LIVE | Coroner Kamel Presents Her Report on Deaths in CHSLDs

Coroner Géhane Kamel presented the conclusions of her report on the deaths of seniors at CHSLDs. That was made public earlier this week.

The coroner attributes the massacre caused by COVID-19 in CHSLDs to decades of public policy failures that were already known.

“It will undoubtedly have taken this health emergency without precedent in Quebec history to bring the actors together around the same table and start this necessary discussion about the future of our seniors,” we read in the investigative report of the coroner Géhane camel.

The investigation looked at the 53 deaths that occurred in CHSLDs and RPAs between March 12 and May 1, 2020, at the start of the social health crisis.

To the Government of Quebec

– Review the role of the National Director of Public Health so that his functions are performed with complete independence and without political coercion.

– Evaluate the possibility of setting up a voluntary social emergency service under the supervision of the Ministry of Public Security, as sometimes happens in the event of a natural disaster.

– Quickly review service offerings to our seniors by converting all private CHSLDs under contract to private CHSLDs.

– Increase the range of home support services for our seniors.

– Ensures an inclusive policy in times of crisis to allow at least two caregivers to visit the person being accommodated in a safe manner.

– Implement safe relationships between caregivers and residents in CHSLDs.

– If necessary, increase the number of managers in CHSLDs to ensure that all shifts are covered (delegated evening and night powers).

– Establish discussions with trade union bodies to review or add clauses in collective agreements, where appropriate, that would allow greater availability and reception of staff during a health emergency.

– Planning new infrastructures or renovations of residential environments by ensuring that the environments can meet health care requirements, especially in times of health crisis.

– Allows residential facilities to provide individual rooms to residents.

To the Ministry of Health and Social Services

– Putting the precautionary principle at the heart of any approach to risk assessment and management.

– Increases the responsibility of managers of CISSS/CIUSSS and the Ministry of Health and Social Services for the care of older people with loss of autonomy by monitoring indicators and an obligation to intervene in problems with the quality of care.

– Ensures necessary protective equipment is available at all times, in addition to planning reserves to meet needs in the event of a crisis.

– Define what minimum comfort care facilities in CHSLDs should be able to provide.

– Develop a national plan to equip all CHSLDs with the necessary equipment to provide this care.

– Revise technical training so that nurses in CHSLDs and, if applicable, auxiliary nurses are able to perform the techniques required for basic care (respiratory care, venous and subcutaneous access, use of volumetric pumps, etc.).

– Develop a tool with scenarios so that residents and/or their guardians can fully understand the implications of a choice of care level.

– Provides management in the CHSLDs in which a responsible manager, a nursing directorate and a medical director are brought together.


– Ensure sufficient presence in the CHSLDs of nurses specialized in PCI to be present in day-to-day operations and to ensure their sustainability.

– Be sure to plan simulations for three years in accordance with pandemic plans.

– Offer medical record-keeping training and periodic follow-ups.

– Provide necessary guidance that justifies the use of emergency protocols and palliative sedation in an acute care setting.

At the College of Physicians of Quebec

– Review the individual medical practices of the treating doctors of CHSLD Herron, Les Moulins and Sainte-Dorothée, in particular with regard to their decision to continue teleconsultation care despite the need for support and the very high number of deaths.


– “The COVID-19 crisis illustrates decades of government policy failures regarding CHSLDs that were already known.”

– “Quebec’s reduced hospital capacity compared to other Organization for Economic Co-operation and Development (OECD) countries, combined with the past vulnerability of CHSLDs, has prompted authorities to have the first instinct to protect our hospital capacity by avoiding the transfer of residents to hospitals.”

– “This protection of hospital environments certainly had its raison d’être, but it now seems clear to me that the pre-existing systemic causes must be reviewed and corrective action taken.”

Source: coroner’s investigation report

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