Herron timeline dissected on inquest's first day
News of the first Covid-19-related death at CHSLD Herron reached the local health authority on March 27, 2020. One patient had been confirmed positive and was transferred to the Jewish General Hospital, where they died.
The incident was recounted
Tuesday as part of the testimony of Lynne Mcvey, director of the CIUSSS de l'ouest-de-l'île-demontréal, on the first day of the inquest led by coroner Géhane Kamel into the deadly COVID-19 outbreak at the Dorval CHSLD in the spring of 2020.
Two weeks after that first confirmed death, Mcvey called the police in the middle of the night to request an investigation into what was happening at the long-term care facility, where 47 people died during the pandemic's first wave. What happened during and after those two weeks was examined and re-examined on Tuesday.
On March 29, Mcvey received an email from a doctor working at the Herron saying there had been no nurses at the facility for 24 hours. When three CIUSSS employees arrived on site later that day to assess the state of affairs, they found a “very preoccupying” situation.
Once there, they found only the owner, her partner and one employee for 133 residents.
“No one was giving food to patients, their bedding hadn't been changed, the floor was sticky,” Mcvey said.
At 12:06 a.m. that night, Mcvey wrote to the deputy health minister describing what had happened and saying “the basic needs of residents weren't being adequately met.” In the days that followed, despite assurances from the Herron's owner to the contrary, the staff shortage continued. Mcvey began sending CIUSSS personnel to help.
“We were sending three to seven people per shift,” she said. “By April 10 or 11, we were sending 20 to 60 people per day. The need was there. There was a gap between our understanding of the gravity of the situation and the owner saying she had enough people to manage the situation. There was a lack of communication which rendered the situation very difficult to manage.”
Mcvey's team heard from Herron employees that the owner was telling them not to come in, and that she would not pay them if they did. Mcvey 's team also had trouble accessing staffing schedules and names and contact information for patients and their families.
They could also not access certain parts of the facility to get bedding and medication, and for employees to safely change into and out of their personal protective gear. She sent two formal notices demanding those things to the Herron, on April 5 and 8.
On April 3, with five patients and six Herron staff who had tested positive for COVID-19, Mcvey emailed Montreal public health director Dr. Mylène Drouin seeking authorization to put the Herron under trusteeship.
After not hearing back, she finally called Drouin on April 7. Unbeknownst to Mcvey, Drouin had been trying to resolve the situation on her end. Drouin agreed to issue an ordinance for the Herron to be taken over.
By April 10, Mcvey's team finally got the keys and a list of staff who had been in contact with infected patients. But over the course of the day, she discovered a large discrepancy in the number of deaths reported by the Herron and her team's list of residents at the facility, “and we questioned if all the deaths had been reported.” The number of deaths since March 13 was not 13, as per the Herron's account, but 31.
That night, she called police. Sgt.-det. Andréanne Laplante and Drouin testified at the inquiry Tuesday morning.
Laplante was one of 10 investigators who arrived at the facility on April 11, 2020, warrants in hand.
“Our goal was to get proof — computers, documentation, lists of residents, staff, families,” Laplante said. “My team and I spent the night and the weeks that followed continuing our investigation.”
They requested interviews with some 60 witnesses, 10 of whom refused — including the owners of CHSLD Herron.
The outbreak at the centre, first reported by the Montreal Gazette's Aaron Derfel on April 10, was the first real sign that the pandemic was spiralling out of control in Quebec's long-term care facilities at the beginning of the first wave.
The inquiry was originally scheduled to take place last winter, but was postponed at the request of the Herron owners' lawyers so as to avoid it interfering with a possible criminal case.
The Directeur des poursuites criminelles et pénales (DPCP) has since announced that no charges would be filed in the case.
Among the most pressing problems found by police, “from the very beginning,” was a lack of staff, Laplante said.
“It wasn't just a problem at the Herron,” Laplante said. “We quickly determined this problem existed at many locations.”
It didn't help that potentially infected staff had to isolate for 14 days at the time.
Drouin first learned of the problems at the Herron on April 3 from Dr. Richard Massé, consultant to Quebec public health director Dr. Horacio Arruda. Massé advised her as to her legal powers to issue an ordinance to establish protective
No one was giving food to patients, their bedding hadn't been changed, the floor was sticky.
health measures at the Herron.
An investigation was opened and an ordinance issued on April 7 by Drouin after her conversation with Mcvey. Drouin said she issued the ordinance because she “believed there was a threat to the health of residents.”
It would have been difficult to act sooner, she added.
“In early April, there were already 46 outbreaks in long-term care facilities and old-age homes. By the (end of the) first week of April, there were 90 active outbreaks.”
Drouin and her team soon determined that a big problem was “the mobility of staff between establishments. Our priority was to limit (the damage), if a worker at the Herron had been to two other establishments, to put in measures so all the health workers could be investigated, like those at other CHSLDS.”
The coroner's inquiry at the Herron continues during the month of September.