Coroner’s report into long-term care home seniors’ deaths highlights lack of care

A damning report into the long-term care deaths of Quebec seniors during the first wave of the pandemic, made public Monday, is shedding light on the lack of care at the time in many of the province’s facilities.

More than 4,000 residents of CHSLDs died in the spring of 2020 – 53 of those deaths were examined in Coroner Géhane Kamel’s over 200-page report.

47 of those deaths occurred at the then-privately run, CHSLD Herron, one of the hardest hit seniors’ homes from March to May 2020.

“Ms. Allo died on April 8, 2020, following heart failure insufficiently cared for,” Kamel wrote in the report of Thelma Jean Allo, who was a resident of Herron.

Many, throughout the public inquiry’s hearings, described the deplorable conditions at Herron, due to a lack of staff.

Volunteer nurse Loredana Mule went to help out at Herron in late March, early April 2020 and was shocked by the scene of seniors left on their own, malnourished and dehydrated.

“I wasn’t expecting to find the sort of horrendous conditions that I discovered that evening that I volunteered to the Herron,” Mule said. “They looked abandoned and lacking basic life care.”

“When I got into my car, I still had the stench of urine and feces up my nose. I just broke down. I couldn’t believe it. I cried,” she told CityNews in April 2020.

Olga Maculevicius was among those the coroner says died because “of the lack of basic care” – likely due to dehydration.

Kamel highlighted in the report that doctors were absent in some of the long-term care homes during this time, and questioned why they relied on phone consultations instead of providing in-person care. 

“The lack of nursing care here meant that the diagnosis was late. The absence of a doctor, in turn, prevented a necessary differential diagnosis from being made,” Kamel wrote of the death of Mary Ruth Wayland, who likely died of COVID-19, but it’s not certain since tests weren’t done on her.

“Mr. Baur’s tracheostomy requires regular care with suction and humidification. In the circumstances, a reduction in the supervision and nursing care required may certainly have contributed to the death,” Kamel concluded of the death of Herron resident. Thomas Baur.

Mule says this is unacceptable.

“That patient should have been transferred to the hospital, especially with a tracheostomy, his airway, breathing, circulation, everything is at stake here. The director or whoever is in charge of that- these are decisions that need to be taken and quickly. And the end result is that death,” she said.

READ: ‘Deserted’: Testimony of a head nurse’s visit at CHSLD Herron during first wave

For Elfriede Sorger, a Herron resident, her probable cause of death is linked to coronavirus. But even before the pandemic hit and Sorger suffered some medical issues, Kamel writes: “The medical notes are not constant, so much so that it is difficult to properly situate the care that was actually given to her.” From March 21 to April 4 2020, the day she died, no medical notes were taken. 

Kamel made 23 recommendations for the provincial government, the Health Ministry, local health boards, and the Quebec College of Physicians, including implementing safer ratios of healthcare professionals to CHSLD residents.

“They need to start implementing work instructions, training, standards of operating procedures, supervisors, team leaders to obtain that functionality,” said Mule.

The coroner also calls on the Ministry of Health and Social Services to ensure the necessary supply of protective equipment at all times, in addition to planning reserves to meet needs in the event of a crisis. 

Herron resident, Florian Poissant, died of COVID-19, but not through transmission at her hospital stay. “It is more likely that the resident was infected by a staff member with insufficient protection,” Kamel wrote.

“The politicians can say whatever they want. They’re saying it’s heaven and the reality is hell for these elderly,” Mule said. “The whole system has to be revamped from A to Z, it is not working at all and people are suffering.”

On Wednesday, Quebec’s minister responsible for seniors, Marguerite Blais, said at press conference that Quebec will put the recommendations in place.

“I have a letter from Francois Legault stating that he was going to implement and he’s going to take care of the situation and frankly, I haven’t seen anything.” Mule said.

Coroner Kamel concluded that the Health Ministry has should learn from the lessons in the wake of the pandemic. 

“We are at the crossroads,” she wrote. “This tragedy that will have unfortunately marked the history of Quebec must push us to innovate and get out of institutional paradigms – for these seniors, for these bereaved families , for these thousands of healthcare workers, we have this duty to remember.”

“My heart goes out to them and to all the family members. I will never forget what I experienced,” Mule said.

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