The embers of the La Résidence du Havre de L'Isle Verte were still smouldering when the calls for a public inquiry began.
That's the Canadian way.
When something horrific happens – like a preventable fire that kills 32 seniors – we don't wail with outrage, we don't take to the streets with pitchforks, we don't demand justice for the dead.
No, when a gross societal failure occurs – do we need to be reminded that the deadly Isle-Verte fire was entirely preventable? – you can always count on Canadian politicians to rise up and…eventually embrace a bureaucratic review.
Shortly after the fire, Quebec Premier Pauline Marois did the obligatory tour of the wreckage, deeming the situation to be "unacceptable." Then she was asked what the government was going to do to prevent similar tragedies, what legislative measures would be taken to ensure this type of this would not happen again?
"First of all, we will wait for the inquiry because now, we don't have the results of this evaluation and examination," Ms. Marois said. "After that, we will see if there are some new rules to adopt."
Quebec Health Minister Réjean Hébert was even more cautious, saying it was too early to commit to any sort of public review. "We have to wait for the results of the police investigation before launching any type of public inquiry," he said.
Make no mistake. There will be a public inquiry. And it will go on for a long time – at least until after the next election. And won't that be convenient?
Inquiries can serve a useful function – more on that in a moment – but they cannot be a substitute for action, an excuse for not making tough decisions and urgent public policy changes.
Let's cut through the fog of political obfuscation and foot-dragging and be crystal-clear about one thing: There should be automatic sprinkler systems in all institutional settings, especially where frail, mobility-reduced and neurologically-impaired citizens live.
If you need a public inquiry to tell you that, you need your head examined.
Had the Isle-Verte seniors' residence had been equipped with adequate safety measures equipment, the fire would likely have had a very different outcome – a few dozen seniors in wet pyjamas, shivering in the cold after smoke set off the sprinklers. That's a far better outcome than 32 funerals.
Yes, making sprinklers mandatory will be costly and those costs will be passed on to the state and to individuals. But if you want to house people in an institutional setting, that's the cost of doing business and it's a small price to pay.
Inquiries are not a reason – and should not be used as an excuse – to sidestep leadership. We need to channel our emotional energy into meaningful public policy change, not into producing another report that gathers dust on a shelf.
This is not to suggest that inquiries do not have a long and noble history and an important role to play.
In a case like Isle-Verte, a public inquiry can help establish the facts and cause of the fire (to date, we just have assumption and rumour); it can serve a cathartic role for those directly affected by the tragedy; it can point fingers of blame if that is appropriate; and it can make recommendations to government on corrective measures that need to be taken.
But, frankly, we don't need another inquiry on appropriate fire safety measures in seniors' residences and nursing homes.
We have 30 years of those reports and it's high time that we implemented the recommendations. The Canadian Association of Fire Chiefs would be happy to provide any government with a quick summary of what needs to be done.
We have the information, we just need a commitment to make the housing of seniors safer now, not at some vague distant future date. We don't need a long, drawn-out, expensive process to tell us what we already know.
What we need in this instance is not a public review of a single tragic event, but a societal reflection on how, in an aging society, we can – and should – house our elders.
There are more than 400,000 Canadians living in seniors' residences, nursing homes, long-term care facilities and so on. There is no common vernacular, let alone common standards of care.
For example, in Isle-Verte, there was a single employee on the night shift, overseeing more than 50 residents. Is it possible to provide adequate care with a 50:1 resident-to-staff ratio? Can a single person assist dozens of frail, slow-moving people in the case of an emergency, whether it's a fire or something else?
We need to probe even deeper than safety and staffing issues, asking ourselves more fundamentally if we should be warehousing seniors the way we do.
Are there really 400,000 Canadians who can't be cared for in the community? Isn't homecare an alternative for many? What about small, more home-like facilities instead of gargantuan ones?
If mass institutionalization is deemed inappropriate – after all, it seems to have happened by default, not be design in Canada – then how can we make our communities and our homes more senior-friendly. (For example, more seniors die in fires in single-family dwellings than in nursing homes so sprinklers in nursing homes are not the only change required.)
We rarely discuss these issues publicly because they make us uncomfortable. This fire should remind of the cost of simply looking away.
What is required is cultural change, wholesale adaptation to the reality of an aging society. That's not going to occur because it's prescribed in a report.
Social change requires debate and consensus-building. What the Isle-Verte can provide is a burning platform – figuratively as well as literally – an an inquiry, done properly, can serve as a means to an end.
André Picard is The Globe's health columnist. Follow him on Twitter: @picardonhealth