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Quebec coroner questions why more wasn't done for neglected Herron residents

Why wasn't more done?

The Quebec coroner overseeing an inquest into long-term care deaths questioned Tuesday why more wasn't done to help residents at a Montreal-area home where dozens died.

Coroner Géhane Kamel has repeatedly asked why it took regional health authorities days to get more employees and front-line staff to Résidence Herron, calling it a "black hole" in her investigation.

Kamel raised the issue again Tuesday as witnesses from the regional health authority took the stand. Even though health network managers had seen by March 29, 2020 that residents weren't getting enough to eat or drink at the understaffed private facility, the inquest heard of a chaotic situation that persisted at the care home well into early April 2020.

Alexandre Mercier, a human resources employee with the health authority for western Montreal, testified that lives might have been saved if they had dispatched more staff to the hard-hit home.

While managers had shown up to help at the residence in late March, the request to send staff to the facility only reached Mercier on April 5. He visited the site two days later and found it disorganized and understaffed with some rooms smelling of urine.

A day later, one of his colleagues confided she wasn't confident the residents would survive the month. Mercier said there appeared to be confusion about the role the health authority was supposed to be playing in what was not a typical trusteeship.

The coroner asked Mercier why residents weren't transferred to other facilities. He said the entire system was overwhelmed by staff shortages and there were fears of overloaded emergency and intensive care units and of COVID-19 spread.

"So we sacrificed them," Kamel replied.

Later Tuesday, Nathalie Pigeon, a senior adviser on infection prevention, said she toured Herron on April 4, finding that personal protective equipment was sparse.

A nurse by training, Pigeon visited with some patients and said some rooms of smelled of urine. Patients were weak, and some were very dehydrated with dry mouths.

"I couldn't believe that people were in this kind of state in Montreal," she said.

Premier François Legault was asked Tuesday about the hearings and said what happened at Herron was terrible. But he said improvements have been made since the pandemic hit, and he pointed a finger at health reforms introduced by the previous Liberal government, which was defeated in 2018.

"I think that today the situation is very different, I think that we’re almost a model, there’s almost nobody having COVID-19 in our (long-term care homes), so it’s a major change," Legault said in Quebec City. "What happened at Herron was unacceptable and terrible, and I hope that I will never see that again in my life.”

The coroner's mandate is to investigate 53 deaths at six long-term care homes and one seniors residence — including 47 at Herron — during the first wave of the COVID-19 pandemic.



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