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Flowers are placed outside a long-term care home in the Montreal suburb of Dorval, on April 12, 2020.Graham Hughes/The Canadian Press

A joint investigation by three professional orders into the high number of COVID-19-related deaths at a Montreal long-term care home says management was more to blame than employees.

The report released Tuesday by Quebec’s college of physicians and the orders of nurses and nursing assistants did not reveal any apparent shortcomings among their members at the hard-hit Residence Herron.

But the investigation did find poor work organization and a lack of knowledge of the health-care field among management at the privately run facility. It also highlighted an absence of experienced staff and a chronic shortage of personal protective equipment.

“The analysis of clinical and management practices before the pandemic allowed to note during the investigation that what happened at the end of March 2020 at CHSLD Herron can be described as a disaster waiting to happen,” the report said. Long-term care homes in Quebec are called CHSLDs.

“Shortcomings observed before the pandemic had uncontrollable repercussions during the outbreak at the end of March 2020.”

Katasa Group, owners of the Dorval, Que., facility, were not available for comment on the report.

The joint investigation announced last April compared the quality of care offered in both public and private nursing homes in the province during the first wave of the pandemic in Quebec, between December 2019 and mid-April 2020.

On the public side, the orders’ investigation looked at Montreal’s public geriatric institute, Institut universitaire de geriatrie de Montreal.

About 60 deaths were recorded at the two long-term care homes during the period under investigation.

The orders’ report found that in Montreal’s geriatric institute, the care provided was adequate despite an intense COVID-19 outbreak. More than 30 deaths occurred at that facility during the period of time analyzed.

When word of 31 deaths at the private Herron facility emerged in April 2020, regional health authorities had said staff had abandoned it, but the report counters that narrative.

“It is important to clarify that, unlike what was broadcast in the media, CHSLD Herron employees neither abandoned the residents nor deserted the CHSLD,” the report read.

“They received an order from their managers to leave the CHSLD if they presented symptoms of COVID-19 or had contact with a resident positive for COVID-19.”

The 78-page report noted the managers gave those instructions to staff without ensuring the facility had enough employees to meet the basic needs of residents.

The deaths at Herron will be a major part of a coroner’s inquest later this fall investigating 47 COVID-19-linked deaths at long-term care homes. Those public hearings were delayed last month until September at the request of the Herron owners, who are waiting to see if they will face criminal charges.

Health Minister Christian Dube and Seniors Minister Marguerite Blais said in a statement Tuesday they will look at the report’s 31 recommendations, adding that many changes have been made to the network since last year.

“Measures have already been taken since last spring, but we will continue work, together with our partners from the three professional orders, to ensure the quality of care and services provided in all CHSLDs in Quebec, whether they are public or private,” Dube said.

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