The Ministry of Health and Human Services (MSSS) as well as many public organizations did not respond to the Coroner's Office recommendations within the required deadlines, La Presse noted.
Published at 1:15 am. Updated at 5:00 am.
For more than a year, that is to say from November 1, 2022, individuals, associations, ministries or organizations must certify to the chief coroner “that they have taken note of his recommendations and inform him of the measures they intend to take, to fix the problem.” situation. A simple confirmation of receipt is not enough.
Due to the negligence of some interlocutors, the coroner's office had been calling for this change in the law for several years. For fiscal year 2022-2023, the response rate to recommendations was 42.4%.
The maximum response time set by the chief coroner in his letters is 45 days, but the MSSS, the organization most frequently requested in the reports, has a tolerance of 90 days to position itself due to the delay incurred during the pandemic.
Yet the department has violated the Coroners Act at least 11 times in the last year. This comes from our analysis of a Coroner's Office document detailing the follow-up to advisories issued from April 1, 2022 to March 31, 2023.
From this count, we excluded requests sent before November 1, 2022, when the new law was not yet in effect. We also ensured that the 90 day period specific to the MSSS has expired.
Some recommendations propose very concrete solutions to “protect human life”. For example, one coroner calls for “support bars for beds (auxiliary bars) with a single crossbar to be banned.” [de les remplacer] through support bars for beds that have at least two crossbars.”
At the time of publication, the Chief Coroner had not yet received acknowledgment of this January 19, 2023 recommendation.
Other recommendations left unanswered by the MSSS included reporting to child protective services, psychological follow-up, identifying suicide risks, and managing emergency calls.
As of March 31, 2023, the Ministry had only responded to the recommendations in 3 of the 22 dossiers submitted to it since April 1, 2022, as we note in the follow-up document prepared by the Coroner's Office. However, this report covers a seven-month period during which responses were not mandatory.
“Delayed” responses
“We are in contact with the ministry,” Reno Bernier, Quebec's chief coroner, said in a telephone interview with La Presse. You are aware of this problem. »
It's true that the response rate hasn't been high, but they're developing a plan to catch up. I am confident, but it is certain that there is still a lot to do.
Reno Bernier, Quebec's chief coroner
The Coroner's Office, which says it has excellent relationships with public organizations, has a contact person at the Ministry of Health. Nevertheless, he would like to see a recommendation follow-up position similar to the one set up by the Ministry of Transport in the management organizational chart.
When asked by La Presse, the MSSS admits to being “delayed” in responding. He particularly blames the accumulation of files during the management of the health crisis of 2020 to 2022. “Work is ongoing to catch up,” a spokesperson said via email, adding that “several responses to the coroner’s recommendations will be submitted shortly.”
The ministry says it attaches “great importance” to the work of coroners. “Where a report contains recommendations for the MSSS, upon receipt, these will be transmitted to the relevant ministerial directorates so that follow-up action can be taken and these recommendations can be taken into account in current and future work.” »
Beyond formal correspondence, the MSSS says it maintains frequent contact with the Coroner's Office, “particularly to ensure the dissemination of information and commitments regarding the new law.”
A widespread problem
The Ministry of Natural Resources and Forests, the Ministry of Transport, the Ministry of Municipal Affairs, the Police Service of the City of Montreal, the Directorate General of Public Health of Montreal, the City of Quebec, the City of Montreal and the Société de l'Assurance Automotive du Québec have committed a violation by its silence beyond 45 days in at least one file dated March 31, 2023.
What is even more ironic is that even the Department of Public Safety, under which the Coroner's Office operates, violated the Coroners Act by failing to act on the January 19, 2023 recommendations in an overdose case within the allotted time.
For the 2022-2023 fiscal year, the Coroner's Office made 754 recommendations in 282 files. According to the independent organization's management report, the response rate was 42.4%. When they show signs of life, organizations agree to implement the recommendations about nine times out of ten.
Around 80 health centers, public organizations, associations, professional associations, municipalities and private companies had not responded to at least one recommendation from the chief medical examiner sent from April 1, 2022 to March 31, 2023. Several were contacted after November 1st, violating the law.
“transitional year”
Quebec's chief coroner, Reno Bernier, notes that his partners are in “a year of transition and implementation” regarding the new coroner law. “However, the situation is not the case [son] taste optimal.” “A response rate of 42% is not enough,” he said. I want it to reach 75%. »
Although the Coroners Act does not provide for criminal penalties, Mr. Bernier assures that it promotes accountability.
Every deputy minister is accountable. Every year when the credits are studied he has to answer for his management. And there are researchers, organizations and journalists who can demand accountability.
Reno Bernier, Quebec's chief coroner
The Coroner's Office is in the process of developing a public tool to monitor real-time referrals that could increase pressure on organizations and departments and “highlight their work.”
“Recommendations are one of the most important parts of the coroner’s job because they make it possible to change things, prevent deaths and contribute to the further development of society,” argues Bernier.
Which deaths require a coroner's report?
A coroner “intervenes systematically when a death occurs in violent or unclear circumstances or may be due to negligence, or when the identity of the deceased is not known”. Various professional groups, for example a doctor or a manager, are subject to a reporting obligation in these cases. The coroner's office must also be notified of any death that occurs in specific locations, “particularly daycare centers, youth centers, nursing homes, police stations, detention centers, correctional facilities and rehabilitation centers.” Nearly 70,000 deaths occur annually in Quebec, about 6,000 of which are investigated by a coroner. If he considers it necessary in the public interest, the Chief Coroner may order a public inquest. This was the case, for example, after the seven deaths in a fire in Old Montreal on March 16. The author of a report is free to make recommendations or not.