Ruminations: Ample Blame to Share on a Wide Scale of Forfeited Responsibility

"There were probably some who died of dehydration. [Efforts of personnel unable to help since they] didn't have time [to do more for the residents]."
"[Personnel shortages resulted in neglect of basic hygiene for residents]."
Occupation therapist, witness, coroner's inquest

"I'm tired of hearing people say, 'That wasn't my job'."
Coroner Géhane Kamel, Montreal

"Some [care workers] were absent because they were scared, some because they had symptoms."
"They [dementia patients] walk hand in hand. They sleep in people’s beds. And if we try to stop them, you set off behavioural problems like you wouldn’t believe."
"You can’t restrain them. You can’t tie them up."
"It was one of the hardest decisions I had to take with Maude. So we left them there. What it meant is that we were condemning them. Not easy for a manager."
"Most of the 21 contracted COVID-19 but more survived than in other units in the nursing home. It might have been because their wandering kept them in better shape than other seniors who were confined to their rooms during their crisis and slowly declined."
Marie-France Jobin, Supervisor, Sainte-Dorothée, Laval long-term care home

The deaths in CHSLDs in the first wave of the pandemic prompted many questions about how the facilities are run. (Ryan Remiorz/The Canadian Press)

The horribly dismal number of residents of long-term care homes in Canada struck with COVID-19 outbreaks, chronically short of personal care support workers, and unschooled in how to react to the presence of a highly contagious virus, the need to segregate the ill in places where there were multiple occupants of a single room, and instances where patients with dementia had a tendency to wander, led to an unsupportable number of deaths. In the Saint-Dorothee residence alone, one hundred and eight people died in last year's first wave.

The coroner's inquest is an attempt to understand more fully the level of dysfunction and incompetence that led to this disastrous outcome. Most of the witnesses by court order have had their identities protected through a publication ban, presumably leaving them free to speak without fear of retribution. About two-thirds of the facility's employees had logged off sick at the time. The remainder of the employees obviously attempted to do as much as they could, and that cannot have resulted in meeting the most basic needs of the residents.

The therapist who was giving evidence spoke of staff shortages which prevented employees from adequately caring for the seniors, along with the other vulnerable patients living in the home. Many of the residents were barely hydrated and had been given little to eat before they died. One of the residents had developed bedsores, left for hours in incontinence briefs, crying out to be changed. When one of the residents was finally given a bath, she wept in gratitude.

A funeral home worker removes a body from the Verdun CHSLD seniors residence Wednesday April 15, 2020 in Montreal. At the CHSLD Sainte-Dorothée, bodies were left exposed for hours because funeral homes were overwhelmed. (Ryan Remiorz/The Canadian Press)

In desperation, patients were restrained as preventive measures to ensure they were unable to move around freely. One patient with dementia insisted on trying to use the telephone "I had to attach him to his chair because he wanted to talk to his wife", the witness explained. An admission rife with matter for speculation; little wonder a patient whose most basic, routine requirements were being neglected attempted in a desperate cry for help to speak to his wife who would become inconveniently involved questioning staff why her husband's needs were neglected.

Left in their rooms, no exercise or physical therapy on offer affected patients' ability to walk, the therapist testified. She had volunteered to assist at the long-term care home, receiving no training. She had been witness to a director at the home breaking down in front of staff members, screaming and crying in sheer frustration. A second witness, a dietitian, described the institute as a "ship without a captain", so disorganized it might take days for the kitchen staff to be made aware that a patient had died before meals were no longer sent up to the room.

Another patient attendant testified that there had been no direction for the workers who had been left to their own devices on a floor of 34 patients. Among them some had a tendency to wander from their rooms. The night co-ordinator remained in her office advising she had no time to help, during this time.

Two assistant directors at the Laval health authority previously testified that staff at the home were tested for COVID-19 in early April 2020. According to the patient attendant "nobody was aware that there had been testing". The outcome of the situation in the number of deaths at six long-term care homes and one seniors' residence in the province are all under investigation in coroner Gehane Kamel's mandate.