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Quebec coroner Géhane Kamel's inquiry into deaths at the Herron nursing home wasn’t Canada’s only official probe into the impact of the pandemic on nursing homes – but it was the only one to hold public hearings.ERIC THOMAS/AFP/Getty Images

Residents at Quebec’s Herron nursing home wouldn’t have died in such gruesome conditions if health officials and the home’s owners hadn’t squabbled for days, coroner Géhane Kamel said in her final remarks at her inquest into the impact of COVID-19 on the province’s eldercare facilities.

Speaking Thursday after the release of her inquest’s report, she said those in charge at the facility in Montreal’s West Island had quarrelled via e-mails and lawyers’ letters in early 2020, in the midst of a COVID-19 outbreak among residents.

“There are people who could have gotten help and would not have died. They might have died later, but they wouldn’t have died in those conditions,” she told reporters.

Ms. Kamel’s inquest, which received testimony from 220 witnesses, wasn’t Canada’s only official probe into the impact of the pandemic on nursing homes – but it was the only one to hold public hearings.

“Out of all of this, one thing is clear: our elders, our most vulnerable people, died in the blind spot of the government,” she said.

Ms. Kamel said that, had it been in her mandate, she would have recommended Quebec hold a full public inquiry on the events of spring 2020, which cost the lives of an estimated 5,000 seniors in the province’s congregate living settings.

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Premier François Legault has so far refused to order a public inquiry, arguing that Quebec nursing homes have already been investigated by oversight bodies such as the coroner’s office, the provincial Ombudswoman and the Auditor-General.

In a joint statement Thursday, Quebec’s Health Minister, Christian Dubé, and its Minister for Seniors, Marguerite Blais, said the government is implementing most of the coroner’s recommendations that come under the province’s jurisdiction.

But her most prominent recommendation, that Quebec make the position of director of public health independent of the government, “will require a more comprehensive assessment, including legislative change,” the statement said.

“I wish to reiterate that this report will not be left on a shelf,” Ms. Blais added.

Speaking to reporters, Ms. Kamel and Jacques Ramsay, the physician who assisted her, said the government needs to be more nimble and more in touch with the problems front-line health care workers face.

“We understand very well that governing is difficult,” Dr. Ramsay said. “But that’s the challenge that we ask of the people who lead – the managers, the government – to always keep the front line in sight, to grasp the impact of their decisions.”

Ms. Kamel added that the inquest heard from relatives of residents and doctors who resorted to contacting newspapers to get the government to notice problems. “It’s not normal that citizens, or doctors, or employees feel the need to go through the media to get things to move.”

One of those cases was the tragedy at Herron. An article in the Montreal Gazette on April 10, 2020, revealed that unfed, debilitated residents were left in their own waste as they died.

The local health authority for Montreal’s West Island, known by the initials CIUSSS, had told the home’s owners on March 29, 2020, that it was taking over the facility after Herron staffers deserted their posts. But for 10 days it wasn’t clear who was in control, and basic care remained spotty.

“No one took charge of it – neither the ministry, nor the owners, nor the CIUSSS. They wrote to each other, exchanged a lot of e-mails, but during that time people were dying, people were dehydrated, people were lying in their feces,” Ms. Kamel said.

She said she was particularly shocked by the case of Leon Barrette, who was transferred to Herron just when the COVID-19 outbreak started and appeared to have been left on his own until he died two days later.

Her report mentions other Herron residents whose deaths might have been avoided, including Thelma Jean Allo, who died after a heart failure the report says wasn’t properly treated.

Another resident, Thomas Baur, had a tracheotomy that required regular care. “A decrease in required monitoring and nursing care may certainly have contributed to the death ... this is the cause that I consider to be the most probable,” the report says.

And Olga Maculedicius, a resident with kidney problems, was dehydrated and likely died of cardiac arrhythmia, according to Ms. Kamel’s findings. “In such a scenario, it is the lack of basic care that would have caused the death,” the report says.

Coroners make recommendations to prevent tragedies from happening again, but don’t ascribe criminal or civil responsibility.

The day after Ms. Kamel’s report came out, the CIUSSS’s chief executive, Lynne McVey, announced she wouldn’t seek another mandate after her term ends on July 8.

Ms. Kamel urged the government to reach out to those who lost relatives during the first wave of COVID-19, to acknowledge their grief.

“The population has the right to get answers,” she said. “But beyond that, there are 5,000 families who lost someone. If we want to be able to get them beyond anger and to mourn properly, out of respect for them you need to revisit some of what has happened.”

With a report from Eric Andrew-Gee

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