MONTREAL -- Lucille Gauthier's family believes she didn't die of COVID-19, but after starving and being dehydrated when caretakers were kept from entering care homes like hers druing the first wave, even while it was severely short-staffed.

The Quebec coroner’s inquiry into Gauthier’s residence, CHSLD des Moulins de Terrebonne, which is overseen by the Arbec Health Group, began on Monday.

Lawyer Géhane Kamel heard first from managers of the regional health board for Lanaudiere (CISSS), to which the CHSLD reports.

Dr. Lynda Thibeault, who is the interim director of public health at the CISSS, said that her team was investigating an outbreak in another CHSLD of the Arbec Health group, the Émile-McDuff establishment, when she realized that some of the employees were also working at the CHSLD des Moulins.

When employees started showing symptoms, Thibeault said it was difficult to get a list of workers to screen. The manager of the two outbreak sites was in administrative segregation and “communication was difficult,” she said.

In an outbreak situation, “deadlines are important,” she said.

However, the CHSLD des Moulins was not considered a problematic establishment at the time, according to Daniel Castonguay, former CEO of the CISSS de Lanaudière.

The problems at Moulins were found throughout the region, even before the pandemic: a shortage of staff.

Under provincial COVID-19 regulations during the first wave, family caregivers were not allowed to enter the home.

Lawyer Patrick Martin-Menard, who is representing the Gauthier family, says “family caregivers played a fundamental role in helping to give basic health care to many residents" at the time.

"So, this decision to prevent them abruptly from going in led to some very severe deprivation of basic health care for some residents."

He said that there wasn't enough preparation from the province.

"Even when the threat appeared in January and February, preparations and protections of CHSLDs were taken very lightly until early to mid March, when we suddenly went into a crisis mode," he said.

"Even as we went into a crisis mode, the CHSLDs were a bit of the blind spot of the government in terms of the planning."

At the hearing, Castonguay said the CISSS intervened in the affairs of the care home on several occasions because the managers were not always on site, and directives were not put in place quickly enough.

We even offered to take control of the premises, said Mr. Castonguay, an offer refused by the Arbec group.

The inquiry also includes one private home, the Manoir Liverpool in Lévis. The other CHSLDs are René-Lévesque in Longueuil, the Laflèche in Shawinigan, Sainte-Dorothée in Laval, Yvon-Brunet in Montreal and Herron in Dorval.

Only deaths that occurred between March 12 and May 1, 2020 are included in the inquiry, and the inquiry was meant specifically to look at those that arose from "inhumane conditions," for a certain reason.

"Coroners intervene in cases of violent, obscure or potentially negligent deaths. Deaths that occur outside of these areas, including those resulting solely from coronavirus infection, are not investigated by coroners," the coroner's office said.

Class action lawsuits have been filed against CHSLD Herron and CHSLD Sainte-Dorothée, alleging negligence on the part of their residents. These class actions have not yet been authorized by a judge, a necessary step before they can proceed.

The province's ombudsman has also indicated that she will investigate deaths in seniors' residences during the pandemic.

Coroner's inquests are not intended to find fault for the deaths, but rather to make recommendations to prevent future ones.

--With files from The Canadian Press