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.

She also called on the Quebec College of Physicians to review the cases of doctors in several of the facilities examined in the report to determine whether they had erred in only providing services by phone at the beginning of the pandemic. 

Families were 'infantilized'

Kamel said the government decision to bar caregivers from entering residences and long-term care homes in the early months of the pandemic was a mistake. She said that prevented vulnerable people from receiving proper care and dignity in death, and it "infantilized" family members. 

The coroner said she and her team experienced a range of emotions over the course of the inquiry, ranging from sadness, to anger, to hope. 

"It's unbelievable, what we heard. We're in a supposedly civilized society where we basically left people to die alone," said Kamel. "It was heartbreaking."

The coroner analyzed the medical histories and circumstances of death of all of the 53 people at the seven institutions targeted by her inquiry. She began each section of the report with one of their stories. 

Kamel said she intentionally omitted the ages of each of those people because the discourse around their deaths had become almost dismissive of their plight. She revealed Thursday that all of the deaths she investigated were of people who had been between the ages of 60 and 95. 

"They were, above all, human beings for whom everyone — their families, caregivers, the health boards and government bodies in charge — had a shared responsibility to ensure care worthy of a civilized society," Kamel said. 

She said the average life expectancy for people in the province's long-term care homes, known in Quebec by their French acronym as CHSLDs, is about 18 months from the time they are admitted to the institution.

That "makes it all the more crucial that their stay in these environments allows for the most peaceful end of life possible — free of suffering," Kamel said.

'At Herron, people failed'

The majority of the deaths examined in the inquiry — 47 in all — took place at CHSLD Herron in Dorval between March 12 and May 1, 2020.

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. People passed the buck." 

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.

Kamel wouldn't comment on McVey's departure Thursday but said the responsibility for what happened at Herron is shared by all three parties involved — the owners, the health board and the Health Ministry. 

The coroner said she has seen improvement in the elder-care system since the first wave, with institutions appearing to have learned from their mistakes. But there won't be meaningful change without political will and until all 23 of the recommendations in her report are acted upon, she said. 

Ramsay, the doctor who worked closely with Kamel throughout the inquiry, said after hearing from hundreds of witnesses, he had found cause for optimism.

"We heard a lot of difficult things, but I'd say that for all the difficult things, we also saw glimmers of hope," Ramsay said.

"We saw people devoted to their work, families taking care of their elders and managers who had really struggled with what happened."