'Gaping holes in oversight': Inquest begins digging into painful story of Herron care home

Red flags at Herron: inquest A coroner warned the inquest into 47 deaths at the Herron care home will get worse, despite troubling early testimony.

MONTREAL — Public hearings into conditions at CHSLD Herron began on Tuesday, nearly 18 months after horrific conditions inside the Dorval, Que. facility were first discovered.

It's part of Quebec's sweeping investigation into the province's long-term care homes (CHSLDs), which is expected to last several months. During the first wave of the pandemic in Quebec, about half of COVID-19 related deaths occurred in long-term care facilities and residences.

At the Herron, a private seniors' home, staff shortages are said to have contributed to deteriorated conditions, leaving workers unequipped to handle a COVID-19 outbreak which spread rapidly through the building in the spring of 2020.

Just three staff members were left to care for 133 residents. Of those infected, 47 people died.

Last week, the Crown announced that no charges would be laid following a criminal investigation into the residence, allowing the inquest to start Tuesday.

Coroner Géhane Kamel, who is overseeing the hearings, called the conditions at CHSLD Herron "deplorable" in her opening statement. She said she expects the testimony to invoke intense emotions.

'I WANT TO KNOW THE TRUTH'

"I try to avoid saying it couldn't get worse because I don't want to jinx anything," Peter Wheeland, whose parents were both residents at Herron, told CTV News last week.

Wheeland's father was eventually transferred out of the facility, but later died of COVID-19.

His mother, he says, was severely neglected.

"She has a catheter, so the urine bag had basically burst and was spread out all over the floor. No one had brought her breakfast. At lunch, her neighbour across the hall brought her a breakfast tray that had been left out across the hall," Wheeland said.

A body is removed from Maison Herron, a long term care home in the Montreal suburb of Dorval, Que., on Saturday, April 11, 2020. THE CANADIAN PRESS/Graham Hughes 

Patrick Martin-Menard is a lawyer representing some of the families at Herron.

"I think there is much to be learned from hearing from these witnesses," he says.

He hopes the inquest leads to an overhaul of the private long-term care system.

"One of the cracks that CHSLD Herron has exposed in the situation [...] is the significant gaping holes in oversight and control," said Martin-Menard.

Wheeland said with Quebec's ageing population, now is the time to act to fix what he calls the province's "fragile" long-term care system.

"Let's take all the warnings that we got from COVID and make sure we have a system that can take care of our seniors," he said.

For Wheeland, the inquest is the start of that process, even if it brings up terrible memories.

"I want to know the truth about what was going on in that building even though it's going to be difficult to live or relive, and I think a lot of the family members feel the same way."

The West Island health authority said it intends to cooperate with the inquest.

Representatives of CHSLD Herron's former owners did not return CTV's request for comment.

MONTREAL PUBLIC HEALTH DIRECTOR TESTIFIES

Montreal director of public health Dr. Mylène Drouin revealed through testimony that on April 3, she received a message from Quebec director of public health Dr. Richard Massé referring to a potentially problematic situation in Herron and raising the possibility of taking additional measures if the situation escalated.

Drouin says she interpreted the email as a "red flag" reminding her of the "graduated approach" that can be taken, citing a section of the Public Health Act.

Her medical chief then took over, since it is the Montreal West Island health and social services centre (CIUSSS-OIM) that manages CHSLDs on its territory, and Montreal public health, which covers the whole territory.

The CIUSSS team then investigated, ensuring that the care home was properly disinfected and following other protocols.

CIUSSS staff then indicated that they did not have access to the list of employees who had been exposed to COVID-19 and who might currently be working in other institutions in Montreal.

The team finally received the list, and the CIUSSS action plan seemed to him to be on track.

An email from the West Island CIUSSS management refers to the fact that "we have the situation under control. The CIUSSS team has been on site for several hours. The residents are being fed, changed, put to bed."

A few times during Drouin's testimony, there was reference to problems with access to exposed staff lists, medical records, and other documents.

-- With files from CTV Montreal's Luca Caruso-Moro and The Canadian Press.