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Plush toys and flowers outside Résidence Herron in Montreal, May 10, 2020.Graham Hughes/The Canadian Press

For days after Montreal health officials discovered dismal conditions at the Résidence Herron nursing home and announced they were taking control, its elderly residents still remained in squalor, with soiled diapers and untouched wound dressings, a coroner’s inquest heard.

A nursing supervisor held back tears Thursday as she described the misery endured by the residents at the privately owned care home in Montreal’s West Island.

Her testimony and other evidence raised questions about how long there had been neglect at Herron, and whether health officials handled the problem in the best possible way when they took control of the troubled facility.

Coroner Géhane Kamel is investigating 47 deaths at Herron as part of an inquest into the impact of the first wave of the pandemic on Quebec nursing homes in the spring of 2020.

The inquest has heard that most of Herron’s staffers left their posts after a first resident died of COVID-19 on March 27. The local health authority, known as CIUSSS ODIM, became aware of the crisis on March 29 when its managers visited Herron and found unattended, unfed residents.

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Stéphanie Larose, the CIUSSS’s head of outpatient services, testified Thursday that she was sent to Herron five days later to assess the quality of care there. She said she sobbed when she called her supervisor. “It’s very, very difficult to see the suffering of these people.”

She recalled one man lying in his room with an oxygen mask, even though the tank was empty, his body covered with sores and crusts. He even had scabs on his eyelids. His bandages hadn’t been changed for so long that they had turned yellow and “the skin was growing over them,” she said, her voice breaking.

She helped another resident to the bathroom. The woman, who was paralyzed on one side of her body, told Ms. Larose that Herron employees often left her after placing her on the toilet. It was a painful position and she would have no choice but to let herself drop on the bathroom floor. She also said she hadn’t been bathed for several weeks.

The next day, nursing adviser Marilyn Leduc was part of a team from Lakeshore General Hospital sent to help at Herron. In an e-mail filed at the inquest, she described seeing unfed, dehydrated residents. “The mouths of the patients were in an absolutely pitiful state – crusted, dried … there were no water glasses in their rooms.”

No one was helping feed the residents. Unable to cut her food, one resident tried to eat a pudding, but it spilled on her chest and dried up. “They’ve been left to their own devices. It’s dreadful,” Ms. Leduc wrote.

Jacques Ramsay, a physician acting as an expert assessor for the inquest, asked why Herron hadn’t flagged to the CIUSSS earlier that it had a personnel shortage. “Wasn’t there an obligation for a [nursing home] to ring the bell and say, ‘We can’t do it – there’s a threat’? If this had been done, we might not have had the carnage that we had.”

He noted that Herron had 79 staffers when twice that many were needed to care properly for its 139 residents. In addition, the residence didn’t have a director of nursing care.

“Without strong management, the table is set for employees who’ll desert at the first glitch, who’ll panic. It takes managers who’ll reassure them, who’ll put in place measures that will make the personnel feel safe,” Dr. Ramsay said.

CIUSSS officials told Herron owner Samantha Chowieri on March 29 that they would take charge of the facility but, because of bureaucratic delays, it wasn’t until April 10 that they assumed full control.

During the period between March 31 and April 10, 24 residents died and the inquest heard that conditions remained chaotic. The CIUSSS and Ms. Chowieri have accused each other of mishandling that recovery phase.

A team from St. Mary’s Hospital who came to help on April 9 still witnessed inadequate conditions. In documents filed in exhibit, the team reported seeing orderlies without masks; haphazard handling of medications; dehydrated residents in unchanged diapers, with dried vomit on their gowns and bandages that hadn’t been changed for weeks.

CIUSSS officials have alleged that Ms. Chowieri was unco-operative and unable to provide proper staffing information.

Former CIUSSS administrator Brigitte Auger, who was asked to take over the management of Herron, testified that Ms. Chowieri was overwhelmed by the crisis. “I wasn’t looking at a person acting in bad faith. I was looking at someone who was in over her head.”

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