The lack of independence granted to Quebec's public health director may have slowed the government response at the beginning of the pandemic, as hundreds were dying in long-term care homes across the province.
Coroner Géhane Kamel published a report Monday following months of inquiry into deaths in seniors' residences, where the pandemic killed more than 5,000 in the spring of 2020.
After hearing testimony from 220 government officials, long-term care home employees, and the loved ones of people who died, Kamel issued 23 recommendations targeting the provincial government, its Health Ministry, local health boards and the Quebec College of Physicians.
One of the report's first recommendations calls on the government to review the role of its public health director so that whoever is in the position can exercise their functions "without political constraints."
The public health director in Quebec is also a deputy health minister, but Kamel wrote that the two roles "are distinct and may not be compatible."
Kamel provided as an example that masks were not mandatory in CHSLDs (Centre d'hébergement de soins de longue durée) at the beginning of the pandemic.
"Would his advice have been the same had he not had to worry about potential stock shortages? I tend to think not. Hence, in my humble opinion, the danger of wearing two hats," Kamel wrote in the report, which can be read online.
At the time, Dr. Horacio Arruda held the role. He resigned at the end of 2021, and was replaced by Dr. Luc Boileau as interim director. Before that, Boileau was the head of the province's institute of public health (INSPQ).
In her report, Kamel notes that in the early days of the pandemic, infection control measures were far more strict in hospitals and at testing clinics than in long-term care homes, where there were far more COVID-19 cases.
"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 that provided a clear timeline of the government's decision-making, Kamel said.
Kamel questions why doctors were absent in some of the long-term care homes where high numbers of people died, and why they relied on phone consultations instead of providing in-person care.
"For a coroner, that many residents died without being allowed a doctor's visit during their final illness is not only sad, but disturbing," Kamel wrote.
"It is hardly conceivable that decisions of life or death could have been made on the basis of a telephone relay alone."
More accountability needed
Kamel was scathing in her recounting of the events that unfolded at one of the long-term care homes she examined in the inquiry, CHSLD Herron in Dorval, Que. Forty-seven of the 53 deaths analyzed in the inquiry took place at Herron in the spring of 2020.
The residence had long been short-staffed and had done little to remedy the situation even as it became clear the COVID-19 pandemic was spreading across the world, according to the report. The doctors responsible for the home's residents did not show up, until weeks after the crisis had killed dozens of them.
The West Island health board took control of the long-term care home on March 29, 2020, after one of the owners called the province for help, but several more residents died afterward as confusion reigned over who was responsible for what.
What's more, the health board appeared more focused on its image and blaming Herron than getting to the root of the problems at the home, Kamel said, noting it had hired a communications consulting firm.
She wondered why Lynne McVey, the head of CIUSSS de l'Ouest-de-l'Île-de-Montréal, took pains to call 911 in the middle of the night April 11, when her health board had had control of the residence for more than a week already.
"Listening to the audio of the 911 call by Madame McVey, it's hard to understand the purpose of the call since the situation had been alarming since March 29, 2020," Kamel wrote.
Earlier that day, Montreal Gazette journalist Aaron Derfel had published an investigation unveiling what was happening at Herron.
The head of the TACT firm, Daniel Desharnais, is now associate deputy health minister and was questioned by Kamel during the inquiry.
Had the CIUSSS and Herron agreed on each other's roles in the crisis, several deaths could have been prevented in early April, the coroner wrote.
The weekend of April 4 to 6, 2020, five days after the CIUSSS took over, was particularly gruesome, Kamel recounted. Whoever was left of the staff — many were sick or had deserted out of fear and frustration — did not know who to refer to for decisions.
Residents were lying in urine and feces. The bodies of those who died were left in their rooms for more than 24 hours before being taken away to a funeral home.
"That image alone is unworthy of a civilized society," Kamel wrote.
Each death provided clues
In her analysis of each death at Herron, Kamel often highlighted the absence or serious lack of medical notes, making it impossible to know if people were given care for their medical conditions. Many causes of death were difficult to determine because of a dearth of information, or because the result to their COVID-19 test was lost or not on file.
In some cases, dehydration or starvation appear to have contributed to the speed at which residents died. That was the case for Olga Maculavicous, who Kamel wrote died because of "a lack of basic care" on April 1, 2020.
WATCH | Olga Maculavicous's grandson wants greater accountability:
Days before, on March 29, another resident, Leon Barrette, was found dead shortly after having been transferred from the McGill University Health Centre.
"The information on file is so sparse, we're under the impression he was forgotten and died alone," Kamel wrote.
In the case of Thomas Baur, who died March 28, 2020, one of the Herron doctors had a conversation about end-of-life care with a family member — without consulting Baur himself, who was cognitively capable of providing consent or not for the kind of treatment he wanted, the report said.
Thelma Jean Allo died of a "heart failure after failing to receive adequate care" on April 8, 2020, wrote Kamel.
Hanna Piechuta died April 4, 2020, after a "lack of basic equipment such as oxygen cylinders … contributed to accelerating her death."
Amid the health crisis on March 23, 2020, Patricia Gaudet was also transferred from a hospital to Herron, where she died barely two weeks later, "begging the question," Kamel wrote, "why have authorized a transfer to CHSLD Herron?"
Calling for safer ratios
In the report, Kamel also discusses the need for more ways to monitor services in long-term care settings and creating an obligation to intervene in the event of problems.
She recommended there be safer ratios for the number of professionals to residents in CHSLDs.
Kamel said the health board's management team was disorganized and she called for greater accountability for managers in local health boards, which oversee long-term care homes.
She said private CHSLDs should receive some government subsidies in order to ensure they can provide residents with proper care.
Kamel did not say whether the government should move forward with a public inquiry, as the Opposition has called for, but said it should "make a retrospective of the events in the way it deems appropriate."
She said the hierarchy of decision-making, agility of the health system in times of crisis and the understanding and execution of responsibilities among the ministries of health and seniors, as well as within local health boards, should be among the areas that warrant an audit.