Coroner Géhane Kamel believes the most vulnerable seniors were in the “blind spot” of government and society.
• Also read: No new mandate for the CEO of the CIUSSS de l’Ouest-de-l’Île-de-Montréal
“History will sadly remember that in Quebec it was seniors living in shelters who paid the highest price during the first wave of COVID, an insidious disease with more dramatic consequences for those already in need of healthcare,” she underscored Thursday by presenting the conclusions of her report on the deaths of elders in CHSLDs.
Earlier this week, it released the conclusions of its investigative report into the 53 deaths that occurred in shelters during the first wave, interviewing more than 200 witnesses.
“These environments, designed to accommodate them so that they end their day, also had to be able to provide them with the care they needed for their health,” Mr. Kamel recalled.
She added that these environments must allow their residents to end life as peacefully as possible. “For all 53 deaths involved, that moral and societal contract was broken,” she said.
Prevent another crisis
During the second wave, the coroner believes the plans were “more substantial” and to that end has good hope that Quebec would be better prepared should another similar situation arise.
Despite it all, she believes there was a “hole” between the field and the Ministry, while information struggled to circulate between the two.
“If there should be a new health crisis, the agility of the health system, it has to go much faster and we have to be able to have people making decisions much faster,” she warned.
The coroner hopes her report will be taken into account by the government and ultimately ensure that a crisis like this “never again” does not happen again.
“I’m not trying to blame people, that’s not my goal or our job. If I’ve skinned people through the bond, it’s because by naming situations that needed naming, we got back to the real thing,” she said.
In her opinion, her 23 recommendations must be implemented, none of which is more important than the others. “It’s like deciding to make a recipe for spaghetti sauce but not tomatoes. It doesn’t work It’s a whole,” she illustrated.
Problematic facilities
After questioning on the matter, the coroner returned to two facilities that were particularly problematic during the first wave.
In the greater Montreal area, CHSLD Herron killed 47 people during the first wave. The many topics listed there have made headlines in the media a number of times.
“People have failed. Whether it’s the owners of Herron, the CIUSSS and the Ministry. To me that is undeniable. People passed the buck,” she said.
However, Me Kamel states that he has no complaints, although there are lessons to be learned.
In the Manoir Liverpool in Lévis, the newspapers had reported several cases of abuse. In particular, the coroner skinned Daniel Paré, who was then CEO of the CISSS de Chaudière-Appalaches.
“It’s impossible to me that he didn’t know, and if indeed he didn’t know, then we have a serious problem,” she said, saying she was baffled by the situation. It’s still a big mystery to me to this day.
Giving the dead a voice
During the hearings, Coroner Kamel said several times that she wanted to give a voice to the deceased.
“I hope I gave them a voice. Those who can judge will be the deceased. I hope that through this report we have been able to restore a little dignity to these people,” explained coroner Kamel, who says she was occupied by the deceased throughout the inquest.
She also deliberately did not mention the age of the deceased in her report. “It was meant to be a personal response to the fact that old people’s deaths were given so much importance that we ended up trivializing their deaths,” she explained.
– With information from TVA Nouvelles
The government welcomes the recommendations
The government says it “takes note” of the recommendations contained in the coroner’s report and that the 18 that concern it will be followed up.
“This report […] is another tool to diagnose what happened and how we can improve the way we work. We will continue our efforts already initiated since the first wave,” said Christian Dubé, Minister of Health and Social Affairs.
According to the government’s statements, eight recommendations have been fully implemented, eight more are in progress and the last two require a more comprehensive assessment and legislative change.
“Coroner Kamel’s recommendations will assist us in our desire to establish a new culture of care and service for the elderly. I would like to reiterate that this report will not be shelved,” said Marguerite Blais, Minister for Senior Citizens and Carers.
RECOMMENDATIONS
To the Government of Quebec
– Review of the role of the National Director of Public Health so that his functions are exercised with full independence and without political constraints.
– Consider the possibility of setting up a voluntary community service for emergencies, which would be overseen by the Ministry of Public Security, as is sometimes the case with natural disasters.
– Quickly review service offerings for our seniors by converting all private CHSLDs to contracted private CHSLDs.
– Expansion of the range of services for home care for our seniors.
– Ensuring an inclusive policy in times of crisis, so that at least two carers can visit the accommodated person in a safe way.
– Introduce a safe healthcare professional/resident ratio in CHSLDs.
– Increase the number of managers in CHSLDs as needed to ensure all shifts are covered (evenings and nights delegated powers).
– Discuss with union bodies to review or add clauses in collective agreements that allow for increased availability and offloading of staff during a health emergency, as appropriate.
– Plans new infrastructure or renovations of housing environments by ensuring environments can meet health care needs, especially in times of health crises.
– Ensures that accommodation establishments can offer residents individual rooms.
To the Department of Health and Social Care
– Places the precautionary principle at the heart of any approach to risk assessment and management.
– Ensure greater accountability of CISSS/CIUSSS and Department of Health and Human Services managers for the care of elders with loss of autonomy through monitoring of indicators and a commitment to intervene in the event of quality of care issues.
– Ensures that the necessary supply of protective equipment is available at all times and plans reserves to cover the needs in the event of a crisis.
– Define what comfort care facilities in CHSLDs must provide as a minimum.
– Establish a national plan to provide all CHSLDs with the necessary equipment to provide this care.
– Review technical training so that nurses in CHSLDs and, where appropriate, auxiliary nurses are able to perform the techniques required for primary care (ventilation delivery, venous and subcutaneous access, use of volumetric pumps, etc.) .
– Development of a scenario tool to allow residents and/or their carers to fully understand the implications of a care level choice.
– Ensures leadership in the CHSLDs, which include an Executive Officer, a Nursing Directorate and a Medical Directorate.
At CISSS and CUSSS
– Ensure the sufficient presence of nurses specializing in PCI in the CHSLDs so that they can be present in day-to-day operations and ensure their sustainability.
– Be sure to schedule simulations in line with pandemic plans on a three-year basis.
– Provide training in keeping medical records and conduct regular follow-up visits.
– Ensure the necessary monitoring that justifies the use of emergency protocols and palliative sedation in an acute care setting.
At the College of Physicians of Quebec
– Review of the individual medical practices of the treating doctors of CHSLD Herron, Les Moulins and Sainte-Dorothée, in particular with regard to their decision to continue teleconsultation despite the need for support and the very high number of deaths.
Conclusion
“The COVID-19 crisis illustrates decades of public policy failures regarding already known CHSLDs.”
“Quebec’s reduced hospital capacity compared to other Organization for Economic Co-operation and Development (OECD) countries coupled with the past fragility of CHSLDs has prompted authorities to have the first instinct to protect our hospital capacity, particularly by avoiding the relocation of residents to hospitals.”
“This protection of the hospital environment certainly had its raison d’être, but it now seems obvious to me that the pre-existing systemic causes need to be reviewed and corrective actions taken.”
Source: Coroner’s Office Inquiry Report