MONTREAL -- After Saturday’s shocking news about 31 deaths at the Maison Herron long-term care facility in Dorval Que., family members of patients, nurses, patients’ rights advocates and others have contacted CTV News with information about the facility and issues that had been observed long before the COVID-19 pandemic shed light on care at seniors’ residences.

Two reports focus specificallly on Maison Herron's inadequacies and the need for it to change its policies and practices.


A 2017 report by Quebec's ombudsman, le Protecteur du Citoyen, found Herron lacked continuity of care, nursing care, and staff for patients with cognitive disorders, in addition to having communication difficulties between management and families, food that was subject to criticism and dissatisfaction with the complaint examination system.

The report paints a picture of a facilty that was understaffed and did not provide proper communication between families and their loved ones.

The reports recommendations were as follows:

  • Ensure that a sufficient and trained workforce is maintained so that nursing and assistance services adequately meet the needs of residents, and, taking this into account, take the steps to increase the clientele
  • Ensure that adequate, complete and understandable information is given to residents and their families upon admission of the person, particularly on the financial aspects of accommodation, for informed decision-making
  • Establish and comply with a complaint examination procedure that complies with the law and promote it to residents, residents and their families
  • Take the steps so that the service quality and complaints commissioner has the tools necessary to exercise its mandate in a neutral and independent way, and in complete confidentiality
  • Promote the proper functioning of the users' committee and respect its legal mandate

The report required the facility take these steps and respond to the Quebec ombudsman by October 31, 2017.


A 2019 report conducted by Quebec Health and Social Services found multiple issues at Maison Herron, including poor communication with loved ones and a lack of a support program for palliative and end-of-life care.

The report recommended that Maison Herron complete these improvements within 60 days:

  • Adopt a policy to combat mistreatment of people in vulnerable situations
  • Develop the palliative care support program and end of life program
  • Improve the procedure for developing interdisciplinary intervention plans
  • All the information relevant to the reception process be transmitted to residents and their relatives
  • Offer annual information activities or awareness about palliative and end of life care, promote good treatment and counter mistreatment
  • Ensure the roles and responsibilities of the beneficiary attendant guide are known to staff, residents and their relatives
  • Organize weekly formal meetings to exchange clinical views and organizational information with the caregiver team
  • Promote the rights of residents by systematically informing the users' committee during a new admission
  • Encourage the participation of the users committee to represent the residents' point of view
  • Take the necessary means so that interdisciplinary intervention plans are achieved in accordance with the institution and that palliative and end-of-life interventions take place by including relatives
  • Inform residents verbally of the daily menu for meals
  • Improve support for volunteers

Both reports are embedded below.