Residents at CHSLD Herron victims of 'organizational negligence' last spring, report finds

If management at the West Island private seniors' home had acted more quickly, "it is reasonable to conclude that the Grim Reaper would not have been as devastating," the report found. It was released alongside a report into CHSLD Sainte-Dorothée, which was also ravaged by COVID-19. 

'The pandemic alone does not justify what happened,' said the minister responsible for seniors

Flowers and notes for loved ones are seen at a makeshift memorial in front of the CHSLD Herron, the long-term care home on Montreal's West Island. (Ryan Remiorz/The Canadian Press)

An investigation into one of the province's hardest-hit long-term care homes, CHSLD Herron on the West Island, has concluded it suffered from "organizational negligence."

The report, released Wednesday afternoon, said that if management at the private seniors' home had understood its responsibilities and used the resources at its disposal, "it is reasonable to conclude that the Grim Reaper would not have been as devastating."

In all, between March 26 and April 16, at least 38 deaths at Herron were confirmed by the coroner's office. During a particularly dark period from April 5 to 10, 23 people died.

When the local health authority, the CIUSSS Ouest-de-l'Île-de-Montréal, arrived at Herron on March 29, there were three employees caring for 133 residents. It was filled with a "nauseating odour of urine and feces" and unwashed dishes. 

The health authority took over management of the facility on April 7.

The findings were released alongside another report into CHSLD Sainte-Dorothée, a Laval residence also ravaged by COVID-19. (More on that report below.)

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Herron plagued by turnover

The report into CHSLD Herron found that its reliance on temp agencies to fill staffing shortages, coupled with a high turnover rate, made the residence particularly vulnerable when the pandemic struck.

Between January 2017 and the end of March 2020, the home had four different nursing directors, the report said. During that time, dozens of employees quit and new hires were brought in.

In early January, several employees quit and a management position remained vacant. 

That additional work for staff led to exhaustion and departures — creating a "cycle that is difficult to break," the report found.

The CIUSSS Ouest-de-l'Île-de-Montréal remains in control of the residence.

In a statement, the health authority said the situation at Herron has been stable for several weeks and that it is working to ensure residents receive adequate care.

The report offered a series of recommendations to improve the situation, including:

  • Managers of private CHSLDs like Herron should be more accountable.
  • Regional health agencies should have more power to intervene in a crisis.
  • As the population ages, caring for seniors with more serious healthcare needs is a task that can only be assured by the government.
  • Management and legal frameworks for private CHSLDs should be reviewed, along with operations at other private homes.
  • Move toward no longer using private placement agencies to fill staffing needs in health.

Katasa Group, the company that owns the Herron, said it is reviewing the report.

"We will take the time to carefully analyze the conclusions and recommendations," said Katherine Chowieri, a manager with the company. 

Lack of PPE, oversight at Sainte-Dorothée

The report into Sainte-Dorothée, a public home, was more forgiving, concluding that staffing shortages, a lack of protective equipment and poor managerial oversight contributed to the fatal outbreak.

The toll at the home, however, was staggering. In all, 100 residents died from COVID-19 and a total of 211 residents contracted the virus, along with 173 workers.

The problems plaguing Sainte-Dorothée, according to the report, were emblematic of those facing the entire network of CHSLDs.

Firefighters and police officers from Laval visited the CHSLD Sainte-Dorothée on Wednesday to cheer on the staff, showing support. (Ivanoh Demers/Radio-Canada)

The report included several recommendations moving forward such as: 

  • The CISSS should favour a structure that gives CHSLD managers the power to make quicker decisions that are adapted to the home's specific needs — especially in a crisis situation.
  • Information systems need to be quickly improved, including callback lists and scheduling.
  • The presence of coaches could help ensure all staff know how to properly use personal protective equipment (PPE) and how to follow infection prevention and control protocols.
  • There was a substantial lack of PPE, and it's imperative that such provisions be sufficient for worst-case scenarios.

The CISSS de Laval said it would not comment on the report into Sainte-Dorothée until Thursday.

Government touts efforts to improve situation

In a statement accompanying the release of the two reports, Marguerite Blais, the province's minister responsible for seniors, said it is "clear to us that the pandemic alone does not justify what happened."

"We learned from the first wave to make sure we never relive human dramas like the ones we experienced last spring."

She said the reports will be used to improve care for seniors and "our vulnerable populations in CHSLDs Herron, Sainte-Dorothée and in all areas of life in Quebec."

A woman looks out from CHSLD Herron in mid-April. (Graham Hughes/The Canadian Press)

Health Minister Christian Dubé added that major changes made to the health network "serve to prepare us for the second wave."

Those include:

  • Modifying the structure of CHSLDs to ensure each facility has an appointed manager.
  • Adding more than 7,000 CHSLD attendants — 3,000 of which will be added this fall.
  • Improving infection prevention and control procedures.
  • Adding equipment to monitor symptoms by the care team and doctors remotely.

The reports were ordered last spring by then-health minister Danielle McCann. They were completed in the summer but quietly released Wednesday, just as Gov. Gen. Julie Payette delivered the Liberal government's throne speech.

In that speech, the government pledged to establish national standards for long-term care homes, and to provide additional support to people who want to stay in their homes longer.

It also promised to amend the Criminal Code to penalize those who neglect seniors in their care and put them in danger.

A separate, wide-ranging public inquiry was ordered by Quebec's chief coroner into the province's long-term care homes, private seniors' residences and other residential institutions for vulnerable people over the first six weeks of the pandemic. Hearings are set to begin next year.

With files from Shawn Lyons and Sudha Krishnan

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