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Quebec must rethink how it treats elders, says coroner after damning report

Quebec’s vulnerable seniors in long-term care were in the government’s blind spot as COVID-19 spread through the province and ravaged already short-staffed residences in the spring of 2020, coroner Géhane Kamel told reporters Thursday. 

“I say this because I believe they are also in the blind spot of our society, and I seriously hope my work will contribute to a better protection of seniors and vulnerable people in group-living settings,” said Kamel at a news conference to present the findings of her 200-page report.

Kamel’s report, published Monday, follows months of inquiry into deaths in seniors’ residences. More than 5,000 Quebecers living in care died in the early months of the pandemic, in the spring of 2020.

The coroner said the government should take one last look at what happened in that first wave. The Official Opposition and some families have called for a more extensive public inquiry, though Kamel said she would leave it up to the government to decide how to revisit the events.

The coroner and her team, Dr. Jacques Ramsay and lawyer Dave Kimpton, heard testimony from 220 government officials, long-term care home employees and the loved ones of some of the people who died. 

Kamel issued 23 recommendations targeting the provincial government, its Health Ministry, local health boards and the Quebec College of Physicians.

She called on the province to find ways for its health-care system to respond faster in crises such as a pandemic or a natural disaster. She pointed to the decision-making hierarchy, noting the present structure leaves too great a distance between the ministry bureaucrats who issue guidelines and people working on the ground. 

Kamel recommended that the role of Quebec’s public health director be made more independent, that the province improve nurse-patient ratios in long-term care and that local health boards and the administrators of long-term care homes be made more accountable.

‘At Herron, people failed’

Kamel examined the deaths of 53 seniors in congregate-living settings, 47 of whom had lived at CHSLD Herron in Dorval.

The situation at Herron, already severely short-staffed in March 2020, quickly became a crisis as COVID-19 arrived in Quebec and spread. Employees struggled to provide residents with even the most basic care. 

“At Herron, people failed,” Kamel said Thursday, “whether it’s the owners, the health board or the ministry. That’s clear to me. I wrote it black on white.” 

The day after Kamel’s report was published, the head of the CIUSSS de l’Ouest-de-l’Île-de-Montréal, the local health board which oversaw Herron and took over control of the institution on March 29, 2020, resigned. Lynne McVey will not be seeking another mandate once hers comes to term in July.


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