`There was no one who saw the big picture'

Coroner plans to recall witnesses, extends hearings by three days

Coroner Géhane Kamel had slept badly on Wednesday night, she announced Thursday as she opened what had been scheduled to be the final day of hearings into the 47 deaths at the Résidence Herron during the first wave of the COVID -19 pandemic in 2020.

Perturbed by contradictory testimony she has heard since the inquiry into the deaths at the Dorval private long-term care centre (CHSLD) began Sept. 7, she is adding three days of hearings — Oct. 25 through 27 — and recalling at least four witnesses. She did not name them, but wants “to challenge them” about information they provided in their testimonies.

“I had the impression of leaving with many questions and half-answers or answers that did not satisfy me,” she said. “If I were one of the families affected by this tragedy, I would be leaving with so many questions — and that is the opposite of what we should be doing. We must shed at least a modicum of light on all this for them.”

The role of a coroner's inquiry is not to look for “absolute accountability on the part of one party or another,” Kamel said. “What we are looking for is the truth.”

And in the Herron file, she has the impression that “the truth is random” because witnesses's versions of events have so often contradicted one another.

When officials with the West Island health authority, the CIUSSS de l'ouest-de-l'île-de-montréal, entered the Herron March 29, having placed the facility under trusteeship, they found many residents unfed, dehydrated and lying in their own urine and excrement.

Even before the pandemic the facility, with about 140 residents, was short-staffed.

The evening of March 28, word spread among staff “the virus was in the building ” that a resident had died in hospital the previous day and, according to some witnesses, employees abandoned the Herron en masse. Kamel told the inquiry Thursday she will view videotapes of surveillance cameras at the Herron for March 27 through 29.

Witnesses, including Samantha Chowieri of the Groupe Katasa, the company that owned and operated the Herron until it closed that November, have described a chaotic scene in which staff was scarce and widespread confusion reigned.

“The government does not have clear rules when it puts a place under trusteeship,” she told the inquiry on Thursday. “There has to be a person in charge,” she said. “A trusteeship should not be left in the hands of the CIUSSS without a clearer structure.”

Kamel said more than once this week there was “a black hole” at the Herron between March 29 and April 10. “Even from the CIUSSS people, we received incomplete answers,” she said. “There was no one who saw the big picture.”

Christiane Boucher, one of a number of children of Herron residents who died during that chaotic period and who addressed the inquiry on Thursday, said “a system that was supposed to help my father killed my father.”

There was “a disconnect with human care to the end.” The pandemic, she said, merely “exposed the fact that the system is broken.”

Before the pandemic, Denis Boucher was restrained in his bed at night because of a lack of staff — and overmedicated, she said.

For the hearings to lead to change so that a horrific situation like that at the Herron is not repeated “would mean a complete overhaul” to introduce proper communication, accountability and a universal emergency plan adhered to by all branches of the health-care system, Boucher said.

All long-term care centres should be not-for-profit, she said, “and workers need to be heard: They are at the heart of the action.”

Tina Gurekas's mother, Olga Maculediciu, was a grandmother and great-grandmother, someone who had a career in dietetics and lived a productive life — and when she died at the Herron, her belongings were raffled off or discarded.

“We are angered and disappointed that the system did not look after her,” Gurekas said, describing “a complete lack of communication and co-ordination” at the Herron. She said communication by staff with families ceased after visits were stopped not long after the pandemic was declared on March 11, 2020 — and did not resume once the CIUSSS took over.

The government needs better oversight of for-profit longterm care centres, a partnership between hospitals and nursing homes and a province-wide disaster plan, Gurekas said.

“After nearly three weeks of hearings, we don't know what happened between the moment our father entered Herron on March 27 and when he died March 29,” Peter Barrette said. “No one seems to have seen him. We know the situation was chaotic. Why did they agree to accept a new resident when they knew they could not take charge?”

Barrette said he and his family “deplore the fact that no criminal charges were laid” in connection with the CHSLD Herron deaths.

As a milieu of care, a CHSLD should have rigorous and structured care, he said, with personnel guaranteed a fixed number of hours to keep them from going from centre to centre.

Barrette favours the nationalization of all CHSLDS and the creation of “a public network that has as its goal not to provide profits for owners but to provide humane care for people in the latter days of their lives.”