Quebec coroner’s report CHSLD deaths first wave of pandemic: public health director should be more independent
Posted May 16, 2022 1:26 pm.
Last Updated May 16, 2022 6:54 pm.
A Quebec coroner’s report into long-term care deaths of seniors during the first wave of the pandemic was made public Monday. More than 4,000 residents of CHSLDs died in the spring of 2020.
Coroner Géhane Kamel says the COVID-19 crisis illustrates decades of failing public policies when it comes to CHSLDs – that were already known. But, that the lack of independence Quebec’s public health director had, slowed the government response when the pandemic first hit. And a lack of coordination and a clear chain of command also played key factors.
The report makes 23 recommendations for the provincial government, the Health Ministry, local health boards, and the Quebec College of Physicians.
Kamel says Quebec needs to ensure the role of the public health director is independent, without political interference. Dr. Horacio Arruda held the role at the time – she writes that he may have had difficulty taking decisions because he was also a deputy minister. Dr. Arruda resigned at the end of 2021.
The report focused on 53 CHSLD deaths between March 12 and May 1, 2020. It includes testimony from over 200 witnesses – many calling the conditions they saw inhumane and shocking, including at CHSLD Herron.
“I think the coroner’s report is one of like seven or eight reports into what happened in Herron and they all made all kinds of recommendations. Some of them had they made 50, 60, 70 recommendations. So the government has should be able to develop a plan of action about all of these things going forward,” said Peter Wheeland, whose parents were living at CHSLD Herron.
CityNews reported on CHSLD Herron in early April 2020, a volunteer nurse telling us of seniors left on their own, dehydrated and malnourished, and sitting in their own feces. At least 47 people died there during the first wave of COVID-19.
Herron was privately run at the time the pandemic hit. Kamel says private CHSLDs should receive some government subsidies to ensure they can provide residents with proper care.
The CIUSSS in the West took control of Herron, the owner testifying that they called numerous times for help with multiple staff out sick with COVID at the time, but say they didn’t get what they needed in time as more seniors died. Kamel said the regional health board’s management team was disorganized. She calls for greater accountability for CHSLD managers as well.
She also says more ways to monitor services in long-term care settings is needed – creating an obligation to intervene in the event of problems. And safer ratios for the number of professionals to residents in CHSLDs.
Kamel also says at least two caregivers must be allowed to visit a loved one during a health crisis – which at the time in 2020, access was fully cut off – leaving many seniors with no one to advocate for them. And to ensure there’s adequate supply of PPE, personal protective equipment, at all times.
“The recommendations that were the most important to families, I think, was this recommendation to ensure that the that caregivers can continue to come in and see their loved ones in these residences the next time that there is any kind of health crisis,” Wheeland said. “The fact that people that the families weren’t allowed in to see their loved ones during the pandemic is responsible for the fact that these problems went on a lot longer than they otherwise would have because if the families had actually been in the homes and seen what was going on, we would have sounded the alarm bells.”
RELATED:
‘Deserted’: Testimony of a head nurse’s visit at CHSLD Herron during first wave
Calls to Info-Santé reveal desperation of Residence Herron owner in March 2020
Email reveals Quebec ministers knew earlier about Herron care home tragedy
“I am concerned that it’s just another report because the word recommendation is too weak., it’s like a suggestion, this is not the time for suggestions,” said patients’ rights advocate, Seeta Ramdass. “We need rules and regulations in place with accompanying sanctions and consequences to those who disobey those rules, who don’t adhere to them because ultimately that leads to compromising the health and well-being of our elders, as we have seen throughout this pandemic. So that accreditation is important, a whistleblowing line, a hotline for families to phone into and the spot inspections, I think, would be very important.”
Many, including opposition parties, have called for a public inquiry into CHSLD deaths during the first wave of the pandemic, but Kamel did not address it in her report specifically, but to say that Quebec should “make a retrospective of the events in the way it deems appropriate.”
“Rather than reacting piecemeal and making a few changes here and there, I really think that Quebec needs to take a long and hard look through some kind of Royal commission into how we’re going to care for our older residents in the next ten, 20, 30, 40 years because these recommendations are not enough to fix the long term problems that we’re facing,” said Wheeland.
