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Residence Herron, a seniors' long-term care facility, is seen in the suburb of Dorval in Montreal amid the first wave of the COVID-19 pandemic on April 11, 2020. A Quebec coroner’s inquest is looking into the deaths of 47 Herron residents during the spring of 2020.CHRISTINNE MUSCHI/Reuters

Elderly residents at the Herron nursing home were in pitiful shape and many were dying during the first wave of the COVID-19 pandemic. But officials didn’t transfer them elsewhere because they worried about spreading the coronavirus to other health care facilities, a Quebec coroner’s inquest heard Tuesday.

During another day of testimony about the severe effects of the pandemic at the troubled facility in Montreal’s West Island, coroner Géhane Kamel grew impatient as she listened to descriptions of the local health authority’s ineffective attempts to take charge at Herron.

Ms. Kamel’s inquest, which is looking into the death of 47 Herron residents during the spring of 2020, has heard that despite the intervention of the health authority, known as CIUSSS, officials were unable to supply enough personnel to ensure the residents were clean and hydrated.

Fewer Herron residents may have died if HR official had been told to hire staff earlier, inquest hears

The coroner asked CIUSSS’s head of human resources, Alexandre Mercier, why no one thought of relocating the residents to facilities where they could receive better care.

“We were short-staffed in our emergencies, in intensive care. The reaction at the time was not to overload the CIUSSS’s other facilities – which were already very, very vulnerable – and spread COVID,” he replied.

“So they were sacrificed,” Ms. Kamel said.

Mr. Mercier had described how he visited Herron on April 7 and found it in a state of “total disarray,” with little personnel, orderlies who spoke neither French nor English, a lack of personal protective equipment and the stench of urine in the rooms.

“I remember a resident who was clinging to the body of his wife. It took three, four nurses to peel him off so the morgue could take her away. Those nurses were devastated.”

A supervising nurse, Stéphanie Larose, told him: “I don’t see how these residents will make it through the month. We will lose them all by the end of the month.”

Herron’s former director, Andrei Stanica, testified Tuesday that the privately owned nursing home was in a precarious state as the pandemic began in early 2020.

The facility’s director of nursing care had left that January, and no replacement had yet been found.

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

Herron always had trouble retaining staff because it paid its orderlies around $14 an hour, when such workers could get $20 per hour in the public sector. In February of that year, Mr. Stanica started using temporary personnel from a placement agency. “I was desperate – I didn’t know what to do. Whatever they gave me, I took it.”

The agency staff had a habit of throwing away towels and facecloths after using them. The inquest previously heard that some residents hadn’t been bathed for weeks because of a towel shortage.

The first Herron resident infected with COVID-19 died on March 27, 2020. Mr. Stanica came down with the virus around the same time, while the nursing co-ordinator resigned because she had to care for her elderly mother.

In that leadership vacuum, Herron lost most of its staff – some because they had been exposed to the virus, and others, mostly agency personnel, just left their posts, the inquest has heard.

The local health authority discovered on March 29 that only a handful of Herron staffers remained to look after more than 130 thirsty, unfed residents left lying in their soiled diapers. The CIUSSS announced that night that it was taking control.

Mr. Mercier said the CIUSSS dispatched four or five people from its bank of new hires. The conditions at Herron were so terrible that “none of them wanted to come back for a second shift,” he said.

One of those people described “very troubling” problems at Herron and wanted to alert the media.

Health care workers are not permitted to talk to journalists without authorization. Quebec’s health minister at the time, Danielle McCann, has said that it wasn’t until the Montreal Gazette broke the story on April 10 that the government realized the scale of the crisis.

During that period, Herron remained in chaos. Nathalie Pigeon, a CIUSSS infection prevention counsellor, visited the residence on April 4.

She testified that she remains haunted by the sight of dried-up intravenous bags, crusted nasal oxygen tubes and weakened residents with their mouths pasty from lack of water.

While there, she heard a rasping sound and found a man in a room who was struggling to breathe. His first words to her were, “I’m thirsty.”

She and a colleague gave the man some water to drink. It was 3 p.m. and his lunch tray was still untouched. When she asked what else she could do for him, he replied, “Leave. It’s not worth it. There’s nothing left to do with me.”

In another room, an emaciated woman was lying on dried urine. Ms. Pigeon couldn’t find clean bedding, so she improvised with a towel. “I could not believe this was happening in Montreal,” she said.

Ms. Kamel noted that Ms. Pigeon’s visit took place six days after the CIUSSS had said it was taking charge of Herron.

“I am left with the impression that between March 30 and April 4, nothing was done. Nada,” she said.

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