Residents at CHSLD Herron victims of ‘organizational negligence’ last spring, report finds


An investigation into one of the province’s hardest-hit long-term care homes, CHSLD Herron on the West Island, has concluded it suffered from “organizational negligence.”

The report, released Wednesday, said that if management at the private seniors’ home had understood its responsibilities and used the resources at its disposal, “it is reasonable to conclude that the Grim Reaper would not have been as devastating.”

In all, between March 26 and April 16, 38 deaths were confirmed by the coroner’s office. During a particularly dark period from April 5 to 10, 23 people died.

When the local health authority, the CIUSSS Ouest-de-l’Île-de-Montréal, arrived at Herron on March 29, there were three employees caring for 133 residents. It was filled with a “nauseating odour of urine and feces” and unwashed dishes. 

The health authority took over management of the facility on April 7.

Lack of PPE, oversight at Sainte-Dorothée

The findings were released alongside another report into CHSLD Sainte-Dorothée, a Laval residence also ravaged by COVID-19. 

The toll in that case was staggering. In all, 100 residents died from COVID-19 and a total of 211 residents contracted the virus, along with 173 workers.

The report into Sainte-Dorothée, however, was more forgiving, concluding that staffing shortages, a lack of protective equipment and poor managerial oversight contributed to the fatal outbreak

The problems plaguing the publicly operated residence, according to the report, were emblematic of those facing the entire network of CHSLDs.

Firefighters and police officers from Laval visited the CHSLD Sainte-Dorothée on Wednesday to cheer on the staff, showing support. (Ivanoh Demers/Radio-Canada)

In a statement accompanying the release of the two reports, Marguerite Blais, the province’s minister responsible for seniors, said it is “clear to us that the pandemic alone does not justify what happened.”

“We learned from the first wave to make sure we never relive human dramas like the ones we experienced last spring.”

She said the reports will be used to improve care for seniors and “our vulnerable populations in CHSLDs Herron, Sainte-Dorothée and in all areas of life in Quebec.”

A separate, wide-ranging public inquiry was ordered by Quebec’s chief coroner into the province’s long-term care homes, private seniors’ residences and other residential institutions for vulnerable people over the first six weeks of the pandemic. 

The report included several recommendations moving forward such as: 

  • The CISSS should favour a structure that gives CHSLD managers the power to make quicker decisions that are adapted to the home’s specific needs — especially in a crisis situation.
  • Information systems need to be quickly improved, including callback lists and scheduling.
  • The presence of coaches could help ensure all staff know how to properly use personal protective equipment (PPE) and how to follow infection prevention and control protocols.
  • There was a substantial lack of PPE, and it’s imperative that such provisions be sufficient for worst-case scenarios.

The CIUSSS Ouest-de-l’Île-de-Montréal remains in control of the residence. In a statement, the health authority said the situation at Herron has been stable for several weeks and that it is working to ensure residents receive adequate care.

Herron plagued by turnover

The report into CHSLD Herron found that its reliance on temp agencies to fill staffing shortages, coupled with a high turnover rate, made the residence particularly vulnerable when the pandemic struck.

In early January, several employees quit and a management position remained vacant. 

Between January 2017 and the end of March 2020, the home had four different nursing directors, the report said. During that time, dozens of employees quit and new hires were brought in.

That additional work for staff led to exhaustion and departures — creating a “cycle that is difficult to break,” the report said.

Watch as  Premier François Legault speaks about Herron: Quebec Premier François Legault talks about what he believes happened at the Herron long-term care home in Dorval, where 31 patients have died in the past month. 1:43

The report offers a series of recommendations to improve the situation, including:

  • Managers of private CHSLDs like Herron should be more accountable.
  • Regional health agencies (CIUSSS) should have more power to intervene in a crisis.
  • As the population ages, caring for seniors with more serious healthcare needs is a task that can only be assured by the government.
  • Management and legal frameworks for private CHSLDs should be reviewed, along with operations at other private homes.
  • Move toward no longer using private placement agencies to fill staffing needs in health.

Katasa Group, the company that owns the Herron, says the report is under review.

“We will take the time to carefully analyze the conclusions and recommendations of the report,” said Katherine Chowieri, a manger with the company. 

The CISSS de Laval is not commenting on the report into Sainte-Dorothée until Thursday.

Government touts its efforts to improve situation

In a statement issued Wednesday, the government is defending the steps it took once officials became aware of the situation at Herron and Sainte-Dorothée.

“The pandemic has brought to light already existing gaps in the network,” says Health Minister Christian Dubé in the statement.

“The government responded quickly to the findings presented in these reports.”

An woman looks out from CHSLD Herron in mid-April. (Graham Hughes/The Canadian Press)

Dubé  says major changes made to the health network “serve to prepare us for the second wave.”

Some of the measures that are either in place or in progress across the province include:

  • Modifying supervisory structures in CHSLDs to ensure each facility has an appointed manager.
  • Adding more than 7,000 CHSLD attendants — 3,000 of which will be added this fall.
  • Improving infection prevention and control procedures.
  • Improved technological infrastructure that facilitates better monitoring of symptoms by the care team and doctors remotely.
  • The roles and responsibilities of private CHSLDs and private residences are being clarified.



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