The lack of independence granted to Quebec’s director of public health may have slowed the government’s response at the start of the pandemic, when hundreds of people died in long-term care homes across the province.
Coroner Géhane Kamel released a report on Monday after months of investigating deaths in seniors’ residences, where the pandemic claimed more than 5,000 lives in the spring of 2020.
After hearing testimony from 220 government officials, long-term care home staff and loved ones of the deceased, Kamel issued 23 recommendations targeting the provincial government, its Department of Health, local health authorities and the College of Physicians of Quebec.
One of the report’s first recommendations calls on the government to review the role of its director of public health so that whoever is in office can carry out his duties “without political constraints”.
Quebec’s director of public health is also deputy minister of health, but Kamel wrote that the two roles “are distinct and may not be compatible.”
Kamel gave the example that masks were not mandatory in CHSLDs (Long-term care residential center) at the start of the pandemic.
“Would his advice have been the same if he hadn’t had to worry about possible stock shortages? I tend to think not. Hence, in my humble opinion, the danger of wearing two hats,” writes Kamel in the report, which can be read online.
At the time, Dr. Horacio Arruda held the position. He resigned at the end of 2021 and was replaced by Dr. Luc Boileau as interim director. Prior to that, Boileau was head of the province’s Public Health Institute (INSPQ).
In his report, Kamel notes that at the start of the pandemic, infection control measures were much stricter in hospitals and testing clinics than in long-term care homes, where there were many more cases of COVID-19.
“We tolerated the intolerable. It was a sad day for medicine in Quebec,” she wrote.
Marguerite Blais, the minister responsible for seniors, was one of the few to provide a clear timeline for government decision-making, Kamel said.
Kamel wonders why doctors were absent in some of the long-term care homes where large numbers of people died, and why they relied on telephone consultations instead of providing in-person care.
“For a coroner, that so many residents died without being allowed to see a doctor during their last illness is not only sad, but disturbing,” Kamel wrote.
“It is hardly conceivable that life or death decisions could have been made on the basis of a telephone relay alone.”
More responsibility needed
Kamel was scathing in her account of the events that unfolded at one of the long-term care homes she looked into as part of the investigation, CHSLD Herron in Dorval, Quebec. Forty-seven of the 53 deaths analyzed in the investigation took place in Herron in the spring of 2020.
The residence was long understaffed and had done little to remedy the situation even as it became clear that the COVID-19 pandemic was spreading across the world, according to the report. Doctors responsible for the residents of the home did not show up until weeks after the crisis killed dozens of them.
The West Island Board of Health took over the long-term care home on March 29, 2020, after one of the owners called the province for help, but several other residents are subsequently died as confusion reigned over who was responsible for what.
Additionally, the health board seemed more focused on its image and blaming Herron than on the root of the problems at home, Kamel said, noting that he had hired a communications consultancy.
She wonders why Lynne McVey, the head of the CIUSSS de l’Ouest-de-l’Île-de-Montréal, took the trouble to call 911 in the middle of the night of April 11, when his board of health had already been in control of the residence for more than a week.
“Listening to the audio of Mrs. McVey’s 911 call, it is difficult to understand the purpose of the call since the situation had been alarming since March 29, 2020,” Kamel wrote.
Earlier in the day, Montreal Gazette reporter Aaron Derfel published an investigation exposing what was going on in Herron.
The head of the TACT firm hired by the CIUSSS, Daniel Desharnais, is now Associate Deputy Minister of Health and was questioned by Kamel during the investigation.
If the CIUSSS and Herron had agreed on each other’s roles in the crisis, several deaths could have been avoided in early April, the coroner wrote.
The weekend of April 4 to 6, 2020, five days after the CIUSSS took power, was particularly macabre, says Kamel. Those who remained on the staff – many were sick or had deserted out of fear and frustration – did not know where to turn to make decisions.
Residents lay in urine and feces. The bodies of those who died were left in their rooms for more than 24 hours before being taken to a funeral home.
“This image alone is unworthy of a civilized society,” wrote Kamel.
Every death provided clues
In his analysis of each Herron death, Kamel often pointed to the absence or serious lack of medical notes, making it impossible to know whether people received treatment for their medical conditions. Many causes of death have been difficult to determine due to a lack of information or because their COVID-19 test result was lost or not recorded.
In some cases, dehydration or starvation appear to have contributed to the rate at which residents died. This was the case of Olga Maculavicous, who, according to Kamel, died due to “lack of basic care” on April 1, 2020.
A few days earlier, on March 29, another resident, Léon Barrette, had been found dead shortly after being transferred from the McGill University Health Center.
“The information on file is so sparse that we feel he was forgotten and died alone,” Kamel wrote.
In the case of Thomas Baur, who died on March 28, 2020, one of Herron’s physicians had a conversation about end-of-life care with a family member – without consulting Baur himself, who was cognitively able to whether or not to give consent for the kind of treatment he wanted, according to the report.
Thelma Jean Allo died of “heart failure after not receiving adequate care” on April 8, 2020, Kamel wrote.
Hanna Piechuta died on April 4, 2020, after a “lack of basic equipment such as oxygen cylinders…helped hasten her death.”
Amid the March 23, 2020 health crisis, Patricia Gaudet was also transferred from a hospital in Herron, where she died just two weeks later, “posing the question,” Kamel wrote, “why allowing a transfer to CHSLD Herron?
Call for safer ratios
In the report, Kamel also discusses the need for more ways to monitor services in long-term care facilities and create an obligation to intervene if something goes wrong.
She recommended that there be safer ratios for the number of professionals per resident in CHSLDs.
Kamel said the health board’s leadership team was disorganized and she called for greater accountability of local health board managers, who oversee long-term care homes.
She said private CHSLDs should receive government subsidies to ensure they can provide proper care to residents.
Kamel did not say whether the government should go ahead with a public inquiry, as the opposition has demanded, but said it should “review events in any way it deems appropriate. “.
She said the hierarchy of decision-making, the agility of the health system in times of crisis, and the understanding and execution of responsibilities between health and seniors ministries, as well as within councils local health authorities, should be among the areas that warrant an audit. .