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A woman and a man hold up a signs outside Residence Herron, a long-term care home in the Montreal suburb of Dorval, Que.Graham Hughes/The Canadian Press

Two years before the pandemic began, the family of a resident at the Herron nursing home in Montreal wanted to move him to British Columbia to be closer to them, but the facility took so long to handle the paperwork that he wasn’t able to leave. He later died there when COVID-19 struck, the coroner’s inquest looking into COVID deaths at Herron heard Wednesday.

In scathing testimony, Moira Davis detailed the miseries her 96-year-old father, Stanley Pinnell, endured while in various elder-care homes, adding such issues were not unique to Herron.

“A national inquiry into senior-care homes in Canada still needs to occur. What happened at Herron wasn’t an isolated incident – it’s happened through Quebec and in every province in Canada,” she said.

She spoke at the inquest held by Coroner Géhane Kamel, who is looking into 47 deaths in the spring of 2020 at Résidence Herron, in Montreal’s West Island.

The discovery of enfeebled seniors left in squalor at Herron marked a turning point in the public’s awareness of the severe effects of the pandemic on long-term care homes.

Misery at Herron nursing home continued for days after officials intervened, Quebec LTC inquest hears

Herron long-term care residents died of thirst, malnourishment, Quebec coroner’s inquest told

But Ms. Davis said that her father’s four years in care homes showed that staff shortages, disorganization and indifferent care were common in such facilities even before the pandemic.

“The system for senior care is broken – not just the [long-term care homes], not just in private for-profit homes. There is a systematic breakdown in just about every senior-care home in our country,” she said.

In 2016, Ms. Davis’s father had to move to a nursing home. The next available spot was at CHSLD Résidence Les Floralies Lasalle, where he was given a small room facing a noisy dining area.

While there, he had to be hospitalized for a urinary tract infection, which Ms. Davis said was caused by the staff failing to clean his catheter and urine bag. His leg was also permanently bent after he was often left for hours in a wheelchair that was too small.

She moved Mr. Pinnell to Herron. “I saw the residents were engaged amongst themselves – playing cards, dating, sharing a cup of coffee. I felt like this was a community – something my father was sorely lacking.”

But Ms. Davis found that it was difficult to contact Herron’s medical staff. She and her sister, Fiona, worried that Herron had overmedicated their father. Once while speaking to him on the phone, they overheard a staffer in the background mocking his dementia.

In March, 2018, Ms. Davis’s sister asked to transfer their father to a care home in B.C., where she lived. But, Ms. Davis said, Herron took months to provide the paperwork, by which time he was too frail to be moved.

A resident waves from her window at Residence Herron, a senior's long-term care facility, following a number of deaths since the COVID-19 outbreak.CHRISTINNE MUSCHI/Reuters

Ms. Davis questioned how well the physician treating her father at Herron, Orly Hermon, could have cared for him when she made only weekly visits to the facility to look after 55 residents. “He was paying a lot of money [for] a private bed. Dr. Hermon could have looked at him as more than part of her Tuesday-morning paycheque.”

The inquest has heard that Herron was poorly run even before the pandemic.

Herron’s director, Andrei Stanica, testified Tuesday that he was simultaneously the chief administrator for another facility, a 186-apartment seniors’ home belonging to the same owners.

The inquest heard that a committee representing families of residents quit en masse in February, 2017, citing in its letter of resignation “a disrespectful, unprofessional management staff, a dearth of integrity and an inability to dialogue together.”

The committee complained about residents suffering from skin lesions because of wet diapers, insufficient staffing, dirty and sticky floors, and poor housekeeping, among other concerns.

By February, 2020, Mr. Stanica was relying on a placement agency to remedy the staff shortage at the facility. The inquest heard that the agency supplied unreliable, poorly trained orderlies and might have double-billed for their work.

Jacques Ramsay, a physician acting as an expert assessor for the inquest, described the agency as “small, amateurish” and wondered whether Herron had retained them because they billed $26 per hour for an orderly, when other firms charged $36.

Mr. Stanica said it was hard to find an agency that could supply staffers steadily. “Maybe I was a bit naive ... I took it for granted that they were trained people.”

The first Herron resident to test positive for COVID-19 died on March 27, 2020. Within two days, most of the staff was missing, leaving behind dehydrated residents, some lying in their own feces.

The local health authority, known as CIUSSS, told owner Samantha Chowieri that it was taking over on March 29. However, little care was provided in the ensuing 12 days while the CIUSSS and Herron management squabbled and accused each other of interfering.

Ms. Davis said she blamed both Herron and the CIUSSS for her father’s death, noting he had not been tested for COVID-19. He had been losing weight, and the family wonders if he died of neglect, Ms. Davis said. “He faded out like a 1950s television screen, until his light was finally gone.”

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