Quebec coroner: many to blame for high CHSLD death toll in COVID first wave

“This report has to serve so that this never happens again,” Quebec coroner Gehane Kamel presenting her 23 recommendations for different parts of the government, following the first wave CHSLD seniors deaths. Alyssia Rubertucci reports.

By Alyssia Rubertucci

Quebec’s coroner says there is plenty of blame to go around for the deaths of 47 residents of a private Montreal-area long-term care home during the early days of the COVID-19 pandemic.

Coroner Géhane Kamel says the provincial government, the local health authority and the owners of the Herron care home “passed the ball around” while residents were left to die.

She detailed the mismanagement of Quebec seniors homes amid the first wave of the pandemic, and offered 23 recommendations in a report, released Monday, for different government bodies. 

“This report has to serve so that this never happens again,” she said at a press conference Thursday, specifying her mandate wasn’t to blame specific people.


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Quebec coroner’s report CHSLD deaths first wave of pandemic: public health director should be more independent

How do we make sure CHSLD Herron doesn’t happen again


Her report says residents of Quebec long-term care homes were kept in a blind spot while the provincial government reacted to the oncoming wave of the novel coronavirus in the spring of 2020. Almost 4,000 residents died between March and June of that year, many of those she called premature deaths.

“There were people who couldn’t get help and shouldn’t have died,” she said. “Maybe they would’ve died later but they wouldn’t have died in those conditions.”

Like Olga Maculevicius, who was in her 90s when she died at CHSLD Herron on April 1, 2020. 

“She didn’t die of COVID, she just died of sheer lack of staff and lack of care,” said her grandson, Paul Cargnello.


Olga Maculevicius with grandson Paul Cargnello. (Credit: Paul Cargnello / handout)


Her death was one of the 53 examined by the coroner, wh  found she died of kidney failure, likely due to dehydration and a lack of care. Some residents were left in their beds unsupervised for two days.

“It’s unbelievable what we were hearing,” Kamel said. “We’re in a civilized society and we left people to die alone. It was heartbreaking.”

For families of the deceased, hearing of the neglect brings up a lot of anger.

“Seeing it in black and white kind of confirmed a lot of suspicions that we had,” Cargnello said.



The recommendations don’t go far enough for him, and he doesn’t agree with giving subsidies to privately-run seniors’ homes.

“The instant that we throw profits in there, we’re playing a dangerous game and this is the proof,” Cargnello said. “I think this is a moment and a reckoning in our history, in Quebec history, to be able to say things have to change.”

Coroner Kamel said many failed during the first wave of the pandemic. 

“Whether it’s the owners of Herron, the CIUSSS and the Ministry – people passed the buck,” she said. “I think there are lessons to take from what happened.”

Some say the report is a start, but a full public inquiry is needed.

“I would love to see more people resign, I’d love to see more people lose their job,” Cargnello said. “I think people need to take more responsibility and until I see that, I’m not going to be satisfied.”

For Olga, who fled war and occupations in Lithuania, her life and her death weren’t easy. But her grandson says many others suffered the way she did.

“They lived hard lives and deserve dignity and I don’t think they received that,” he said.

“We all have a duty to remember and we owe at least that to the families of the deceased,” Coroner Kamel said.

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