During the public inquiry, which she led for two years, Coroner Kamel heard more than 200 witnesses in 69 days: health network officials, hospital staff, politicians, but also relatives and family members of 53 people who died in four public CHSLDs, two private and a senior residence (RPA) during the first wave of COVID-19 in spring 2020.
Ms. Kamel explained that she voluntarily omitted to include in her report the ages of the deceased – they ranged in age from 60 to 95 – and denounced the discourse that these elderly people in CHSLDs were sentenced to short-term death anyway.
Since residents of CHSLDs have been shown to have an average life expectancy of 18 months, it is all the more important that their stay in these environments allows for the most peaceful, suffering-free end of life possible.
“They were, first and foremost, people for whom all, namely their families, the carers, the CISSSs, the CIUSSSs and the government agencies concerned, had a shared responsibility and had to provide care worthy of a civilized society. »
— A quote from Géhane Kamel, coroner
However, this was not the case for the 53 people whose deaths were the subject of the forensic medical examination. Ms Kamel says she is still haunted by a few stories, including that of Mr Barrette, who was not visited by a single member of staff for at least two days and was later found dead in his bed.
Recalling the importance of dying with dignity in a society that aspires to be as progressive as ours, she believes the fact that caregivers have been prevented from going to CHSLDs is a mistake they made Dignity has darkened and infantilized families.
For all 53 deaths involved, this moral and social contract was broken, the coroner said bluntly.
“Our most vulnerable seniors have been in our governments’ blind spot. […] In my opinion, you are also in the blind spot of our society. »
— A quote from Géhane Kamel, coroner
The Herron Chapter
In the 193-page report she filed this week, the coroner is not particularly friendly to the CIUSSS de l’Ouest-de-l’Île-de-Montréal, as well as its CEO, Lynne McVey, in the CHSLD Herron file special.
In particular, the coroner noted the disorganization of the CUSSS management team and the lack of accountability in the system. She points out that the vast majority of deaths occurred when the CIUSSS was already managing the private CHSLD Herron.
Remember that in this private CHSLD in Dorval, 47 people died in appalling conditions, without any basic services, sometimes for days. Blame this carnage on the desertion of the staff and the poor management of the owners and the CIUSSS, who had to take control of the establishment at short notice in the spring of 2020.
“As far as Herron is concerned, people have failed, be it the owners, the CIUSSS or the Ministry. »
— A quote from Géhane Kamel, coroner
Lynne McVey this week warned the Secretary of State for Health and Social Services (MSSS) that she would not seek re-appointment at the end of her current term as CEO of CIUSSS, which expires in July 2022. Géhane Kamel declined to comment on his departure.
Fragile environments even before the pandemic
In her observation of the situation in the seven establishments she was responsible for investigating, Géhane Kamel emphasizes that all these environments already existed before the arrival of COVID, with factors that aggravated the difficulty of fighting the virus.
According to the witnesses heard, the CHSLDs were already facing a shortage of nursing staff at the beginning of the pandemic. The lack of personal protective equipment, lack of fluid communication, decision-making hierarchy, and contingency plans deployed to varying degrees were all complicating factors, Ms. Kamel notes.
According to Géhane Kamel, the lack of agility in Québec’s healthcare system has been particularly glaring during this crisis. Have you seen the incalculable number of directives coming into the field from the Ministry? […] It can take a few hours, even days, for the information to reach the people on the ground.
An order could be issued in the morning, changed the next day, and changed the day after. Should there be a new health crisis, […] We have to be able to have people who make decisions much more quickly.
“It’s a very big machine. Just looking at the flowchart gave me a headache. »
— A quote from Géhane Kamel, coroner
Me Kamel explains that it was not his mandate to analyze the bureaucratic process of the Ministry of Health and, given his work, believes that one of the government’s priorities must be to narrow the gap between the reality on the ground and the decisions, that are met in the department.
She complains that it is not normal for citizens, doctors or employees to feel the need to go through the media to make a difference.
It is an invitation I extend to the government. Find a way to talk to your country…
The 23 recommendations of coroner Géhane Kamel
That the Government of Quebec :
to review the role of the national director of public health so that his functions are exercised with full independence and without political constraints;
examines the possibility of setting up a voluntary civilian emergency service, 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 private CHSLDs by appointment;
expands the range of home care services for our seniors;
ensures an inclusive policy in times of crisis to allow at least two carers to safely visit the person;
implements safe health care professional/resident conditions in CHSLDs;
increases the number of managers in CHSLDs as needed to ensure all shifts are covered (evening and night delegated powers);
plans to hold talks with union authorities to review or add collective bargaining clauses that allow for increased availability and relief for staff during a health emergency, as appropriate;
plans new infrastructure or renovations of living environments to ensure facilities can meet healthcare needs, particularly in times of health crises;
ensures that accommodation providers can offer residents individual rooms.
This is the Department of Health and Social Care :
places the precautionary principle at the heart of any risk assessment and management process;
ensure greater accountability of CISSS/CIUSSS and MSSS managers in relation to the care of elders with loss of autonomy through monitoring of indicators and a commitment to intervene in the event of problems with the quality of care;
in addition to providing reserves to meet needs in the event of a crisis, ensures that the necessary supply of protective equipment is guaranteed at all times;
define what minimum comfort care facilities in CHSLDs must provide;
establish a national plan to equip all CHSLDs with the necessary equipment for this care;
Review of technical training so that nurses at CHSLDs and, where appropriate, nursing assistants are able to perform the techniques required for primary care (ventilation delivery, venous and subcutaneous access, use of volumetric pumps, etc.);
develops a tool with scenarios to allow residents and/or their carers to fully understand the implications of a choice of care level;
provides management in CHSLDs that brings together a responsible manager, a nursing board and a medical board.
That the CISSSs and CIUSSSs :
ensure the sufficient presence of PCI-specialized nurses in the CHSLDs so that they can be present in day-to-day operations and ensure their sustainability;
Ensure simulations are scheduled every three years in line with pandemic plans.
Provide training in keeping medical records and conduct regular follow-up visits.
Ensure the monitoring required to justify the use of emergency protocols and palliative sedation in an acute care setting.
That the College of Physicians of Quebec :
is reviewing the individual medical practices of the treating doctors of CHSLD Herron, des Moulins and Sainte-Dorothée, particularly with regard to their decision to continue teleconsultation despite the need for support and the very high number of deaths.