Report on deaths in CHSLDs | “People have failed in Herron,” says coroner Géhane Kamel

“People have failed in Herron,” coroner Géhane Kamel said. “Other than that, I have no complaints. But there are lessons to be learned from what happened,” said the lawyer, who on Thursday presented the conclusions of his investigation into the deaths that occurred in CHSLDs during the first wave of the pandemic.

Posted at 3:24 PM
Updated at 16:31

Emilie Bilodeau

Emilie Bilodeau
The press

The coroner was critical of the management of the pandemic at the CHSLD Herron, where “people were throwing the ball at each other”. “No one took charge of the situation, whether it was the Ministry, whether it was the owners, or the CIUSSS. There were many email exchanges, but at that time people were dying, people were dehydrated, people were sitting in their stools. The president and CEO of the CIUSSS de l’Ouest-de-l’Île-de-Montréal Lynne McVey also announced her departure on Tuesday.

During the press conference, the lawyer also skinned Daniel Paré, who was the president and CEO of the CISSS de Chaudière-Appalaches during the first wave and who was named director of the vaccination campaign in the winter of 2021. Speaking to the coroner, he said he was not aware that there were cases of abuse and unsanitary conditions at Liverpool Manor.

“To me it is still a great mystery today,” said Géhane Kamel. It’s impossible for me that he didn’t know. If indeed he didn’t know, we have a serious problem. To have support measures in a private home for so long and that a CEO doesn’t know anything about it amazes me. †

Of the 23 recommendations, coroner Jacques Ramsay emphasized the importance of converting private CHSLDs in Quebec into private CHSLDs in concert. Thanks to this change, staff would earn the same salary as employees in the same category elsewhere in the healthcare network.

“It’s not normal that in a private CHSLD without a contract we have employees who are paid less than at Tim Hortons, the D said.r Ramsay. By contracting, we stabilize the workforce and ensure competent people. †

The CISSS and CIUSSS could also intervene more quickly in private CHSLDs with an accord in the event of a crisis, he argued, and seniors would have the same living conditions whether in public or private residence.

An unprecedented crisis

Géhane Kamel insisted that the health system needs to show more “agility”. “If a new health crisis were to break out, we would need people to make decisions much faster.”

“You have seen the countless number of directives that started from the ministry and went to the field. It can take several hours, even several days, for the information to reach the people in the field. And a directive issued in the morning can change the next day and change again the day after,” she continued.

Among her recommendations, the coroner calls for greater accountability from CISSS/CIUSSS and ministries. We also need to review the role of the national health director, who also acts as a deputy minister, so that he performs his functions “with complete independence and without political coercion”.

She says there is a need for more home care and reserves of emergency equipment. Caregivers should be able to continue to visit loved ones even in critical circumstances, the report suggests.

The lawyer acknowledged that Quebec has been going through an unprecedented crisis. Its “size” and “virulence” were taken into account in preparing the 193-page report.

On a more personal note, Géhane Kamel said she felt at times sadness and at times anger upon hearing some of the 220 testimonials.

“Often, we said to ourselves, it’s unbelievable what we hear. We are in a society that is said to be civilized and where people are left alone to die. It was heartbreaking,’ said the person who systematically rejects interview requests from journalists who want to paint her portrait, because she does not want to offend the next of kin.

“History will sadly remember that in Quebec, it was the seniors who were accommodated who paid the heaviest price during the first wave of COVID, a sneaky disease with dramatic consequences,” said the coroner, reading her report.

The Minister of Health and Social Services, Christian Dubé, and the Minister responsible for Seniors, Marguerite Blais, reacted after the report was unveiled. They welcomed the findings of the study, noting in a press release that some of the 23 recommendations had already been implemented.

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