There are a few things to know about Olga Maculavicous, who died at CHSLD Herron, one of Quebec's hardest-hit long-term care homes during the pandemic, in the spring of 2020.
First is that she drove a Trans Am sports car with flames on it and wings in the back. Second is that she loved to pick mushrooms and cook them fresh for her grandchildren.
Third is that she was a nurse for decades in Montreal hospitals, caring for children and sick people with the kind of dignity she herself did not receive in the last days of her life.
"She was feisty and tough and profoundly independent," her grandson Paul Cargnello, 43, said in an interview Tuesday.
Maculavicous died on April 1, 2020, as the private long-term care home in Dorval was in the grips of a crisis so serious it captivated media attention for two years afterward, but failed to shake people in charge to act quickly enough at the time.
She was one of 47 people to die at Herron between March 12 and May 1, 2020, and one of the 53 people whose deaths were examined as part of coroner Géhane Kamel's inquiry into what went wrong in long-term care homes and seniors' residences during the first wave of the pandemic in Quebec.
Kamel published her report Monday after hearing months of testimony from 220 government officials, long-term care home employees and the loved ones of people who died.
She issued 23 recommendations targeting the provincial government, its Health Ministry, local health boards and the Quebec College of Physicians, calling for greater oversight and accountability in their institutions.
Kamel analyzed the medical histories and circumstances of death for all 53 people at the seven facilities targeted by her inquiry. It is with their stories that she began each section of the report.
'Lack of care'
In it, the coroner wrote that she believes Maculavicous died of kidney failure, possibly brought on by dehydration. There were no notes on her file at the home between March 26 and March 31, 2020.
Kamel wrote that it was possible that "a lack of care was the cause of death."
Maculavicous, whose grandson says she was in her 90s, died overnight between March 31 and April 1. Her body was found, already cold, at 5:50 a.m.
Maculavicous was born in Lithuania but escaped in her teens as the country was occupied first by the Soviet Union, then Nazi Germany and again by the Soviet Union during the Second World War.
"She survived horrible, horrible things," Cargnello said in another interview with CBC News Monday, reacting to the publication of Kamel's report.
"And then this is how she has to go, with no proper respect, no proper dignity. It's not fair."
Maculavicous was stoic about the events she lived through in her youth. But as Cargnello poked and prodded later in her life, she began to open up.
"I think it might have been a relief, I can only suspect," he said.
Cargnello is wary of "individualizing" what happened at Herron. Every single person there lived a hard life, he says, and deserved to die in dignity.
For-profit doesn't work, says grandson
He agrees with most of Kamel's recommendations but rejects her suggestion that private long-term care homes should be at least partly subsidized. Cargnello believes the very spectre of profit in health care is a slippery slope.
"It's such a tragedy and a travesty to choose profits over these people," he said.
Tuesday morning, the CIUSSS de l'Ouest-de-l'Île-de-Montréal, the West Island health board overseeing Herron and which took control of the home March 29, 2020, announced CEO Lynne McVey would not be seeking to renew her mandate in July.
Cargnello said he sees her resignation "as a very positive thing," but that more action is needed to bring about the kind of systemic changes required in Quebec's elder care network.
Carol Barrette agrees. Barrette's father, Leon Barrette, was 93 when he died at CHSLD Herron on March 29, 2020, barely two days after having been transferred there from the McGill University Health Centre.
Kamel wrote in the report that the information in Barrette's file was so sparse, "we're under the impression he was forgotten and died alone."
Barrette said her father's death certificate listed dehydration as the only cause. She still wonders what happened in the 48 hours between his arrival at Herron and his last moments.
"Did no one come in to see him and tend to him?" Barrette said in an interview Tuesday.
Barrette remembers her father as a gentle soul, "the nicest man I ever knew." He was a hard worker, but each summer the family vacation in different places. He was still driving at 92.
Next Thursday, Barrette's family will be receiving another form of closure in the death of their beloved "Leo," whose memory will finally be honoured in the form of a proper memorial and burial service.
"It's been a long time coming and it takes place at our parish church, where my brothers and I all had our first communion," said Barrette, who has two brothers.
Patrick Martin-Ménard, the lawyer who represented several families during the inquiry, said he is satisfied with Kamel's findings but that there needs to be accountability at a higher level.
Martin-Ménard is calling for a public inquiry into what happened, so that public health officials must answer to failures in the system as a whole.
Few took responsibility
He noted that many witnesses in the inquiry by Kamel, whose duty was not to lay blame to specific individuals, avoided taking personal responsibility.
"Very few of them have actually called themselves or their own decisions into question, and that's a problem," said Martin-Ménard.
Premier François Legault said Tuesday he was not given complete information about the situation at Herron at the time by the West Island health board.
Martin-Ménard believes McVey should not be alone in shouldering blame for what happened at Herron.
"There's been significant shortcomings … on the part of decision-makers who intervened on site, who saw the terrible situation the residents were in and who did nothing really proactive enough to help them," the lawyer said.
"You can remove the person in charge, but it will not change anything as to the systemic failures that led to this situation to happen in the first place."