Shocking details about Quebec's 1st wave revealed at inquest into long-term care deaths

A shortage of oxygen equipment to treat suffering patients; dead bodies left untouched for hours; staff working despite having symptoms of COVID-19 — these were the grisly scenes at some long-term care homes in Quebec during the first months of the pandemic.

An ongoing coroner's inquest is revisiting what happened in the care homes in the spring 2020, and surfacing new details that underscore just how dire the situation was.

The goal of the inquest is not to determine guilt, but to come up with recommendations to prevent future tragedies, said the coroner leading the proceedings, Géhane Kamel.

But last week, Kamel expressed her frustration as she heard testimony about organizational confusion at a facility in Laval, Que., where more than 100 residents died.

"I'm tired of hearing people say, 'That wasn't my job,'" Kamel said. 

Six publicly regulated care homes — known as CHSLDs — and one private seniors residence have been selected to be examined by Kamel. One death is examined for each establishment.

Last week, and again this week, Kamel is probing the death of 94-year-old Anna José Maquet on April 3, 2020 at CHSLD Sainte-Dorothée, in Laval.

Jean-Pierre Daubois, Maquet's son, said in his testimony that he was outraged by the amount of buck-passing from other witnesses at the inquest. 

"They have washed their hands of responsibility," said Daubois, who both raised his voice and sobbed openly while testifying. 

Daubois described how his mother was administered a cocktail of painkillers and sedatives, called the "respiratory distress protocol." No one told him what that could entail, including that it could lead to her death. 

He consented to her not being sent to hospital, but said his response would have been different had he known the facility didn't have proper oxygen equipment.

Sylvie Morin, a nurse at Sainte-Dorothée, used her testimony to deliver a message to the top officials at the Ministry of Health.

"I want people making the decisions above everyone else to understand that they need to listen to the nurses and patient attendants on the floor," Morin said. "Being heard is important."

Staff went untested

At least four witnesses so far have told Kamel they knew of colleagues who were forced to work despite having COVID-19 symptoms.

Dr. Maude Saint-Jean, an infection-control specialist who advised the regional Laval health authority during the pandemic, described a visit she made to the Sainte-Dorothée CHSLD in late March 2020.

She testified that a patient attendant told her he'd lost his sense of smell two days earlier and had flu-like symptoms. He was told told he couldn't be tested because he hadn't traveled abroad, according to Saint-Jean.

Several witnesses have testified that other staff members at Sainte-Dorothée also couldn't get tested, depite having symptoms of COVID-19.

The inquest's witnesses have laid out a number of factors that led to the crisis in nursing homes. 

Saint-Jean explained the Quebec government had assumed the pandemic would enter the province through hospitals treating sick travellers.

The government didn't account, at first, for the possibility that community spread may have already been happening because of asymptomatic transmission, which allowed the virus to enter and spread among vulnerable residents in long-term care homes. 

Noting COVID-19 has an incubation period of between three and 14 days, Saint-Jean said she believes contamination inside Sainte-Dorothée began in the week of March 9, several days before Quebec first declared a public health emergency.

In addition to the slow government response to developing knowledge about the disease, the inquest heard how staffing shortages and a lack of managers led to disarray.

By April 1st, all senior managers, including the site coordinator and three other managers, were absent, most of them infected with the virus.

The head of the Laval health board, Christian Gagné, said that destabilized Sainte-Dorothée's governing structure.

'It was a horror movie'

The inquest also heard there was little infection control oversight because the main nurse in charge was sick and could only help guide decisions from home.

Even before the pandemic, Sainte-Dorothée was short about a quarter of the staff it needed to operate. At the height of the first wave, nearly 70 per cent of the staff was absent, Gagné said.

More than 200 Sainte-Dorothée residents and 173 staff were infected by COVID-19; 101 residents died.

The witnesses who appeared last week also spoke of the trauma the crisis caused them and their peers. 

Morin recounted the story of a man who survived the hot zone at Sainte-Dorothée, but was left traumatized because the body of a woman who died next to him was left for hours before being taken away, as there was no temporary morgue at the residence. 

"It was a horror movie," another nurse, whose identity is protected by a publication ban, said of the delays in funeral homes retrieving bodies. 

The inquest resumes Monday and will continue to hear witnesses outline what went wrong at Sainte-Dorothée this week.

By this time last year, nearly 4,000 people had died in Quebec's CHSLDs or private residences.