In a sprawling, 141-page report released today, Quebec coroner Cyrille Delâge pointed to six factors that contributed to the deaths of 32 people after a fire swept through a seniors' residence in L'Isle-Verte, Que., more than a year ago.

The Résidence du Havre housed 52 elderly people, including many who couldn't move around without the use of a walker or wheelchair.

The factors cited by the coroner are:

  • Not enough personnel on duty the night of the fire on Jan. 23, 2014, who were trained in helping residents in case of an emergency.
  • A significant delay in the firefighters' arrival on the scene, as well as the request for backup from adjacent municipalities.
  • Questionable management and execution of operations once the firefighters arrived on scene.
  • Delay in the transmission of alarms.
  • Co-ordinated response plan and automatic support were not implemented.

The combination of all of these factors, as well as the fact the fire happened in the winter, led to the ultimate result, the coroner's report says.

Coroner Delâge made several recommendations to avoid such tragedies, including better fire-detection tools for seniors’ residences.

coroner Cyrille Delage L'Isle-Verte inquest

Coroner Cyrille Delâge heard testimony about the ineffective response from the local fire department the night of the fire at the Résidence du Havre. (Radio-Canada)

He pointed to the need for visible and audible smoke-detector alarms in seniors’ residences, as well as heat sensors, automated sprinklers and an alarm system linked to the region’s 911 network.

Delâge also cited the need for properly trained staff in case of an emergency, as well as a sufficient number of staff members on duty, particularly overnight.

The L’Isle-Verte fire began just after midnight.

Long response times were criticized during the inquest, which wrapped up in December.

The co-ordinator for fire safety for the Rivière-du-Loup region, Christian Chénard-Guay, told the inquest that when he arrived on the scene about 45 minutes after the building’s fire alarm was triggered, he saw no measures in place to get the residents out of the building.

Delâge also recommended the creation of emergency response networks in both rural and urban environments to better organize a concerted and simultaneous response to fires and other emergencies. He pointed out that a lack of co-ordination between regional fire services contributed greatly to slow response times.

“There is no valid reason why Quebec — which has just over eight million inhabitants — is served by just over 700 emergency services when Ontario, which has a population of more than 13 million inhabitants, is served by about 400 emergency services," the coroner wrote in his report.

Other recommendations include having Quebec’s Régie du bâtiment, the provincial body responsible for building safety regulations, make automatic sprinklers mandatory in all certified buildings without exceptions.

Public Security Minister Lise Thériault commended Delâge for his "incredible" work on the report.

She said the government would look to implement the recommendations as soon as possible. She said work has already begun to improve training for volunteer firefighters,

In December, Thériault announced the government would invest $19.5 million over five years into volunteer firefighter training.

Christian Morin, a local resident who lost his godmother and his uncle in the tragedy, said the one thing that's missing from the report is what caused the fire to start in the first place. 

"Why did this happen? We'll still be with left with a feeling of doubt," Morin said.