How Quebec’s response to COVID-19 left 4,000 dead in long-term care homes

The bad news arrived by fax just before 11 p.m. It confirmed that a resident with flu-like symptoms at the Sainte-Dorothée nursing home had tested positive for the novel coronavirus, the first confirmed case at the facility. By the next day, March 26, 2020, another eight residents showed similar symptoms.

Despite the fact that COVID-19 was spreading in that long-term care setting, north of Montreal, the momentum of the health bureaucracy carried on. Another 11 people were admitted to Sainte-Dorothée before that practice ended on March 30, by which time there were 84 cases of COVID-19. Four of those 11 people later died of the disease.

Details of that troubling episode, which were previously unreported, are found among more than 2,300 pages of documents filed at coroner Géhane Kamel’s inquest into the death toll in Quebec nursing homes when COVID-19 first struck.

After examining events at six elder-care facilities, Ms. Kamel’s public hearings resume Tuesday with a look at a final facility, Résidence Herron, whose appalling conditions first drew public attention to the horror sweeping nursing homes during the pandemic.

Even though Canada had the highest recorded long-term care death tolls among wealthy countries during the first wave, Quebec is the only province holding public hearings to understand what went wrong and why so many long-term care residents died during the pandemic.

Many Quebec LTCs, known by the French abbreviation CHSLD (centres d’hébergement et de soins de longue durée), were already dismal places where disillusion and discomfort were the norm. The pandemic turned those facilities, which were supposed to be living environments, into charnel houses – even ones with reputations for adequate management, like Sainte-Dorothée.

Canadians died of COVID-19 in long-term care by the thousands. So why are there so few coroners’ reports?

During seven weeks of hearings this spring, Ms. Kamel’s inquest opened an unprecedented window into the havoc at six elder-care homes and revealed how the misery at Herron – missing staff, multiple deaths, neglected residents left in squalor – was far from unique.

A series of mistakes and shortcomings, some resulting from years of underfinancing, others from recent misguided moves to prioritize hospitals, amplified each other in a disastrous chain reaction that resulted in the death of more than 4,000 care-home residents in Quebec alone.

Worse, it appears some of them didn’t succumb from COVID-19 but rather from the resulting chaos – starved and dehydrated, or sedated with morphine rather than having a chance for recovery in hospital, the inquest heard.

VULNERABLE RESIDENTS AND AGED FACILITIES

At each of the six homes that the inquest scrutinized so far, one fatality was examined in further detail as a representative case, giving a human face to the tales of failures at their facility. Moving these six vulnerable people into care homes had been a reluctant, remorseful process for their families.

Micheline Guimond’s testimony was typical. Her husband, Yvan Brodeur, a retired labour arbitrator, had Parkinson’s and Alzheimer’s diseases. “I tried to keep him at home as long as I could. But he started falling repeatedly. I wasn’t strong enough to help him,” she told the inquest. So her husband moved to CHSLD René-Lévesque, in Longueuil, south of Montreal. “I found the place depressing,” she said. “But you get used to everything in life. You make do with what you have.”

Several families testified that they held back from complaining about the poor conditions out of fear it would affect how their loved ones were looked after. They also felt they had to contribute to the upkeep of the homes, where understaffing meant that urine spills might just be sponged up rather than fully sanitized.

“When your father is vulnerable and you leave him there, you really don’t want to criticize the people who take care of him,” Mr. Brodeur’s daughter Amélie said.

In January of 2020, Mr. Brodeur’s family got a foretaste of what could happen during a pandemic when a flu outbreak forced the nursing home into a lockdown. Without the presence of family caregivers, dependent residents were neglected and declined rapidly.

When his family was able to visit again, they found Mr. Brodeur in a dehydrated state. “He looked like he was dying. His chest was heaving, his eyes were hollow,” his daughter Amélie testified.

They insisted that he be hospitalized. When he came back from the hospital, “he was like before. If I hadn’t insisted, he would have been dead by then,” Ms. Guimond said.

According to the Canadian Institute for Health Information, 88 per cent of Quebec’s 440 LTC homes are public, the second-highest provincial ratio. Quebec also has fewer LTC beds available per capita. The national average is 29 beds per 1,000 people aged 65 and older, while Quebec’s ratio is 24.

As a result, thousands are on waiting lists for a nursing-home bed. The year before the pandemic, nearly 2,400 were on standby. The current waiting list has over 3,300 names.

The Quebec coroner’s inquest is examining four public nursing homes and three operated by the private sector. Some of these facilities weren’t originally built for chronically ill, dependent people. The Sainte-Dorothée and René-Lévesque homes were too cramped for their current residents, the inquest heard.

Louise Potvin, chief executive for the local health authority, said CHSLD René-Lévesque’s hallways and elevators were too tight for people in electric wheelchairs. There was no air conditioning. Windows didn’t open fully. “If I had money I would rebuild it completely.”

In Shawinigan, an orderly at CHSLD Laflèche recalled seeing bats fly indoors, a “festival of dead bugs” on the light fixtures and, one spring, an infestation of ladybugs. She also mentioned dusty TV screens on which someone had written with a finger “clean me” and urine stains left untouched for days.

Johanne Grenier, whose father, Ephrem, a former brewery worker, was a resident at Montreal’s CHSLD Yvon-Brunet, said two wheelchairs couldn’t fit through its hallways at the same time. The entrance ramp was too tight for wheeled geriatric chairs. “I have trouble imagining how we could get all the residents out in time if there was a big fire.”

Yvon-Brunet was a pioneering facility when it opened in the 1980s. The managing director at the time, Germain Harvey, thought residents deserved respect and dignity in their waning years. “As you get older, the energy to fight, to advocate your points of view, diminishes. So it’s very easy to overlook what an elderly person wants,” Mr. Harvey said in an interview.

Until a few years ago, there was even a tavern, a convenience store and a daycare in Yvon-Brunet’s basement, to make the place more homelike, a living environment rather than a medical setting.

This “living environment” approach was officially adopted across Quebec in 2003. But the departmental directives outlining that new philosophy acknowledged there had been, at the same time, a shift in the type of people they looked after.

The 2003 directives noted that the increasing number of elderly Quebeckers receiving home care meant that those admitted to LTC facilities were now more dependent people.

According to Quebec’s current policy statement on residential care, 70 to 80 per cent of LTC residents have major neuro-cognitive disorder, a designation that includes Alzheimer’s disease and dementia syndromes. The policy statement also forecasts that the number of Quebeckers with such disorders will grow from 100,000 in 2008 to 180,000 in 2030.

“People in CHSLD are very dependent. They need help for dressing, for feeding, for all the basic activities of daily living, or else they have important behavioural manifestations,” Howard Bergman, a McGill University medical professor, said in an interview.

In 2009, he headed a panel of experts who warned the Quebec government that, with the aging population, Alzheimer’s was a growing concern that needed to be addressed urgently. That hasn’t happened because, in a cash-strapped health care system, nursing homes suffer most, having to rely on an awkward setup with partial public funding and co-payments from their residents.

“The impact of sub-optimal financing is felt most in LTC institutions … with obsolete buildings, where reduction of services has led to pathetic debates about a second bath per week,” Dr. Bergman said.

A SHORTHANDED, UNHAPPY WORK FORCE

Convincing health professionals to work in such challenging environments was arduous. “It’s hard to recruit young people coming out of school for CHSLD work,” said Sonia Bélanger, chief executive of one of Montreal’s health authorities.

It was even harder for private facilities, which didn’t pay as well as the public ones. CHSLD des Moulins owner Paul Arbec said the private sector labour shortage became even more acute after 2017.

The health minister of the time, Gaétan Barrette, faced an outcry because understaffed homes only offered baths once a week. Some residents even resorted to paying employees under the table to get a second bath. Mr. Barrette announced funding so 600 more orderlies could be hired. The result was “a sizable exodus that affected private homes across the province,” Mr. Arbec said.

Many private homes, including CHSLD des Moulins, relied on temporary workers from staffing agencies. “That undermined its stability,” said Daniel Castonguay, former Lanaudière health authority CEO. The inquest heard that officials believe the coronavirus entered CHSLD des Moulins through staffers who also worked at another home where an outbreak had already started.

The rotating cast of employees caused by staff scarcity was hard on residents with cognitive challenges, such as Lucille Gauthier, a former nurse who had moved to CHSLD des Moulin in October, 2018.

Some testified that she was “difficult” and aggressive. But those who were better acquainted with her said she was just uncomfortable when receiving care from people who weren’t familiar to her.

Head nurse Jocelyne Bourque said Ms. Gauthier was anxious and didn’t like strangers entering her room. Ms. Bourque tried to bond with her about their common nursing background when she came to take blood samples. “She’s a lovely lady, adorable,” Ms. Bourque said.

In small towns, nursing homes couldn’t turn to agency workers. CHSLD Laflèche, for example, is located in Mauricie region, midway between Montreal and Quebec, where few agencies operate, local health authority CEO Carol Fillion testified.

He said that even before the pandemic, CHSLD Laflèche pressed employees to work overtime. “At 4 p.m. you might have to ask a young father or a young mother: ‘You can’t go pick up your child at daycare, call someone else to do it, I absolutely need you to stay. Can you stay at least until after dinner time?’ ”

Elsewhere, each place had its own theory to explain its staffing woes. Montreal health official Isabelle Matte said it was harder to find employees for care homes in the city’s southwest like CHSLD Yvon-Brunet, because many orderlies live in north-end immigrant neighbourhoods. In Laval, health official Marie-France Jobin said it was because Sainte-Dorothée wasn’t well served by public transit.

And even though some homes needed agency staff, those workers, often newcomers to Canada, weren’t always warmly welcomed.

Employees at CHSLD des Moulins and Manoir Liverpool complained at the inquest that agency workers lacked adequate language skills. “Some orderlies can’t even speak French. … I’m an immigrant. I went to school in French,” a CHSLD des Moulins supervisor said. She added that some residents with cognitive problems would panic when looked after by a man of colour.

A former Manoir Liverpool manager, Sylvie Guyot-Gagné, said her employees were xenophobic toward agency workers, and used the N-word to complain about them. “‘Another damn [N-word] showing up’ – I heard that often,” she testified.

PROTECTING HOSPITALS AT THE EXPENSE OF CARE HOMES

Quebec health officials preparing for the onset of the coronavirus in early 2020 feared they would experience what befell Italy, one of the first countries to be hit outside China.

“What was emerging from Italy was that emergencies, hospitals, intensive-care were overwhelmed … nothing was pointing towards nursing homes,” Olivier Haeck, an infection-control specialist for the Laval health authority, testified.

The province made it a priority to free more hospital beds by discharging people who no longer needed intensive treatments. A March 18 Health Department pandemic plan filed as an exhibit at the inquest stated that a priority was reducing the number of those patients by 80 per cent, in part by transferring them to nursing homes.

In addition, the government made it harder for CHSLD residents to get into hospitals by asking doctors to update the care levels of their nursing-home patients.

Care levels indicate in advance the degree of medical interventions should a patient’s condition severely deteriorate. They range from A (maximal efforts to sustain life) to D (palliative care).

Several relatives at the inquest testified that they felt pressured to revise their loved ones’ care level to C or D. What the families didn’t fully realize was that the C and D designations would put the priority on relieving pain, rather than on prolonging the life of a patient.

In addition, a March 23 provincial directive said that LTC residents who contracted COVID-19 should only be hospitalized “on an exceptional basis and after consultation with the doctor on duty.”

The emphasis on hospitals also had an impact on the availability of personal protective equipment.

Nursing homes were still supplied with masks and smocks, but managers understood that they had to be parsimonious. “We were told the stock was saved for the hospitals. They delivered in dribs and drabs,” Sainte-Dorothée site co-ordinator Julie Proulx testified.

Lost in all the efforts to gird hospitals against COVID-19 were early warnings that the new virus could be transmitted before its carriers showed signs of illness.

The Jan. 24, 2020, edition of The Lancet medical journal had mentioned the potential for asymptomatic infections. A Feb. 6 memo from INSPQ, Quebec’s public-health institute, warned that “some papers mention the possibility of transmission before symptoms appear.”

During the inquest, Maxime Dupuis, a lawyer representing the FIQ nursing union, noticed that, among the pandemic briefings sent to Montreal health officials in March 2020, one email had an attachment of a New England Journal of Medicine clipping mentioning the potential for carriers “to shed and transmit the virus while asymptomatic.”

But those warnings were lost in the flurry of memos about the new disease. Public-health offices meanwhile had their own difficulties managing the flow of information.

“We weren’t computerized at all, we worked a lot with paper,” Marie-Josée Godi, regional public-health director for Mauricie, testified.

Her Montreal counterpart, Mylène Drouin, said COVID-19 test results still arrived by fax to her regional office, with no clear indication which LTC home was involved – “It wasn’t marked ‘CHSLD Yvon-Brunet,’ so you had to find where the person was.”

There were further hassles digitizing the test results, said Maude Saint-Jean, head of microbiology for the Laval health authority. “We had to retype it and then it would be faxed to our CHSLDs. We had a stack of messages on our fax machine and we had to find people to deal with it in due time.”

The fax bottleneck even hampered the removal of Sainte-Dorothée’s first COVID-19 fatalities. “Because everything was done by fax, there were delays and it was a while before funeral services got the guidelines on how to come pick up those people,” said Laval health administrator Marie-France Jobin.

The first deceased resident wasn’t picked up for 48 hours, Ms. Proulx, the site co-ordinator, said. There was no morgue or cold storage so they left the body in bed and locked the room to keep out dementia residents. Because of the smell, “we opened the window,” she said.

INADEQUATE MEDICAL CARE

As the outbreaks started, the priority given to hospitals trapped vulnerable residents in facilities without adequate medical care and haphazard staff-mask policies.

The inquest heard that at one LTC facility, the Montreal Chinese Hospital, employees took the initiative to use masks at all times, weeks before it became mandatory. None of their residents died of COVID-19.

Meanwhile, at Sainte-Dorothée and Yvon-Brunet, workers initially could only wear masks when in proximity to someone with symptoms. They were told that it could scare residents or that “everyone would then want to wear masks.”

At the same time, frustrated employees recalled some supervisors who donned masks, saying that they had a sore throat or a dripping nose.

The uncertainty was too much for some. One Manoir Liverpool orderly testified that she abandoned her post for four days. “I thought I was going to die of COVID. I had never heard of it. …I was scared.”

By that time, the nursing homes were scrambling to isolate residents who had tested positive. However, shuffling residents inside buildings already filled to capacity was like trying to solve a Rubik’s cube. “When beds are all taken up and you have infected cases, where do you relocate them if it’s full everywhere?” Ms. Potvin said.

Meanwhile, relatives and family caregivers had been locked out since a mid-March directive banned visitors.

When families asked that their ailing relatives be hospitalized, “we had to tell them we wouldn’t transfer,” Agnieska Mroz, who was assistant head nurse at Sainte-Dorothée, testified.

“I saw a case where the lady was very desaturated, very confused, very agitated because of the lack of oxygen. The family wanted to transfer because she was a [care] level A. The head nurse told us not to transfer. … So the family called 9-1-1 themselves. The ambulance technicians showed up.”

Another Sainte-Dorothée assistant head nurse, Ms. Morin, testified that, as COVID-19 spread and more residents had breathing problems, the facility repeatedly resorted to its respiratory-distress protocol. Under the protocol, morphine, the sedative Ativan and scopolamine, which reduces respiratory secretions, were administered if a resident’s breathing troubles met a number of criteria.

One resident put on the protocol was former Bell employee Anna José Maquet, after she gagged and had trouble breathing the morning of April 3. The inquest heard that she appeared lucid and in good health the day before. But she had been reclassified to a care level that ruled out hospitalization. She died that evening under sedation. There is no evidence she had COVID-19 because her test sample was lost.

In defending their unwillingness to send sickened LTC residents to hospitals, health officials testified that they wanted to avoid “therapeutic obstinacy,” needlessly inflicting treatment on a dying person.

A year after losing her, Ms. Maquet’s son was still incensed when he appeared at the inquest. “That’s not therapeutic obstinacy,” Jean-Pierre Daubois testified. “Therapeutic obstinacy is when you try many things and nothing works. Not only was there no therapeutic obstinacy, there were no therapeutic attempts.”

For other residents, the end didn’t come serenely either.

At CHSLD des Moulins, Ms. Gauthier went through what coroner Géhane Kamel described as a drawn-out agony before she died on April 12.

Her weight dropped under 90 pounds and she kept falling from her bed. She needed pureed food and her daughters believe that in the confusion created by the pandemic, she wasn’t getting meals of the proper consistency and slowly starved away.

Mr. Brodeur’s family also wonder if he died because orderlies at CHSLD René-Lévesque were too shorthanded to feed and hydrate residents properly. By the time of his death, he had lost 25 pounds during the six weeks the home was inaccessible to relatives.

His daughter Amélie said she was told Mr. Brodeur had been sedated and didn’t appear to suffer. “Maybe at some point the hunger, the thirst, you don’t feel it anymore because you’re so weak but that doesn’t mean he didn’t suffer before that. And he couldn’t express it.”

At CHSLD Yvon-Brunet, Mr. Grenier lost his life on the same day as Ms. Gauthier.

Allowed a final visit, his children found him emaciated and half-conscious, struggling to breathe. He was in a darkened room, his bedding tossed aside, diapers on the floor. “The smell was almost unbearable,” his daughter Sonia said.

Her sister Johanne testified at the inquest.

“If the government is going to use CHSLDs as a hospital for their residents during a pandemic,” she said, “then it has to offer the same level and quality of care you find in hospitals, with the necessary equipment, ventilators, masks for the residents and staff.

“Otherwise these places become death chambers.”

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