Who was the captain of the ship?
The voice of the CEO of the Integrated University Health and Social Services Center (CIUSSS) of the West Island of Montreal, Lynne McVey, is echoing through the loudspeaker. She announces that she takes over the management of Herron “on behalf of the government”.
Herron’s owner, Samantha Chowieri, is in shock. It is approximately 9 p.m. on March 29, 2020. Mr.me Chowieri is sitting in an office at her CHSLD with Brigitte Auger, director responsible for the CHSLD – home support service at the CIUSSS.
PHOTO FRANÇOIS ROY, PRESS ARCHIVES
Lynne McVey, CEO of the CIUSSS de l’Ouest-de-l’Île-de-Montréal, during a press conference on the situation at CHSLD Herron, April 11, 2020
The conversation is tense. Mme McVey “me [dit] that the center is not going for a long time. She asks me if we’re here just to make money. She talks about abuse, ”says the owner. An official letter will be sent to him the next day.
A few hours earlier, managers from the CIUSSS arrived at Herron as reinforcements. What they discovered is beyond comprehension. Elders haven’t eaten all day. Several are soiled, abandoned in their stools and urine for hours.
Alerted to the situation, the CEO asks Quebec if she can put the establishment under supervision. It receives the agreement of Deputy Minister Yvan Gendron.
It mandates Brigitte Auger in writing as manager during the crisis.
Behind the scenes, a standoff of several days takes place between the management of the CHSLD and the health authorities. We talk to each other through attorneys. The CIUSSS sends two formal notices to the Katasa group to have access to the telephone numbers of the employees, the names, file numbers and room numbers of the residents, the list of service providers and the building keys. Items that the owners claim to have provided from the start.
Even if she has already announced that she was taking control of the establishment, Lynne McVey is increasing exchanges with deputy ministers and Public Health. She wants a “writing from the MSSS [ministère de la Santé et des Services sociaux] for the care of Maison Herron ”. “The owner asks a lot of questions,” she says. The DD Mylène Drouin, regional director of public health in Montreal, will issue an order on April 7 under article 106 of the Public health law, which allows a public health director to intervene if he is of the opinion that there is a real threat to the health of the population.
Confusion
For days, no one in the field seems to know who is doing what.
According to Mme Chowieri, the CIUSSS is responsible for the site. It was made clear to him.
On the evening of April 8, the head nurse in the emergency department of St. Mary’s Hospital, Marie-Ève Rompré, came to lend a hand. Here is what his superiors told him: “We were in support for the moment. It was not a support and it was not necessary to go beyond. ”
On April 11, a team of nurses from the Lakeshore hospital arrived as reinforcements. When they arrive, no one comes across as being responsible. “It was difficult to know what they needed and where they wanted us to go,” nurse Tina Phair wrote that evening in a stunned email to her supervisor.
Even Brigitte Auger, who is officially responsible for the management of the site, will say that her role was one of collaboration.
In my head, we go there, we help, we give our expertise. But in my head, I give Herron back to the people responsible.
Brigitte Auger
Why, then, have sent on March 30 an official letter in which the CIUSSS announces that it is taking over the management of the center “in the name of the government”, Coroner Géhane Kamel will ask him during the public inquiry.
Why did the CIUSSS support fail?
From the night of March 29 to 30, when the CIUSSS “takes control” of the establishment, one might think that the crisis is on the way to being resolved. This is not the case. Several caregivers, both those sent by the CIUSSS and the employees of Herron, report situations of extreme mistreatment and a crying lack of personnel and basic equipment until April 11.
On April 3, a nurse noticed that there was “no or practically no” equipment. Even trash cans are scarce. In the following days, she discovers thirsty residents.
Their mouths are dry and thick. “They were taking the glasses of water and it was as if they were coming out of the desert. It is sometimes impossible to have their blood drawn. “It’s caramel in [leurs] veins. ”
On April 9, a team of nurses at St. Mary’s Hospital saw a man who had not been drinking for 10 days except to take his daily medication. His tongue is chapped and his cheeks are full of ulcers. A lady has stool “up to the neck”. A resident has three incontinence briefs one on top of the other. They are brown. He has dried vomit in his mouth which prevents him from speaking.
On April 11, a team of Lakeshore nurses found dehydrated residents, dirty wounds and stuck bandages.
Staff shortage
How to explain such situations when the CIUSSS has been there for days?
The issue of staff shortages is central. Already, before the pandemic, 50% of the workforce at the Dorval CHSLD is missing.
PHOTO PATRICK SANFAÇON, ARCHIVES THE PRESS
Jacqueline Sénéchal, resident of CHSLD Herron, in April 2020
During the outbreak, it is not clear who is responsible for finding arms. For the owners of Herron, it is up to the CIUSSS to do so, they were also told in writing on March 30. They still try to find people, but very often those who agree to come do not show up. At the CIUSSS, we count for days on Herron’s help when we complete the schedules.
On March 30, nurse Maria Nelson was called to Herron through a placement agency. She is the evening coordinator, responsible for the entire establishment. She notices the lack of manpower as soon as she arrives. While theoretically she must manage the CHSLD, she rather spends the first weeks providing care.
The first evening, going upstairs, she noticed a smell of urine. Residents are not changed. Dressings were not changed.
The staff shortage will last for weeks. The lists of employees provided by the management of the CHSLD before each shift are “not compliant”. People who are on the schedule do not show up. To fill in the gaps, the CIUSSS sends people, “but sometimes it’s for two hours, three hours”. Many come to help after their shift elsewhere. This turnover is problematic. Caregivers must be constantly trained and reformed.
PHOTO ROBERT SKINNER, PRESS ARCHIVES
CHSLD Herron staff members, in April 2020
At the start, the CIUSSS called on its employees to volunteer, rather than forcing them to come and lend a hand. Herron was high on the priority list, but the territory was plagued with numerous outbreaks and under-staffed everywhere, deputy CEO Najia Hachimi-Idrissi told the coroner. According to her, even if we had forced people to go to Herron, there would not have been more employees.
In September, Alexandre Mercier, head of the human resources department at the CIUSSS, had a different speech. It was not until April 5 that he was officially asked by his bosses to find massive staff for Herron.
According to him, the CIUSSS will not succeed “ to take some form of control ”only in June. He is adamant: the situation could have been different if he had been involved as early as March 30. “There would have been a lot more staff in the previous week. We might have avoided a lot of deaths. ”
Only 40% of shifts will be filled in the first few weeks.
Why did the doctors not lend a helping hand?
On April 8, 2020, nurse Victorine Leunga loses patience. Coordinator in a public CHSLD west of Montreal, she was then on her fourth day in support of Herron. And she’s tired of not having a doctor there. “We have to transfer patients [à l’hôpital] that we should not transfer if there were doctors, ”she said.
At the time, Herron had three associated physicians, the Dres Orly Hermon, Lylia Lavallée and Adriana Ionescu, who did, before the pandemic, a weekly round.
Since mid-March, the first two have stopped their visits, like many CHSLD physicians, after receiving a directive from the Fédération des médecins omnipraticiens du Québec (FMOQ) encouraging telemedicine in long-term care establishments.
PHOTO MARTIN TREMBLAY, PRESS ARCHIVES
As of mid-March, two of the three doctors at CHSLD Herron cease their visits. The third will be on site until March 29.
The third, the DD Ionescu, goes to Herron until March 29. That evening, when the crisis broke out and CIUSSS managers arrived as reinforcements, she also lent a hand. Then, she lines up behind the advice of her colleagues and begins to do telemedicine.
The owner of the establishment, Samantha Chowieri, calls on the DD Hermon. “She said the doctors are telecommuting and cannot travel. ”
A Herron employee without any medical baggage therefore shuttles between the CHSLD and the doctors ‘homes to have residents’ death forms signed. She is also the one who goes upstairs to ask questions, on behalf of one of the doctors, about the state of health of the residents when the doctor cannot reach a caregiver.
“We discussed several times [d’y aller] », Assured the DD Hermon in front of the coroner. “However, there was the major issue of the lack of equipment and we realized that going there would be counterproductive. “
We could see that nurses were falling ill one after another and that it would happen to us and that we would not be available for our patients and our nurses.
The DD Orly Hermon
Doctors are instead opting to be on call 24 hours a day, seven days a week.
“Physician assistants”
On April 7, the DD Lavallée says she asked, during a conference call with CIUSSS leaders, if she and her colleagues should go there. “We asked them if what we were doing was correct. We worked 24 hours a day. [La Dre Larente] told us: keep doing what you do from home. ”
On April 8, nurse Victorine Leunga questioned the doctors. She tells them that “things are not going well” and asks them to come. “When we assessed the residents, they were on the phone. It took a lot of my time. A bit like medical assistants. In a context like this, everyone has to do what they have to do. The three general practitioners refuse to come. Mme Leunga wrote to two managers of the CIUSSS to complain, to no avail.
On April 11, after the matter broke into the media, a geriatrician at St. Mary’s Hospital, Dr.D Julia Chabot decides on her own to go and help. Never, since the start of the crisis, has she been approached by the CIUSSS, she testified. “If I could go back, I wish I could get there sooner. ”
Herron’s doctors followed suit the same day.