MONTREAL -- A Montreal-area long-term care home where dozens of people died during the first wave of COVID-19 was seriously understaffed in the early days of the pandemic, in part due to a self-isolation directive from the province's health hotline, a Quebec coroner's inquest heard Wednesday.

Dr. Nadine Larente testified that there were so few employees on site when she first arrived at Residence Herron on March 29, 2020 that she called her husband and three children to come help feed and change patients.

Larente, who is a director of professional care for the local health authority, said she was told some employees had stayed home because they were afraid, but most were following advice from the province's Info-Sante telephone line to self-isolate for 14 days after coming into contact with a positive COVID-19 case.

Larente, who is also a geriatrician, said she questioned the wisdom of the directive given the long-standing staff shortages throughout the long-term care network.

"Between the risk of transmitting COVID and deserting a centre with no care given altogether, there's a difficulty," she said. She said she was worried enough about it that she contacted Dr. Lucie Opatrny, an associate deputy health minister, to express her concerns.

"I was worried because, with all the centres in outbreaks across the province, that directive didn't make sense, to abandon people before there are replacements," she told the inquest.

Coroner Gehane Kamel's mandate is to investigate 53 deaths at six long-term care homes, known as CHSLDs in the province, and one seniors residence. The portion of the hearings involving Herron began Tuesday after being suspended while prosecutors decided whether to pursue charges against the owners of the now-closed facility. Ultimately they decided no criminal charges would be laid.

Forty-seven people died at the home during the first wave of the pandemic.

Larente said her group did their best to care for residents on March 29, but they didn't have enough masks for everyone or enough personal protective equipment to change it between patients.

They found residents in need of changing and food trays that had been left in the halls since lunchtime, many of them untouched. Larente said she was also surprised to find the facility appeared to be short of basic material, such as adult diapers and wipes.

At one moment, Larente said a patient fell to the ground as she helped her to the bathroom, and yelled for her daughter to help. Later, she learned the patient had COVID-19.

A report tabled on Wednesday described dire conditions found in the home, including residents who were dehydrated, laying in soiled bedding and with wound dressings that hadn't been changed in weeks.

But Larente said the ground floor, where she worked that evening, held patients who were more independent and most of them were dressed, hydrated and had received their medication and food that day.

At one point, Kamel interjected to ask whether doctors should have been called to do a proper examination of each patient.

"When I read this, and I get a chill up my spine to say this … I get the impression we let these people die," the coroner said.

Larente acknowledged that in retrospect, many things should have been done differently. By the time the second wave came around, she said teams of doctors were going to care homes to assess the needs of the residents and ensure everything was in place to care for them.

But in the pandemic's early days, she said, the health network was still scrambling to train personnel in hospitals, assuage fears and deal with shortages of personal protective equipment and staff as the number of outbreaks grew by the day.

"On March 29, we weren't yet organized at that level," she said. "We weren't prepared."

The portion of the inquest involving Herron is expected to last until at least Sept. 19 and include testimony from dozens of witnesses. The coroner's investigation is not intended to assign blame but to make recommendations to avoid similar occurrences.

-- This report by The Canadian Press was first published Sept 8, 2021.