Health officials who arrived at a Montreal-area long-term care home during a COVID-19 outbreak last year found residents who were desperate for water and had been left in beds soaked with urine and feces, a Quebec coroner’s inquest heard Wednesday.
Martine Daigneault, a co-ordinator for the local health authority, testified that she went to Residence Herron the evening of March 29, 2020 after being informed that the facility was struggling with staff shortages.
What she saw shocked her: carts piled with barely touched trays of food, representing two or three meals; bandages that hadn’t been changed in days; residents with greasy hair and long nails who were so soaked in urine and feces that it left burns on their skin.
“I never saw a centre like that, never saw residents like this,” she told the coroner’s inquest.
Daigneault, who began her career as a nurse, said she began making the rounds to help feed the residents, accompanied by a nurse who had come to volunteer.
She said most residents didn’t want to eat the food, which had been left out for a while and contained large chunks she felt were unsuitable for elderly people, but they were very thirsty.
“I saw residents drink two, three cups of water and kissed our hands over our gloves to say thank you,” said Daigneault, who added that some residents showed signs of dehydration.
“You’re telling a horror story,” Coroner Gehane Kamel said a moment later.
Kamel’s mandate is to investigate 53 deaths at six long-term care homes and one seniors residence. The portion of the hearings involving Herron began Tuesday after being suspended while prosecutors decided whether to pursue charges against the owners of the now-closed facility. Ultimately they decided no criminal charges would be laid.
Forty-seven people died at the home during the first wave of the pandemic.
Daigneault said the residence lacked basic equipment such as bedsheets, soap and wipes, as well as personal protective equipment such as gowns.
Oxygen canisters were old and often empty, she said. Over the next few days, several people died following respiratory problems that were presumably linked to COVID-19. “Would they not have died had we given oxygen? I don’t know,” said Daigneault, who added that she isn’t a doctor.
Daigneault said she continued working at the home over the next two weeks because there wasn’t enough staff to care for residents. She said relations with Herron’s owners were strained, and the health authority never succeeded in obtaining work schedules in advance. Rather, she said they would get the schedules written on scraps of paper half an hour before shifts started, and often many of the names on the list didn’t show up.
Earlier Wednesday, another manager from the health authority testified that Herron’s severe understaffing issues were in part due to a self-isolation directive from the province’s health hotline.
Dr. Nadine Larente testified that there were so few employees on site when she arrived on March 29 that she called her husband and three children to come help feed and change patients.
Larente, who is a director of professional care for the local health authority, said she was told some employees had stayed home because they were afraid, but many others were following advice from the province’s Info-Sante telephone line to self-isolate for 14 days after coming into contact with a positive COVID-19 case.
Larente, who is also a geriatrician, said she questioned the wisdom of the directive given the long-standing staff shortages throughout the long-term care network.
“I was worried because, with all the centres in outbreaks across the province, that directive didn’t make sense, to abandon people before there are replacements,” she told the inquest, adding that she contacted Dr. Lucie Opatrny, an associate deputy health minister, to express her concerns.
Larente said her group did their best to care for residents, but they didn’t have enough masks for everyone or enough personal protective equipment to change it between patients.
At one moment, Larente said a patient fell to the ground as she helped her to the bathroom, and yelled for her daughter to help. Later, she learned the patient had COVID-19.
But Larente said residents on the ground floor, where she worked that evening, were more independent. Unlike what Daigneault encountered on higher floors, she said most of the patients she saw were dressed, hydrated and had received their medication and food that day.
At one point, Kamel interjected to ask whether doctors should have been called to do a proper examination of each patient.
“When I read this, and I get a chill up my spine to say this I get the impression we let these people die,” the coroner said.
Larente acknowledged that in retrospect, many things should have been done differently. By the time the second wave came around, she said teams of doctors were going to care homes to assess the needs of the residents and ensure everything was in place to care for them.
But in the pandemic’s early days, she said, the health network was still scrambling to train personnel in hospitals, assuage fears and deal with shortages of personal protective equipment and staff as the number of outbreaks grew by the day.
“On March 29, we weren’t yet organized at that level,” she said. “We weren’t prepared.”
Our Morning Update and Evening Update newsletters are written by Globe editors, giving you a concise summary of the day’s most important headlines. Sign up today.