Coroner Géhane Kamel believes that the most vulnerable seniors have been in the “blind spot” of government and society.• Read also: Deaths of seniors in CHSLDs: decades of failed policies
“History will unfortunately remember that in Quebec, it was the seniors who lived in accommodation who paid the heaviest price during the first wave of COVID, a sneaky disease with more dramatic consequences for people who already have a health deficit”, she underlined Thursday by presenting the conclusions of her report on the deaths of elders in CHSLDs.
Earlier this week, it published the conclusions of its investigation report on the 53 deaths that occurred in accommodation settings during the first wave, interviewing more than 200 witnesses to do so.
“These environments which were to welcome them so that they end their days there also had to be able to provide them with the care that their health required”, recalled Mr. Kamel.
She added that these environments had to give the most peaceful end of life possible to its residents. “For all 53 deaths involved, this moral and societal contract has been broken,” she said.
During the second wave, the coroner believes that the plans put in place were more “substantial”, showing herself to be optimistic that Quebec will be better prepared if another similar situation were to occur.
Despite everything, she believes that there was a “hole” between the field and the ministry, while information circulated with difficulty between the two.
“If there were to be a new health crisis, the agility of the health system, it has to be much faster, and we have to be able to have people who make decisions that are much faster” , she warned.
The coroner hopes that her report will be taken into account by the government, and that ultimately, it will make it possible to ensure that such a crisis does not happen again “never again”.
“I’m not trying to blame people, that’s not my goal or our job. If by the tape I skinned people, it is because we returned to the factual by naming situations which had to be named, ”she mentioned.
According to her, her 23 recommendations must be implemented, none being more important than the others. “It’s like you decide to make a recipe for spaghetti sauce, but not tomato. It does not work. It is a whole”, she illustrated.
After being questioned on this subject, the coroner returned to two establishments which were particularly problematic during the first wave.
In Greater Montreal, 47 people died at CHSLD Herron during the first wave. The many issues listed there have made the media headlines a few times.
“People failed. Whether it’s the owners of Herron, the CIUSSS and the ministry. That, to me, is undeniable. People passed the ball to each other, ”she said of this.
However, Me Kamel indicates that he has no complaints, although there are lessons to be learned.
At the Manoir Liverpool in Lévis, several cases of abuse had been reported by the newspapers. The coroner particularly skinned Daniel Paré, who was then CEO of the CISSS de Chaudière-Appalaches.
“For me, it’s impossible that he didn’t know, and if indeed he didn’t know, we have a serious problem,” she said, saying she was flabbergasted by the situation. For me, it is a great mystery until today.
Several times during the hearings, Coroner Kamel said she wanted to give a voice to the deceased.
“I hope I have given them a voice. Those who will be able to judge it will be the deceased. I hope that through this report, we will have been able to restore a little dignity to these people,” explained coroner Kamel, who says that she was inhabited throughout the investigation by the deceased.
She also deliberately omitted to mention the age of the deceased in her report. “It was meant to be a personal response to the fact that so much emphasis had been placed on the death of old people that we ended up trivializing their death,” she explained.
Listen to Vincent Dessureault at the microphone of Mario Dumont on QUB radio:
On the government side, it says “take note” of the recommendations contained in the coroner’s report, and that a follow-up will be done on the 18 that concern it.
“This report […] is one more tool for diagnosing what happened and how we can improve our ways of doing things. We will continue our efforts already initiated since the first wave,” said Christian Dubé, Minister of Health and Social Services.
According to the government’s explanations, eight recommendations have been fully implemented, eight others are in progress, and the last two will require a more complete assessment and a legislative amendment.
“The recommendations made by Coroner Kamel will help us in our desire to establish a new culture of care and services for seniors. I wish to reiterate that this report will not be shelved,” said Marguerite Blais, Minister responsible for Seniors and Caregivers.
RECOMMENDATIONS
To the Government of Quebec
— Review the role of the national director of public health so that his functions are exercised completely independently and without political constraint.
— Evaluate the possibility of setting up a voluntary emergency civic service that would be overseen by the Ministère de la Sécurité publique, just as is sometimes seen in the event of a natural disaster.
— Quickly review the service offer to our seniors by converting all private CHSLDs into private CHSLDs under agreement.
— Increase the service offer for home support for our seniors.
— Ensures an inclusive policy in times of crisis to allow at least two caregivers to visit the person being accommodated in a safe manner.
— Implement safe healthcare professional/resident ratios in CHSLDs.
— Increase, when required, the number of managers in CHSLDs to ensure that all shifts are covered (evening and night delegated powers).
— Provide for discussions with union authorities in order to review or add, where applicable, clauses in collective agreements allowing for increased availability and relief of personnel during a health emergency.
— Plans new infrastructure or renovations to residential settings, ensuring that the settings can meet the health care requirements, particularly in times of health crisis.
— Ensures that residential facilities can offer residents individual rooms.
To the Ministry of Health and Social Services
— Introduces the precautionary principle at the center of any risk assessment and management process.
— Ensures greater accountability of managers of CISSS/CIUSSS and the Ministry of Health and Social Services with regard to the care provided to seniors with loss of autonomy by monitoring indicators and an obligation to intervene in the event of problems in the quality of care.
— Ensures that the necessary supply of protective equipment is maintained at all times, in addition to planning reserves to meet needs in the event of a crisis.
— Define what comfort care facilities in CHSLDs must at least be able to offer.
— Establish a national plan to equip all CHSLDs with the equipment needed to provide this care.
— Review technical training so that nurses in CHSLDs and, where applicable, nursing assistants are able to perform the techniques necessary for basic care (respiratory care, venous and subcutaneous access, use of volumetric pumps, etc. .).
— Develop a tool with scenarios so that residents and/or their tutors can clearly understand the implications of a choice of level of care.
— Ensures management in the CHSLDs, which brings together a responsible manager, a nursing care directorate and a medical directorate.
At the CISSS and CIUSSS
— Ensure the sufficient presence of nurses specializing in PCI in the CHSLDs so that they can be present in daily operations and ensure their sustainability.
— Make sure to plan simulations in line with pandemic plans every three years.
— Offer training in keeping medical records and perform periodic follow-ups.
— Ensure the necessary supervision justifying the use of distress protocols and palliative sedation in an acute care setting.
At the College of Physicians of Quebec
— Review the individual medical practices of attending physicians at CHSLD Herron, Les Moulins and Sainte-Dorothée, in particular with regard to their decision to continue teleconsultation care despite the need for support and the very large number of deaths.
Conclusion
— “The COVID-19 crisis illustrates decades of failing public policies concerning CHSLDs that were already known.”
— “Quebec’s reduced hospital capacity compared to other countries in the Organization for Economic Co-operation and Development (OECD), combined with the prior fragility of CHSLDs, prompted the authorities to have the first instinct of protecting our hospital capacity by avoiding including the transfer of residents to hospitals.”
— “This protection of hospital environments certainly had its raison d’être, but it now seems obvious to me that the pre-existing systemic causes will have to be reviewed and corrective measures will have to be taken.”
Source: coroner’s office investigation report