More than 10 days after local health authorities were made aware of horrific conditions at the Herron nursing home in Dorval, Que., residents were still without access to proper care and medical treatment, a coroner's inquest heard Friday.
Marie-Ève Rompré, a head nurse at Montreal's St. Mary's Hospital, said she first visited Herron on April 8 to provide assistance.
The West Island health authority, which oversees the home, had been alerted to the crisis unfolding at the privately run home on March 29 — and concerns had even been raised two days earlier, on March 27.
When Rompré arrived, after her day job at the hospital, she said the situation was still dire. She returned the next day having recruited a team of nine nurses. They divided up to care for the 131 residents in the home.
In one room, Rompré recalled, she found a woman unconscious, with a fever. The phone rang. It was her husband.
"He said, 'it's been weeks I've been trying to talk to someone,'" Rompré recalled.
Rompré was able to wake the woman up, and the couple spoke. The woman called her daughter as well.
She died soon after, Rompré said.
Timeline of inaction 'profoundly troubling'
Coroner Géhane Kamel is presiding over an inquest into the crisis at Herron, where 47 people died during the pandemic's first wave.
Kamel praised Rompré for heroic efforts but said she was "gutted" by her testimony. She said it was "profoundly troubling" that it took so long for authorities to rectify the situation at Herron.
"You're saying on April 8, there was nobody there except managers. It's not the portrait we had up to now," she said.
The inquest previously heard from staff who had tried to improve the situation at the home in early April. The West Island health authority formally took over management April 9.
Several witnesses, including a doctor who testified Friday, have said things only began to change after the appalling conditions were documented by the Montreal Gazette in a report the afternoon of April 10
Addressing the families of residents listening to the inquiry, Kamel said, "I am so sorry that you are hearing this testimony."
Problems prior to crisis
At the inquest, which began Tuesday and will continue for two more weeks, Kamel has set her sights on trying to understand the poor management and gaps in communication that resulted in an extended period where residents were not provided adequate care.
It became clearer Friday that some of the problems at Herron preceded March 29.
Rompré said it was apparent by the condition of some of the residents that they had not been given proper care prior to that date. She said a woman they treated had not had a bath since December 2019.
Hélène Paradis, head pharmacist at the West Island health authority, described how prescription drugs for the residents were poorly organized.
Some prescriptions had not been updated in a week or more, she said, and some medications dating back to 2017 or even earlier were still at the site.
Stéphanie Larose, another nurse, saw horrific conditions when she arrived to help at the home on April 3. In her testimony Friday morning, Larose said she tried to slowly improve the dire situation, day by day.
"Every day the situation improved, but the whole network was in crisis," she said.
"It was better April 4 than April 3, and it was better April 5 than April 4. "