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Fire engulfs a seniors residence in L'Isle-Verte, Que., early Thursday, Jan.23, 2014.Francois Drouin/The Canadian Press

A coroner's report says the 32 seniors who died in a fire at a Quebec nursing home in 2014 were victims of multiple failings from those who should have protected them, including regulators who allowed part of the building to remain without sprinklers, staff who did not help when the blaze started, and poorly trained firefighters who took too long to intervene.

In a report released on Thursday, veteran coroner Cyrille Delâge said the province needs to make sprinklers mandatory, upgrade standards for firefighters and even merge smaller fire departments so they can better respond to emergencies.

"We are not immune to another fire in a nursing home. It's up to us to take the key steps to limit the impact to a minimum," Mr. Delâge concluded in his 141-page report.

Coroners can only make recommendations and do not assign criminal blame.

Nevertheless, Mr. Delâge's strongly worded report was caustic about the failings of some of the key figures in the tragedy.

The blaze started just after midnight on Jan. 23, 2014, in the kitchen of the Résidence du Havre nursing home in L'Isle-Verte, 230 kilometres downriver from Quebec City.

The older wing of the building, where most victims died, had no sprinkler system.

The small town's volunteer firefighters took 18 minutes to arrive at the scene.

Furthermore, the fire chief, Yvan Charron, did not immediately call in reinforcements from neighbouring municipalities.

He did not set up a command centre, and there was no evacuation plan, the report noted.

Mr. Charron's training was not to standard but, because he had been a firefighter before 1998, he was "grandfathered" by law and not required to take updated, mandatory training courses.

Mr. Charron "does not have the proper training to exercise that function and showed it the night of Jan. 23," the report said.

The report recommends that grandfathering for firefighters be abolished within two years.

A more co-ordinated response would have been possible if the area had not been served by a patchwork of fire departments, the coroner also argued.

There is no valid reason that Quebec, which has a population of eight million, should have more than 700 fire departments when Ontario, with 13 million people, has fewer than 400, he said.

The report also focused on the single employee on the night shift, Bruno Bélanger, who was responsible for 52 residents, most of them with impaired mobility.

Instead of ushering the residents out when the fire started, Mr. Bélanger focused on waking the co-owner of the residence, Irène Plante, who was sleeping in another part of the nursing home.

"They [the elderly residents] were left to their own devices by the night shift orderly," the report said, noting that Mr. Bélanger insisted he was following "protocol."

As for Ms. Plante, the report said she "slept well in her bed and left unscathed. Most were not as fortunate."

The report said nursing-home operators and municipal officials might complain about the findings: "Let them do it until there is another disaster ... then they will have to explain to taxpayers why they didn't act," the report said, in another example of the blunt language Mr. Delâge used.

The report offered little consolation for families who lost loved ones. Jean-Eudes Fraser raced to the blaze after receiving a frantic call from his 89-year-old mother, a resident of the home. He arrived before the firefighters.

He lay by his mother's side on her third-floor balcony, expecting firefighters to show up to rescue them. None ever did. He nearly lost consciousness, and then his mother, in her final breaths, told her son to escape and save himself. "Help isn't coming," Angéline Guichard said.

Mr. Fraser still has nightmares about the fire and hopes Mr. Delâge's report will make nursing homes safer for families in the future, since it is too late for his.

"We can't bring back the dead," he said. "But maybe this will help others. For us, it's just disappointing."

The Quebec government said it will study the recommendations closely.

Premier Philippe Couillard said "there are clearly things that have to be done."

With a report from Ingrid Peritz in Montreal