Quebec 'cast aside' seniors in long-term care, needs to make changes now, ombudsman says

Quebec's ombudsman submitted her final report into what went wrong in the province's long-term care homes during the first wave of the pandemic, saying residents were "cast aside" and imploring the government to right its wrongs by making recommended changes immediately. 

Marie Rinfret says she is asking Quebec Health Minister Christian Dubé to provide her with ongoing progress updates, starting this spring, until all 27 recommendations in her report are implemented.

Rinfret's investigation is separate from the Quebec coroner's inquiry into the pandemic death toll at seniors' residences and the impact of the pandemic on the sector as a whole — though both share the goal of uncovering what went wrong and identifying what needs to change.

Despite expressing concern about seniors in long-term care in January 2020 ahead of the COVID-19 pandemic's first wave in Quebec, health officials did not take any actions to safeguard them until mid-March, Rinfret found. 

The ombudsman presented her findings in a news conference Tuesday afternoon. She noted that the day before Quebec declared a province-wide emergency on March 13, it handed a "very general" guide to health boards on pandemic measures. 

She compared it to guidance provided to long-term care providers in British Columbia, which was much clearer and more robust. 

The first outbreaks in Quebec long-term care homes appeared around March 23, but it wasn't until mid-April that the government acknowledged the extent of the crisis and sent in reinforcements. 

"The strategy was based on freeing up spaces in hospitals. They truly believed in good faith that that's where the crisis would be," Rinfret said. 

But in doing so, officials failed to evaluate the risks and potential impacts moving resources to hospitals would have. 

For example, in mi-March of 2020, seniors in hospital care were transferred to long-term care homes without being tested for COVID-19 and without regard for the fact that they would push facilities beyond their capacity. 

Majority of 1st wave deaths in long-term care

Rinfret released an interim report last fall in which she identified major problems in the government's pandemic planning, noting the province's long-term care facilities — commonly known by their French abbreviation CHSLD — were a "blind spot."

Most of the 3,890 deaths in Quebec during the first wave were among CHSLD residents, while staff watched helplessly, fled the overwhelming conditions or were themselves sick with the virus.

In her final report released Tuesday afternoon, Rinfret concluded long-term care workers "bore the brunt of public authorities' inaction."

Those workers represented 25 per cent of COVID-19 cases at the time and 11 died.

Officials knew how under-resourced long-term care homes were before the pandemic, Rinfret said, yet failed to act accordingly in the first wave. She also highlighted the fact that the homes were expected to deliver services similar to hospitals, despite lacking the expertise and personnel to do so.

Meanwhile, hospital resources were beefed up. The document details how Quebec officials were distracted by the disaster in European hospitals, notably in Italy, and believed the province's would be under siege by the virus as well.

Staff and personal protective equipment were transferred to hospitals, but the type of patient surge they expected never came. At the same time, hundreds of seniors were dying in long-term care facilities.

Quebec Premier François Legault acknowledged that his government was too focused on preparing hospitals in reaction to the report. 

"We were very focused on hospitals and not enough on CHSLDs, that's definitely a lesson," Legault said, adding that Quebec wasn't alone in overlooking long-term care, saying other provinces and countries were surprised by similar crises.

Gravity of situation flew under the radar

Officials grossly underestimated what would happen if the virus entered the establishments, where Quebec's most vulnerable live, Rinfret said.

A lack of "real-time data about the health-care system as a whole" meant that the gravity of the situation flew under the radar. 

"While Quebec's eyes were turned toward Italy, no risk analysis tailored to Quebec's residential-resource model and its specific features was carried out," Rinfret wrote. "This is how CHSLDs slipped through the cracks of any scenario."

The report also provides a portrait of the results of that lack of foresight.

It describes how personal protective equipment wasn't adequately distributed, how staff moving from one facility to the other contributed to the virus's rapid spread, and how basic hygiene, feeding and hydration care was postponed or cancelled. 

"The fact that informal caregivers were shut out took a heavy toll on residents' mental and physical health," a summary of the report said. 

The document builds on the interim report, which also described widespread institutional failures. 

It listed shorthanded, inadequately trained and under-equipped staff, residents being deprived of care and dying alone, and a planning process that simply didn't account for the on-the-ground reality in CHSLDs, which were stretched to the limit even before the pandemic began.

The final report is based on interviews and 1,355 witness statements from CHSLD residents and their family members, CHSLD employees, health authority managers and caregivers. Rinfret wrote that her investigation did not seek to cast blame, but to help avoid such a disaster in the future.

Among the recommendations, Rinfret is calling on the government to create:

• A risk assessment and management policy for long-term care.
• A detailed plan for strengthening residences' ability to apply infection prevention and control measures.
• A personal protective equipment supply strategy. 
• A plan for deploying emergency personnel within the health network.
• Protocols with professional orders, federations and associations, unions, and educational institutions for deploying extra staff in exceptional circumstances.
• A provincewide strategy to combat staff shortages and to promote health and social services trades and professions.
• An action plan to recognize the complexity of care and service provision in long-term care homes.

Dubé, Quebec's health minister, said he has so far only read the report quickly, but that about half of Rinfret's recommendations have already been implemented. 

One thing he said the ministry is working on is increasing the frequency of inspections of long-term care homes, to make sure infection prevention and control measures continue to be in place and that the homes are adequately staffed.