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Plush toys and flowers are shown outside Résidence Herron in the Montreal suburb of Dorval on May 10, 2020. A coroner's inquest is underway, looking into the death toll in Quebec nursing homes during the first wave of the COVID-19 pandemic.Graham Hughes/The Canadian Press

The hallway was dark, the floor sticky and a nauseating smell hit Martine Daigneault when she stepped out of the elevator into the second storey of the Herron nursing home.

In the rooms, she found elderly residents with grimy hair and nails, their lips crusted by dehydration, their skin inflamed by unchanged diapers. There was little soap, a shortage of bedding and even a lack of wipes, so she had to use brown paper towels to clean soiled residents.

Testifying at a coroner’s inquest on Wednesday, Ms. Daigneault recalled how she and a small group of volunteers came to the rescue at the long-term care home in Montreal’s West Island that had been deserted by most of its staff after an outbreak of COVID-19.

Health authority’s efforts to assist at Montreal nursing home hindered by bureaucratic delays, inquest told

How Quebec’s response to COVID-19 left 4,000 dead in long-term care homes

Coroner Géhane Kamel’s inquest is looking into the death toll in Quebec nursing homes during the first wave of the pandemic. The inquest is looking this month at 47 deaths that occurred at Résidence Herron.

The hearings heard questions about whether pandemic directives contributed to the problem and when officials first noticed it.

Nadine Larente, a geriatric specialist who was among the first to arrive with Ms. Daigneault, said one reason Herron’s staff left their posts was because they had been advised by the Info-Santé government medical hotline to isolate for 14 days if they had been in contact with an infected resident.

“That directive made no sense, abandoning people before we had replacements,” Dr. Larente testified.

She and Ms. Daigneault showed up at Herron the evening of March 29. However, documents filed at the inquiry showed that two days before, Herron management had made calls seeking assistance, although it wasn’t clear whether they gave any indication that there was an emergency.

The difficult relationship between Herron and the local health authority, known by the acronym CIUSSS ODIM, underpinned the events of that spring, with both accusing the other of inadequately handling the crisis.

When the novel coronavirus emerged in early 2020, the province placed nursing homes in lockdown on March 13. Dr. Larente said this prevented family caregivers from visiting and helping. “A lot of decisions were taken in the context of prevention and control of infections. Unfortunately, in other ways, these were not for the best for elderly people,” she said.

The problems at Herron emerged on March 27 when the first resident tested positive for COVID-19 and died. Documents filed at the inquest show that on that day and the two days following, Herron’s manager, Andrei Stanica, and owner Samantha Chowieri contacted two CIUSSS administrators seeking assistance.

One of those administrators, Kim St. Hillaire, who was in charge of human resources at the CIUSSS, received a text message from Ms. Chowieri on Sunday morning and tried to help the owner by looking up agencies and volunteers. Meanwhile, that afternoon, Dr. Larente got a text message marked “SOS” from a physician with patients at Herron, who explained that the home’s staff had disappeared.

Dr. Larente went to Herron, where she was met by Ms. Chowieri and her husband and learned that there were only three employees looking after 139 residents.

Ms. Daigneault, a CIUSSS administrator dealing with elder care, had arrived by then, followed by two volunteer nurses. Dr. Larente also called her husband and children to come help.

Ms. Daigneault and one nurse went to the second floor, where there was only one orderly for 60 people.

Several residents indicated they needed something to drink, which was striking to Ms. Daigneault because elderly people often don’t feel thirst unless they are very dehydrated. They gulped down several glasses of water then held her hands in gratitude.

One man sat on a large urine stain in his bed. Ms. Daigneault said the edges of the stain were dry and dark, a sign it had been unattended for a long time. He sighed with relief when she cleaned him.

Her superior, Brigitte Auger, had shown up to help, too. She said she asked Ms. Auger, “Is that normal what we’re seeing?”

The inquest has heard that CIUSSS chief executive Lynne McVey asked the health department for a mandate to take control of Herron. However, because of bureaucratic delays, it wasn’t until April 10 that the CIUSSS took full control.

During that period, the health authority dispatched workers to help at Herron, but they faced resistance from the owners, Ms. Daigneault testified.

Patrick Martin-Ménard, a lawyer representing the families of four of the deceased residents, showed Ms. Daigneault a report from nurses who came to help on April 8 and found the place in disarray with residents carrying wounds that hadn’t been tended in days.

“Between March 29 and April 8 there wasn’t much improvement,” the lawyer noted.

“We gave intensive care to deal with the situation at the time,” Ms. Daigneault said.

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