepare, while the first case of COVID-19 in a CHSLD appeared on March 2.

“There are 10 days between the two!” she said.


Rosebush was returning to the coroner's office at the coroner's request to clarify some points, including the issue of the CHSLD visits in the spring.

She explained that observers had been visiting the CHSLDs as early as April with a “checklist” in hand, which they annotated before recording the information in a “common tool” online.

Rosebush was forced to admit that her teams had prepared a compilation of information on Nov. 16 specifically for the coroner's inquest.

She added that all the backups of all the visits were eventually found and forwarded to the coroner.

Initially, Rosebush said no written records were kept of the visits.

“We had no indication that we had the whole history," she said Wednesday.

Prosecutor Dave Kimpton asked if the coroner would find the same information in both documents.

“Yes, normally you would find the same information,'' Rosebush replied.

She stated that she had done the matching exercise herself and found only a few “squares.”

She also said that she had found a few reminders, which she did not think should be kept. However, these documents are “very rough,” she said.

In the course of questioning, Rosebush also revealed that there was a national report of long-term care home visits dating “from April or May.” The coroner asked for this document.


The facilities and the ministry had access to the findings from the monitoring visits, and follow-ups were done, Rosebush said.

The lawyer representing six families of seniors who died in CHSLDs, Patrick Martin-Ménard, asked her for examples of the ministry's interventions.

“We have had a lot of communication with caregivers," Rosebush offered in response.

Martin-Ménard then turned his attention to the essential care that wasn’t rendered, notably at the CHSLD Ste-Dorothée, where 70 orderlies were missing on April 27.

As of April 16, an observer noted that 263 people had not been dressed in the last three days. Half had not received bed hygiene or snacks.

“Is there a concern at this point in the department for the safety of the residents?” asked the lawyer.

“There certainly is,” replied Rosebush. “There was a lot of action around Ste-Dorothée.”

The coroner asked why it was an observer, and not an employee of the facility, who entered findings into the “common tool.”

“Bathing, snacks, meals, it could have been the person at the facility entering the data. (...) The evaluator, I see him more as an external person who (...) makes sure that people are well,” said Kamel.


The coroner's inquest will resume on Jan. 10 with new witnesses: the person in charge of civil security for health, Martin Simard, and his superior, Pierre Lafleur.