Dissatisfied with the contradictory testimonies heard during the hearings, Géhane Kamel extends the three days of proceedings and plans to recall witnesses.

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Coroner Géhane Kamel slept badly on Wednesday night, she announced Thursday as she opened what was to be the last day of hearings on the 47 deaths at the Herron Residence during the first wave of the COVID pandemic -19 in 2020.


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Troubled by the contradictory testimonies she has heard since the start of the investigation into the deaths at the private CHSLD in Dorval on September 7, she adds three days of hearings – from October 25 to 27 – and recalls at least four witnesses. She did not name them, but wants to “challenge” them on the information they provided in their testimonies.

“I felt like I came away with a lot of questions and half answers or answers that were not to my satisfaction,” she said. “If I were one of the families affected by this tragedy, I would walk away with so many questions – and the opposite of what we should be doing. We must shed at least a minimum of light on all of this to them. “

The role of a coroner’s inquest is not to seek “absolute liability on the part of one party or another,” Kamel said. “What we are looking for is the truth.”


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And in the Herron case, she feels that “the truth is random” because the witness’ versions of events have so often contradicted each other.

When officials from the West Island Health Authority, the CIUSSS de l’Ouest-de-l’ÃŽle-de-Montréal, entered the Herron on March 29, after placing the institution under guardianship, they found many residents not fed, dehydrated and lying in their own urine and feces.

Even before the pandemic, the facility, with around 140 residents, was understaffed. On the evening of March 28, news spread among staff that “the virus was in the building” and that a resident had died in hospital the day before and, according to some witnesses, employees drove out of the building en masse. Herron. Kamel told the inquest on Thursday that she would view video tapes from surveillance cameras at the Herron from March 27-29.


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Witnesses including Samantha Chowieri of the Katasa Group, the company that owned and operated the Herron until it closed in November, described a chaotic scene in which staff were scarce and widespread confusion reigned.

“The government has no clear rules when it puts a place under supervision,” she told the inquiry on Thursday. “There must be someone in charge,” she said. “Trusteeship should not be left in the hands of the CIUSSS without a clearer structure. “

Kamel has said more than once this week that there was “a black hole” at the Herron between March 29 and April 10. “Even from the people at the CIUSSS, we received incomplete responses,” she said. “There was no one who saw the big picture.”

For Christiane Boucher, one of the many children of Herron residents who died during this chaotic time and who responded to the inquiry on Thursday, “a system that was supposed to help my father killed my father.”


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There was “a disconnect from human care to the end.” The pandemic, she said, has simply “exposed the fact that the system is down.”

Before the pandemic, Denis Boucher was held up in bed at night due to understaffing – and over-medicated, she said.

For the hearings to lead to a change so that a horrific situation like the Herron’s does not repeat itself “would mean a complete overhaul” to introduce proper communication, accountability and a universal contingency plan to which all branches of the system health adheres, says Boucher.

All long-term care facilities should be non-profit, she said, “and workers need to be heard: they are at the heart of the action.”

Tina Gurekas’ mother, Olga Maculediciu, was a grandmother and great-grandmother, someone who had a career in dietetics and led a productive life – and when she died at Herron, her property was drawn tossed or thrown.


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“We are angry and disappointed that the system is not taking care of her,” said Gurekas, describing “a complete lack of communication and coordination” at Herron. She said staff communication with families ceased after visits ceased shortly after the pandemic was declared on March 11, 2020 – and did not resume once the CIUSSS took over.

The government needs better oversight of for-profit long-term care facilities, a partnership between hospitals and nursing homes, and a province-wide emergency plan, said said Gurekas,

“After nearly three weeks of hearings, we don’t know what happened between the time our father entered Herron on March 27 and his death on March 29,” Barrette said. “No one seems to have seen it.


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“We know the situation was chaotic. Why did they agree to accept a new resident when they knew they could not take care of him?

Barrette said he and his family “deplored the fact that no criminal charges have been laid” in connection with the deaths at CHSLD Herron.

As a care setting, a CHSLD should have rigorous and structured care, he said, with staff guaranteed a fixed number of hours to prevent them from going from center to center.

Barrette is in favor of the nationalization of all CHSLDs and the creation of a “public network whose objective is not to provide profits to owners but to provide human care to people in the last days of their life”.

  1. Paramedics leave the Herron Residence after picking up a resident at the Dorval CHSLD in April 2020.

    “Elderly care system is broken,” Herron inquiry said

  2. A worker in personal protective equipment walks through the Herron Residence in Dorval on April 15, 2020.

    Herron infection control practices were lacking, coroner’s inquest

  3. A family places a rainbow outside Residence Herron, a long-term care facility for the elderly, following a number of deaths since the coronavirus disease outbreak (COVID- 19), in the Dorval suburb of Montreal Quebec, Canada, April 12, 2020. REUTERS / Christine Muschi

    The situation in Herron was “10, 15, 20 times worse” than that of other CHSLDs, according to the survey

  4. Mary prays before leaving flowers at Residence Herron in Dorval, west of Montreal on Monday, April 13, 2020. Mary's mother was a resident of the long-term care facility where more than 30 people have since died. March.

    Archives reveal chaos before staff abandon the Herron




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