A total of 47 people died at the Herron long-term care home in the Montreal suburb of Dorval during the pandemic's first wave in the spring of 2020.
There were higher death tolls at other long-term care homes in the province and beyond, and many of the documented problems — a shortage of staff, a lack of personal protective equipment — were present elsewhere, too.
But the appalling conditions experienced by many of Herron's 133 residents, detailed in news reports in early April 2020, shook the public and prompted larger questions about the state of the long-term care system in Quebec and across the country.
"What happened at Herron wasn't an isolated incident — it's happened throughout Quebec and in every province in Canada," Moira Davies, whose father, Stanley E. Pinnell, died at Herron, told the coroner's inquest into the home.
Davis called for a national inquiry into senior-care residences and an end to private facilities.
WATCH | Families of former Herron residents seek accountability for 'nightmare' conditions:
The inquest into the deaths at Herron took place over three weeks and included testimony from nurses, doctors, officials with the local health authority, the owner of the privately run home, and the families of residents.
It was scheduled to end Thursday, but coroner Géhane Kamel extended the hearings after families of residents who died said they still have questions after hearing contradictory testimony about what happened at the home.
Three more dates will be added at the end of October to hear from at least four more witnesses.
Here's a look at what we have learned so far.
Crisis continued after health authority took over
The first confirmed COVID-19 case in the home was on March 27, 2020.
Samantha Chowieri, the owner of the home, told the inquest she called the local health authority, the CIUSSS de l'Ouest-de-l'Île-de-Montréal, the following day for assistance, as staff began to get sick.
By the morning of March 29, many of the workers who were supposed to be on shift had left. Others had not shown up at all.
Officials with the local health authority said they found only a handful of staff on duty, the hallways dark and quiet, and residents without sufficient food and water.
From then on, the health authority was involved in running the facility.
Yet the poor conditions persisted through early April. One worker, whose name was under a publication ban, described the situation during the first week as "chaos."
Even after the health authority took control, residents lacked basic care for several days, witnesses said. By April 11, a total of 31 residents had died.
"I felt anger that we were told that everything was under control, and yet people were still dropping like flies," the same worker told the inquest.
An infection control specialist with the CIUSSS, Nathalie Pigeon, testified that she sent a member of her team to evaluate the measures at Herron on March 30, 2020. That inspection found many problems, including a shortage of disinfectant and handwashing stations, and no clear indication of which patients were positive with COVID-19 and which were not.
Pigeon testified that she visited Herron to follow up on April 4, and found that most of the recommendations from the March 30 inspection had yet to be implemented. At that point, the entire building was declared a red zone.
Bureaucratic tension contributed to the problem
Questions lingered throughout the coroner's inquest over why precisely it took so long for the situation to improve. Kamel often described the reason for the delays as a "black hole" in her investigation.
Several workers testified that managers from the local health authority and the residence weren't on the same page as they tried to rectify staffing shortages, access to patient records and a lack of equipment, including personal protective gear and basic medical equipment to measure oxygen levels.
Emails introduced as evidence showed a lack of co-operation between the health authority and the owners of the home, the Katasa Group.
At one point, Kamel commented to a witness that her testimony was creating the impression "that Herron people stayed in their offices, that the [regional health authority] remained in their offices, and that in the middle of all that, while there are small procedural tussles, that there are people who are dying."
Deaths could have been prevented, worker says
The goal of the inquest, Kamel repeated throughout, was to determine whether deaths at the home could have been prevented.
Alexandre Mercier, a human resources worker at the health authority, was candid on this point: If action had been taken sooner, "we might have avoided a lot of deaths."
Despite the abhorrent situation inside the home, he was not asked until April 5 to recruit more staff, he said.
When asked why it took so long, Mercier said: "I think there were things to be clarified, namely what our role was, our responsibilities, maybe."
Facility was understaffed, disorganized
Staffing was a problem at the home long before the pandemic. In fact, Herron lost many of its workers to the public system in January 2020 following a recruitment drive.
At the time, Herron paid orderlies $14 an hour, while the health authority offered them $20. Andrei Stanica, the manager of the home, turned to temp agencies to find workers.
Many of them had not been trained, which contributed to the disorder at the home leading into the pandemic, the inquest heard.
Marie-Ève Rompré, a head nurse at Montreal's St. Mary's Hospital who helped at the home in early April 2020, said it was clear some residents had not been given proper care for weeks. One resident in particular had not had a bath since December 2019, Rompré said.
Hélène Paradis, head pharmacist at the health authority, described how prescription drugs for the residents were poorly organized and improperly stored when she arrived in April. She said she found vials of opened insulin and drugs in freezers with no marked dates, as well as some medications dating back to 2017 or even earlier.
In their statements to the coroner, several families called for an end to private care homes.
Peter Barrette, whose father, Leon, died at Herron, told the inquest the province should nationalize private long-term care homes in order to ensure the primary goal of the facilities is to "provide humane care" and not to "make profits for the owners."
Lynne McVey, CEO of the health authority, testified that in early April 2020, she became increasingly concerned about the situation at CHSLD Herron.
She said the health agency twice sent legal notices asking the home's owner, the Katasa Group, for the medical files of patients and information about staff at Herron, but the requests were refused.
News reports provoked change
A Montreal Gazette story by Aaron Derfel on April 10 was a catalyst for change at the home, multiple witnesses said at the inquest.
Dr. Lilia Lavallée, a doctor who had patients at the facility, said she returned to the home the day after reading the story and realizing "the extent of what was happening there."
The coroner questioned how she couldn't have known, given that other doctors had seen the situation first-hand and one even brought her family in to help care for patients.
"I tell myself that if this man [Derfel] hadn't written the article in the Gazette, would we have gone from 47 to 130 residents that died?'' Kamel said.
McVey, the CEO of the health authority, called police after the article was published. Kamel suggested the phone call amounted to a bit of "theatre," given the health authority had been involved for more than a week at that point.
After April 10, the CIUSSS brought in more staff and appointed a full-time director of care.
Health-care workers praised for their efforts
Despite the many problems at Herron, the orderlies, nurses and doctors on the front lines relayed harrowing stories of doing their best to provide comfort and care for residents during difficult circumstances.
"I got into help mode," said Brigitte Auger, an official with the health authority who helped out. "I am not a practising Christian, but I did the cross in my head, and I wanted to find, in each room, a living person."
Following their testimony, Kamel often made a point of thanking the witness for their work at the home.
"Rest assured that the coroner's office doesn't lay blame on health-care workers,'' Kamel said. "And each individual who went to work, whether in a CHSLD or at the hospital, has nothing but thanks and respect from us.''