The coroner's inquest into how people were treated in Quebec's care homes during the first wave of the COVID-19 pandemic is hearing how things worked — or didn't work — at one residence in the Quebec City region.
Manoir Liverpool in Lévis made headlines when reports surfaced that the mixed public and private residence was filthy — its residents neglected, undernourished and dehydrated.
Coroner Géhane Kamel has focused on one death that occurred on April 26, 2020 at Manoir Liverpool, as a way of looking at the bigger picture.
She was clearly shocked by what she heard about 60-year-old Jacques Levesque's demise during hearings on Wednesday.
"It was a preventable death," she said. "It's sad and distressing."
Uncharacteristically, the coroner, a workhorse who has the habit of shortening breaks and extending the day, adjourned for lunch early.
"I've heard enough for this morning," she said curtly.
An auxiliary nurse — her name is under a publication ban — who was in Levesque's room had just testified about how she had watched him choke to death.
She told the coroner she had been too scared to approach Levesque as she watched him choke and change colour. Once he stopped moving, she performed CPR, but later testimony explained the manoeuvres were likely ineffective as he was hanging off the bed, his torso in mid air.
Levesque had diabetes and several witnesses testified his blood sugar level was hard to control. An otherwise kind man, Levesque could become aggressive when it dropped and he became hypoglycemic.
A co-ordinator at the home testified he once hit her during an episode but said she understood it was involuntary.
The nurse who was in his room said she took his blood sugar level and realized he was at risk of falling into a diabetic coma. She gave him sweetened orange juice, a snack including peanut butter on a piece of bread and a prescribed sweet gel.
Shortly afterward, he started to rock while sitting in his bed and threw a tissue at her and an orderly who was in the room. They took that as a sign of aggression and the orderly warned the nurse not to approach him.
So she didn't. Not when he started to choke. Not when he began to change colour.
After the testimony the coroner told the nurse she hoped she had found inner peace despite not having helped a man who was agitated, not aggressive, while he choked to death.
Staff and managers at Manoir Liverpool testified there was never a debrief after Levesque's death, something the coroner said she found unusual and that "fascinated" her.
The owners of Liverpool testified they did not know how Levesque died until months later.
The pandemic 'war zone'
Several witnesses were called to testify about how the home dealt with the pandemic.
At the end of March 2020 the residence received confirmation that four residents had tested positive.
Co-ordinators testified as soon as staff learned this, panic swept through the building and several employees abandoned ship.
Public health also ordered several staff and managers home because they were symptomatic or had been in contact with someone who was COVID positive.
The general co-ordinator testified that in one day, she lost 75 percent of her staff. She herself was in isolation for a week.
In the lead-up to the last weekend of March and again on April 9, management contacted the regional health board, the CISSS, to say they needed reinforcements otherwise there would be a break in service.
Starting in April, the health board sent two managers and an army of staff over a nearly three month period.
One of those CISSS managers, nurse David Lacombe, said he walked into an institution that was in chaos: sanitary measures weren't in place or were not being followed properly by staff, residents who were COVID-positive were poorly identified.
A nutritionist testified many residents were underfed, dehydrated and being fed food textures that were not suited to their ability to chew or swallow.
Several people who were present during those first weeks of the pandemic described the home as a "war zone."
Lacombe said the staffing shortages were so crippling corners had to be cut.
Witnesses testified several managers and the owners at the Manoir Liverpool worked from home for much of the first wave. The coroner compared the situation to "going to war without a captain."
A Radio-Canada investigation which aired in April 2020 brought to light several problems, including severe care and hygiene issues at the home.
In response to the media report, the health board launched an internal investigation which corroborated many of the findings. It also said the problems had been present before the pandemic and were made worse by COVID.
But early in the week, the CEO and the director of quality, performance and ethics for the health board testified they had not been informed of the problems before Radio-Canada reported on them.
Coroner Kamel questioned how the health board could have remained in the dark when its staff had been in and out of the home since 2014.
The inquest will now move on to study other residences, including CHSLD Herron in Dorval, and is expected to take months.