Quebec coroner's office orders public inquiry into COVID-19 deaths in long-term care homes

Quebec's chief coroner has ordered a wide-ranging public inquiry into deaths that have occurred in the province's long-term care homes, private seniors' residences and other residential institutions for vulnerable people in the first six weeks of the pandemic.

Most Quebecers who have died in the pandemic have been seniors in care

Flowers and notes are placed at a makeshift memorial in front of the CHSLD Herron, a privately run long-term care home in Montreal's West Island where many people died in the first weeks of the pandemic. (Ryan Remiorz/The Canadian Press)

Quebec's chief coroner has ordered a wide-ranging public inquiry into deaths that have occurred in the province's long-term care homes, private seniors' residences and other residential institutions for vulnerable people over the first six weeks of the COVID-19 pandemic. 

More than 60 per cent of the province's COVID-19 deaths have occurred in public or private long-term care homes, known by their French initials as CHSLDs, many of which were plagued by chronic staffing shortages long before the pandemic hit. 

The coroner's office has already begun investigating one privately run long-term care home that had a high number of COVID-19 deaths — the CHSLD Herron in Dorval, in Montreal's West Island.

In a news release, the coroner said that investigation will be the starting point for a much larger inquiry, which will look at several different kinds of residences and several regions of the province, gathering evidence from key players in order to present a "representative portrait" of what has happened provincewide.

Quebec's chief coroner Pascale Descary said the investigation will be totally public, from beginning to end. Coroners will hear testimony in public and make the process and final report available to all.

Not till January

But it could take several months before those hearings are held: the first public meeting won't take place until January 2021, Descary said. 

"The population needs answers, so we will do it as quickly as possible with the resources we have," she said. 

The inquiry will determine the causes and circumstances of the deaths and provide recommendations on how to prevent these types of deaths in the future.

Descary says those recommendations could be for institutions, individuals or the government — but the goal is to find constructive solutions to avoid these types of deaths in the future.

"We don't place blame. We have to understand what happened," Descary said. 


Descary says the inquiry won't examine all deaths that have taken place in these residences. The deaths that will be investigated must meet the following criteria: 

  • The death occurred while the person was living in a CHSLD, private seniors residence or a residential. institution for vulnerable people or those who have lost some degree of autonomy.
  • The death occurred between March 12 and May 1, 2020.
  • The coroner's office was alerted to the death because of its violent nature or because of the possibility that negligence contributed to the death.

Lawyer Géhane Kamel, the coroner responsible for the CHSLD Herron inquiry, will preside over the larger inquiry with the assistance of Dr. Jacques Ramsay, a coroner with extensive medical training. 

Descary's decision to use her powers to order a "vast public inquiry" comes while Premier François Legault has resisted calls for an inquiry, saying the province is focused on addressing the immediate crisis inside the homes.

Last month, Ontario became the first province to announce a wide-scale investigation into its long-term care system as a result of the coronavirus pandemic.

Quebec to co-operate with coroner

Quebec's minister responsible for seniors and informal caregivers says the government will co-operate completely with the coroners in the independent investigation.

"Anything [they] want from the government, information, we will give it to [them]," Marguerite Blais said Wednesday afternoon.

Since the inquiry will likely provide recommendations on how to avoid negligence and abuse in care homes, Blais said she would be open to revising existing legislation aimed at combatting the mistreatment of seniors accordingly.

"If I have to reopen this law to make it stronger, I will do it," Blais said.

Personal stories to paint a true picture

Peter Wheeland's father, 85-year-old Ken Wheeland, died of COVID-19 on April 4 at CHSLD LaSalle. He had been transferred there from CHSLD Herron two weeks earlier. 

He said it's important that personal testimonies will be heard, to paint a picture of what really happened in the residences. 

"I think those stories are going to very well illustrate what the problems were," Wheeland said. "I think they're going to discover some things that we're going to be shocked to hear." 

The wide-ranging public inquiry is a step in the right direction, Wheeland said. He is hoping the government will act fast to change its policies before there is a potential second wave of COVID-19. 

He said the government's reluctance to send COVID-19 patients in care residences to hospital is part of the reason so many people died. Understaffed nursing homes were simply not equipped to care for them, he said, and family members want answers. 

"We all go through grief in different ways, and some people are going to be looking for the right to blame somebody to find out who exactly is responsible for these deaths," Wheeland said.


  • A previous version of this story said Ken Wheeland died on March 17 after living at CHSLD Herron for three weeks. In fact, he died April 4 at CHSLD LaSalle after living there for two weeks.
    Jun 17, 2020 9:24 PM ET

With files from Cathy Senay and Radio-Canada


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