Coroner Géhane Kamel’s report | “We tolerated the intolerable” in the CHSLD

Quebec’s national director of public health should no longer wear two hats. Several questionable decisions, including one “of rare insensitivity”, were made at the CHSLD Herron. And Minister Marguerite Blais delivered the testimony “the most credible despite the speech formatted for the present investigation”.

Ariane Lacoursiere
The Press

These are some of the conclusions contained in the report by coroner Géhane Kamel, who looked at deaths that occurred in CHSLDs in the spring of 2020.

In 2021, Coroner Kamel heard from more than 200 witnesses. In her report released on Monday, the coroner makes a series of hard-hitting observations and recommendations.

The coroner returns in particular to the crisis which affected the CHSLD Herron, where 47 residents died in a short time at the end of March and the beginning of April 2020. M^and Kamel notes that at CHSLD Herron, like at the intermediate resource Manoir Liverpool in Lévis, significant shortcomings had been noted long before the pandemic. And yet, the health network did not hesitate to entrust vulnerable seniors to it.

For the CHSLD Herron, the coroner believes that “the follow-up was done aesthetically”. Manor Liverpool was “known for recurring difficulties for at least five years”. Coroner Kamel writes that it is “therefore surprising to hear the CEO who was in office at that time (Editor’s note: Daniel Paré, appointed in 2020 as head of the provincial vaccination campaign against COVID-19) endorse preventive measures. accompaniment and support over such a long period without being aware of the seriousness of the alleged measures”.

Criticisms of Herron’s Doctors

While the virus was claiming more and more victims at the CHSLD Herron, the three doctors of the establishment were content to do telemedicine, which “led to approximate care”, writes the coroner. She notes that it is only on April 12, 2020 that the doctors of the CHSLD Herron will come to the field, when “more than 50% of the residents were dehydrated”. In her recommendations, the coroner asks the College of Physicians to “review the individual medical practices of the attending physicians of CHSLD Herron, des Moulins and Sainte-Dorothée, in particular with regard to their decision to continue teleconsultation care despite the need for support and the huge number of deaths. The College of Physicians has already reacted on Twitter by announcing that this recommendation will be followed.

A callous decision

Still at the CHSLD Herron, Mr.^and Kamel criticizes the managers of the CIUSSS de l’Ouest-de-l’Île-de-Montréal for having decided at the start of the crisis to consider the entire CHSLD Herron as a “red” zone. A decision “of rare insensitivity, absolutely ruthless and which raises the question: where were the CIUSSS infection prevention and control experts? writes the coroner. The latter believes that such a measure “would have been absolutely decried if it had been applied in a hospital center” and that “that day, we tolerated the intolerable”.

Coroner Kamel also criticizes the call made to 911 by the CEO of the CIUSSS de l’Ouest-de-l’Île-de-Montréal, Lynn McVey, on April 11. “It is difficult to understand the purpose of this call since the situation was alarming as of March 29, 2020,” writes the coroner.

For her, we wanted to lay all the blame on the management of the CHSLD Herron, closed in November 2020, when we must also look at the “disorganization of the CIUSSS management team”.

Marguerite Blais was credible

Coroner Kamel points out that several testimonies given to her were contradictory. She believes that the testimony of the Minister responsible for Seniors, Marguerite Blais, is “the most credible despite the speech formatted for the present investigation”. And that it seems that the government only really started to prepare the CHSLDs in March 2020, according to coroner Kamel. It speaks of the “undeniable contribution” of Minister Blais and her deputy minister during the crisis.

In her report, Coroner Kamel is also interested in the “two hats” of the national director of public health in Quebec, who is also deputy minister. “Two distinct roles” which “may not be compatible”, according to the coroner. “This is perhaps what puts a filter on the transparency of the backstory” since “health imperatives do not necessarily correspond to the political and economic interests of a government”.

For her, it is “imperative that public health authorities benefit from total independence to base their directives on scientific bases and in application of the precautionary principle”.

M^and Kamel also believes that this “precautionary principle” should “be enshrined in the legal and regulatory provisions that govern public health”.

The coroner concludes her report by issuing more than twenty recommendations. Including the enhancement of the training of nurses in CHSLDs. It also invites the government to “make a retrospective of the events by the vehicle that it deems appropriate”. ” We are at the crossroads. This tragedy, which will unfortunately have marked the history of Quebec, must push us to innovate and break out of institutional paradigms. For these seniors, for these bereaved families, for these thousands of health care workers, we have this duty to remember,” concludes the coroner.