Vulnerable seniors suffered “extreme” and “unbearable” heat during two heatwaves in the summer of 2020 in a private residence in Montreal, to the point where authorities had to evacuate five emergency users and one man was found dead in his room.
“It’s terrible to leave people in there,” said a patrolman from the Emergency Measures Service, after arriving at the Ville-Marie residence, in Plateau Mont-Royal, on the evening of June 23, 2020.
“We are having difficulty breathing,” another speaker testified on July 9, 2020, describing the heat as “unbearable.”
In the midst of a heatwave and the COVID-19 pandemic, users with mental health disorders who lived in this intermediate resource (IR) in Montreal lived in suffocating conditions:
- The temperature felt reached 48 degrees
- Air conditioning problems in several rooms
- Heating worked in some rooms
- Residents wore boots and coats
- They were served hot soup and lasagna
All these facts were recorded in a “confidential” administrative investigation report carried out for the Integrated University Health and Social Services Center (CIUSSS) of the West Island of Montreal (ODIM), which The newspaper obtained after more than a year of efforts at the Access to Information Commission. Recently, The newspaper demonstrated that Access requests can be very complicated and not very transparent despite the public interest.
Two heatwaves in 2020
“This entire period was very trying for the residents who experienced it, their integrity and their well-being having been undeniably affected,” wrote attorney Gilles Lauzon in his November 2020 report.
“Photo COURTESY, Excelsoins”
In 2020, the Ville-Marie residence was an RI and a residence for the elderly (RPA). The exhaustive 84-page document sets out the problems that occurred to RI residents during two heatwave episodes: from June 23 to 24 and from July 9 to 10, 2020. A few weeks before, the same CIUSSS had had to manage serious management problems at the Private CHSLD Herron, where 47 seniors died during the first wave of COVID-19.
“The police officers who were also dispatched to the scene noted that there was a certain panic in the RPA,” wrote a coroner in her report after the death of a 72-year-old man. “There is an obvious lack of organization among employees on the night of June 24, 2020 in connection with the oppressive heat and the significant consequences for the various residents.”
In total, around thirty patients who all had “serious mental health problems” had been placed in this RI by the CIUSSS of ODIM, since 2018. The users were on average 70 years old and several presented a loss of autonomy . Some also had other physical health problems.
- Listen to the press review commented by Alexandre Dubé via QUB :
“24/7” support
They lived on the second and third floors and required “24/7” supervision, the report indicates. As early as 2019, a report was made by the management of the residence due to high temperatures in certain rooms and the fact that some residents were wearing clothing not suitable for the heat. According to the report, the residence said it was in the submission process to resolve the problem. The RPA is located in a dense urban area.
Note that people who live with a mental health disorder are more vulnerable to heat (difficulty feeling the heat, dehydration caused by medication, etc.)
Furthermore, several safety, hygiene and care issues were raised in April 2020 in the report:
- Difficulty managing confined residents
- Dirty rooms (accumulation of waste in unemptied bins, urine odors)
- Residents have been wearing the same dirty clothes “for several days”
- Uncooked or sometimes still frozen meals
- Residents left to their own devices
On the evening of June 23, 2020, two residents were rushed to hospital due to discomfort “related to the heatwave,” the coroner wrote. One of them was even hospitalized for two weeks in intensive care “with the main symptoms: delirium, hallucinations, confusion, dehydration and disorientation,” said Mr. Lauzon’s report.
Around 3:30 a.m. on June 24, a 72-year-old resident was found unconscious in room 349. He was lying face down on the floor in the bathroom. He died of “probable medical complications during an episode of extreme heat”, writes coroner Me Stéphanie Gamache.
This resident’s family had provided him with an air conditioner for his new room, but the installation was not scheduled until June 24, the coroner’s report states. Meanwhile, there was a standing fan.
Security at risk?
In total, nearly ten emergency responders were moved to the residence on June 23 and 24, writes Mr. Lauzon in his report.
“The temperatures and humidex indices recorded at the RVM on June 23 and 24 combined with the highly documented vulnerability of elderly residents with mental health problems have strained, if not jeopardized, the safety, health and well-being of be one of these residents.”
On July 9 and 10, 2020, during a second heatwave episode, the same heat problems occurred. Five users were urgently evacuated. After this episode, the CIUSSS of ODIM transferred all its users from this RI to other facilities. An independent investigation report was then produced.
“Photo COURTESY, Excelsoins”
“Very visible” masses
After two residents left the Ville-Marie Residence, “very visible” masses were discovered, says Mr. Lauzon. For one of them, the diagnosis was reportedly advanced prostate cancer. Since the events, the Ville-Marie residence is no longer an RI. This section has been converted into residential housing. The CIUSSS of the ODIM refused the interview request of the Newspaper.
With the collaboration of Yves Lévesque
No hotter than elsewhere in Quebec, pleads the owner
The heat felt at the Ville-Marie residence was not worse than elsewhere in Quebec and the protocol was respected, argues the owner who also deplores the lack of transparency and collaboration from the CIUSSS.
“The investigator presents us as if we were the epicenter of the heat in Quebec. What is happening in Ville-Marie […] is the same situation that is happening in hospitals, in CHSLDs in Quebec. We are not unusual. We are the same. We are even better off, because we have provided air conditioning at our expense to our customers to make them more comfortable,” assures Christian Archambault, the owner of the Excelsoins group.
Photo Agence QMI, JOEL LEMAY
Protocol respected
Questioned about the report, the latter ensures that the heat management protocol was respected and that everything was done to manage the heatwave.
He denies that residents were dehydrated and specifies that only one heater was on during a heatwave. According to Excelsoins, the examples of poor care or hygiene problems cited in the report are isolated cases over three years.
“We are deeply troubled by the fact that the facts are carefully selected,” said Mr. Archambault.
“We are not perfect, far from it,” he admits, while ensuring that problems are resolved as they come. Serving soup on a hot day like that was inappropriate.”
Furthermore, Mr. Archambault deplores having received a copy of the report only in July 2022, after several requests. A lack of transparency that he considers “unacceptable”.
“They acted in a way that we have never seen […] and which for us is completely unacceptable. It’s contrary to all the principles of partnership we know.”
“Left to our own devices”
“We had no support. We had very little information communicated to us. […] We were left to our own devices to a certain extent.”
The owner also denounces that the CIUSSS called on the police to force recalcitrant residents to move in July 2020.
“For us, it’s terrible to experience something like this,” laments Mr. Archambault.
The evening of June 23 to 24 at the Ville-Marie residence
4:50 p.m.: a resident fell on at least three occasions. Patient ‘seems confused’
Around 17H: Call to 911
Around 7:45 p.m.: the patient is transported by ambulance to the CHUM.
The paramedics reported a situation of “overwhelming heat” to the Environmental Emergency and Major Emergencies Guard of the Montreal Public Health Department.
Around 10 p.m.: A patrolman from the Emergency Measures Service arrives at the residence. “It’s terrible to leave people in there,” he said.
There is a wall-mounted air conditioner in the hallway. “This one is working, but it seems faulty and there is no cold air, only hot air, being expelled.”
The temperature reaches 31°C in room 2029. “The electric baseboard is in operation and producing heat.”
10:35 p.m.: A supervisor from the Ville-Marie residence is contacted and is on the way
Around 10:40 p.m.: A resident falls in room 3005. He is in a “semi-conscious state, difficulty breathing.” 911 is contacted.
Around 11:15 p.m.: Arrival of paramedics. A second resident is transported to the emergency room.
- New report of oppressive heat by Urgences-santé.
At the same time, the residence maintenance services manager arrives on site.
“There were only two free fans in the entire residence, no air conditioner. He explained to me that he had made a request for the purchase of air conditioners, but that he had not yet heard back from the company, which, according to him, should take more or less 24 hours,” he explained. -he explains.
He then said he could close the vents of the air exchanger system on the roof to prevent hot air from entering, but that would only go into the morning.
Around 12:46 a.m.: An action plan is established after a conference call:
- Room rounds every hour to check the condition of residents
- Temperature monitoring
- Move users of rooms where the heating was on to the basement. In fact, only one resident on the 2nd floor will be moved.
- Water distribution
Around 2 a.m.: A second patrolman arrived with 159 cooling ties, but they were not cold. They are placed in the freezer.
Around 3 a.m.: distribution of refreshing ties.
Around 3:30 a.m.: A resident was found unconscious in room 349. He was lying face down on the floor in the bathroom.
Around 3:40 a.m.: Paramedics arrive, but no maneuvers are performed on the resident.
Around 9:30 a.m.: Two police investigators were dispatched to the scene due to the death.
*Source: “Confidential” administrative investigation report carried out by Gilles Lauzon for the CIUSSS de l’Ouest-de-l’île-de-Montréal