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Inquest hears of inadequate infection control

Site lacked even basic infection control, experts testify during coroner's inquest

SUSAN SCHWARTZ sschwartz@postmedia.com

Infection control experts with the West Island health authority who visited the CHSLD Herron in Dorval in late March and early April found an absence of even basic elements of infection prevention and control at the private residence for seniors, a coroner's inquest was told on Tuesday.

Headed by coroner Géhane Kamel, the hearings are looking into 47 deaths among the 134 residents at the Herron and deaths at six other long-term care centres during the first wave of the COVID-19 pandemic.

Among other problems, there was a shortage of personal protective equipment (PPE) for staff and inadequate training in their use; no separation of hot zones (where COVID-19 was present) and cold zones (where it was not); a shortage of hand sanitizer dispensers and of sanitizer; and cleaners who did not understand pandemic cleaning protocols, such as the need to disinfect high-touch areas in residents' rooms.

Nathalie Pigeon, at the time head of the infection prevention and control service for the West Island health authority, the CIUSSS de l'ouest-de-l'île-de-montréal, was contacted on March 29 by public health to send a member of her team to the Herron to determine what was needed there, she testified Tuesday. Staff had deserted the facility en masse on March 29, in the middle of a suspected COVID-19 outbreak, leaving residents unfed, in soiled diapers. The Herron was placed under trusteeship of the Quebec government via the West Island health authority.

The next day, Pigeon sent one of the 11 nurses on her team to the Herron. Among other things, her report said, staff needed training in infection control and PPE use.

That Saturday, she herself visited the Herron with a colleague: By then, she had some information about residents being isolated because of COVID -19, but found no signs on doors indicating who was in isolation. There was an acute shortage of personnel and PPE: “When I wanted gloves, I had to wander around the floor to find them,” she said.

In one room, she found a resident was gasping for air. “The first thing he said was that he was thirsty,” Pigeon recalled. Although it was mid-afternoon, his lunch tray was untouched. There was a strong odour of urine and the cotton pad over the bedsheet was stained with dried urine, she recalled.

Other residents also appeared dehydrated. “It was a shock. I could not believe people were in this kind of condition in Montreal,” Pigeon said, through tears. “It is 18 months later and there are images I can still picture.”

She returned subsequently to the Herron to train staff caring for residents in proper use of PPE. She told them to carry gloves in their pockets, “in case you don't find gloves when you need them.”

Staff shortages in CHSLDS (centres d'hébergement et de soins de longue durée) were widespread in the pandemic's early days, but Alexandre Mercier, who worked in the CIUSSS de l'ouest-de-l'île-demontréal's human resources department during the first wave and testified Monday and Tuesday at the inquest, said he was not told by the West Island CIUSSS until April 5 that he could hire more staff.

“Many deaths could have been presented if we had been able to hire earlier,” he told the inquest.

On arriving at the Herron on April 7, his first day on-site, he found only a handful of employees. “There were trays everywhere and residents in distress,” he said. The oxygen tanks of many were empty and there were few masks. The CIUSSS sent oxygen and a compressor; he managed to locate masks and thermometers.

Mercier told the inquest he called CIUSSS managers to send help — and they did, including a team from the Lakeshore General Hospital and one from St. Mary's Hospital. Others, including lawyers and psychologists, stepped up to the plate.

In one half day, he said, six residents died. Had the CIUSSS not come in, he said, more would have died.

Coroner Kamel asked Mercier why the Herron residents were not dispersed among other facilities. “There were staff shortages everywhere,” Mercier replied. “So the reflex was not to overload the other places.”

By April 17, he told the inquest, he had a system in place to confirm that the people scheduled to work were, in fact, coming in. Some were from an agency and while they were not especially well-trained or efficient, “to get rid of them would have meant losing half the staff.”

What has emerged from the coroner's inquest into the Herron is “terrible” and “totally unacceptable,” Quebec Health Minister Christian Dubé said Tuesday.

Each time he thinks of the Herron, “I think of my mother — and never, never, will I accept that people are treated the way they were treated in that CHSLD.”

Asked whether the government intends to nationalize private CHSLDS, Dubé said a plan is being developed whereby about 40 private long-term care centres would no longer be fully private: Ownership would remain private but there would be “a mechanism of watching them, of making sure that the standards are there.”

Premier François Legault said his government has addressed the situation in CHSLDS by increasing salaries for patient attendants to attract them. “I think that today, the situation is very different,” he said. “There's almost nobody with COVID in our CHSLDS, so it's a major change.

“But what happened at Herron was unacceptable and terrible.”

I could not believe people were in this kind of condition in Montreal. It is 18 months later and there are images I can still picture.

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2021-09-22T07:00:00.0000000Z

2021-09-22T07:00:00.0000000Z

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