Allison Hanes: Too many deaths to count at Herron residence

Authorities struggled to keep track of who and how many died after the West Island CIUSSS took over the nursing home.

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When Lynne McVey, CEO of the West Island CIUSSS, summoned police to the Maison Herron in the wee hours of April 11, 2020, she told the 911 operator health authorities had just “uncovered many deaths” among the elderly residents there that she wasn’t sure were related to COVID-19.

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She later testified at a coroner’s inquest looking into the appalling conditions at the privately run long-term care home put under trusteeship by the CIUSSS de l’Ouest-de-l’Île-de-Montréal, that during the day on April 10, her staff had finally gotten access to a room at the facility where they discovered a stack of forms that brought the known death toll from 13 to 31.

In total, 47 patients at the care home died during the first wave of COVID-19, while survivors were found dehydrated, unfed and in soiled diapers because so many staff members had fallen ill or were in quarantine. The Montreal Gazette’s Aaron Derfel broke the story of the tragedy on April 10, 12 days after the CIUSSS first arrived at the troubled Maison Herron and undertook steps to assume control.

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But a trove of documents filed during and after the hearings presided over by coroner Géhane Kamel shows the CIUSSS struggled to account for who and how many died once its involvement began on March 29. Email exchanges and text messages reveal that there were differing procedures to officially declare deaths being used by the various parties working at the Herron. Confusion over which method was being employed and by whom may have slowed the removal of bodies, complicated record-keeping as the number of deaths rose and hampered communication with families.

The paper trail has allowed journalists to independently reconstruct who knew what when in real time as the awful events at the Herron unfolded, and compare and contrast that to what those responsible said they did during their turns on the witness stand.

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According to a sworn statement by Dr. Orly Hermon, a general practitioner who followed many patients at the Herron, there had been a system in place for over a year before COVID-19 struck in which doctors would fill out official declaration of death forms from a distance with assistance from a nurse from the floor who sent the necessary clinical details.

“The nurses were trained accordingly and this way of functioning worked well,” Hermon said in her filing. “If the physician was not on site, the SP-3 form would be filled out by the physician after discussion with the nurse. … The physician would then quickly email the form to the nursing station … as this form is necessary for the body to be recovered by the funeral home.”

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The doctors, she added, would later deliver the originals to the long-term care home themselves on their regular visits.

A series of text messages between Hermon and Tina Pettinicchi, then-director of sales and external relations at the Herron, revealed that the GP continued to issue SP-3s — “constat de décès,” as the official declaration of death is called in French — once COVID-19 started tearing through the facility. But this process began to break down after the CIUSSS intervened.

“Please find out about the CIUSSS nurses not doing Constats a Deces forms [sic] later SVP,” the doctor wrote on April 1.

Over subsequent days, the two exchanged messages about different patients who had died so Hermon could fill out the documents. They also made arrangements for Pettinicchi to pick up the originals or the doctor’s husband to drop them off.

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On April 6, Hermon texted that she was down to her last SP-3.

During these conversations, the doctor also expressed increasing frustration about how difficult it was to get in touch with nurses at the Herron so that she could help care for her patients from afar and provide records for the deceased.

A funeral home worker spotted outside the garage at Maison Herron on April 13, 2020, waiting to load a van.
A funeral home worker spotted outside the garage at Maison Herron on April 13, 2020, waiting to load a van.  Photo by John Mahoney /Montreal Gazette

Emails show Hermon repeatedly raised concerns about difficult communications, equipment shortages and how deaths were being accounted for by officials from the CIUSSS. But she herself never went to the Herron in person during that period, because GPs were told to work via telemedicine due to the pandemic and she was on call around the clock for multiple facilities.

On April 5, Hermon emailed a CIUSSS employee trying to find out who she should contact about her patients. The doctor was told CIUSSS employee Martine Daigneault was now the manager in charge. The liaison swiftly put them in touch via email.

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Hermon wrote back: “I forgot to ask you one more thing. They tell me there isn’t enough oxygen over there for all the residents who need it. We were asked to maintain a Level-C over there — no transfers, but we can offer oxygen as needed. Can this problem be resolved tomorrow?”

Later that day, Hermon wrote to Daigneault and Brigitte Auger, the first manager from the CIUSSS put in charge of the Herron. Auger contracted COVID-19 a few days after she went to help at the Herron on March 29 and had to isolate, but she still participated in discussions about the facility virtually.

“The biggest problem right now is communication,” Hermon told them. She also explained once again the procedure that had been in place for officially recognizing deaths when doctors aren’t on site and suggested it continue now that the Herron was under trusteeship.

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“We’ve been working this way for about a year and it functions well. The nurse sends a document to the MD with the time of death, the diagnosis, the name of the patient, the medical insurance number, etc. The physician then fills out the original SP-3 which is put aside and an email sent to the floor. This allows the funeral home to be called so they can come get the body. The original can then be taken to the CSHLD (method to be determined at the moment, but previously it was brought by the MDs when they made their visits).”

On April 8, Hermon wrote to Daigneault, Auger and Dr. Nadine Larente from the CIUSSS that “there are several problems I’d like to resolve today.” This included the inability of doctors to get in touch with nurses and issue instructions for how to care for their patients.

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She again noted: “constat à décès from a distance (have) to be done even if a protocol has not been developed for the nurses from the CIUSSS. I’ve attached a copy of the forms. Can they be made available on each floor so each team knows where to find them?”

A few minutes later, Auger wrote to her colleagues: “Is what Dr. Orly proposes possible?”

Lynne McVey, CEO of the West Island CIUSSS, summoned police to the Maison Herron in the wee hours of April 11, 2020, telling the 911 operator that authorities had just “uncovered many deaths.”
Lynne McVey, CEO of the West Island CIUSSS, summoned police to the Maison Herron in the wee hours of April 11, 2020, telling the 911 operator that authorities had just “uncovered many deaths.” Photo by Christinne Muschi /MONTREAL GAZETTE

An eight-page document entitled “management of corpses during the pandemic” prepared by the West Island CIUSSS and dated April 8 stipulated that when patients died of COVID-19, SP-3 forms were supposed to be filled out by clinical and administrative staff and faxed to the public health unit.

In an interview she gave Montreal police during their investigation, Maria Nelson, a nurse brought in by the CIUSSS on March 30, said death declarations were issued from a distance and she was told to report COVID-19 fatalities to public health but not the CIUSSS.

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The police summary noted: “Afterwards, she had to advise the family and the funeral home. Sometimes it took 12 hours for the bodies to be taken.”

On April 9, the debate about Hermon’s proposal continued, but bureaucratic hurdles arose.

“Since Mme. McVey wants the corpses to be disposed of as soon as possible and the declarations from a distance seem to pose a challenge to the ministerial orientations … I offer to verify whether there is another technological avenue to explore that can help us,” one CIUSSS bureaucrat wrote.

Forty-five minutes later, a colleague replied that after checking, senior health department officials were willing to look into the possibility of nurses helping with the death declarations. “But until we have the agreement of the Ministry of Health and Social Services, we cannot proceed.”

Amidst this back and forth, Victorine Leunga, a nurse working for the CIUSSS at the Herron, sent an email on April 8 reporting that 14 residents had been hospitalized and 13 had died. Instead of listing the names of the sick and deceased, she made note of their room numbers. She also alerted senior CIUSSS officials that there had been no doctors on site since the beginning of the month.

It was the discrepancy between this figure and the death records the CIUSSS uncovered in a previously locked room on April 10 — the day Derfel broke the story — that McVey said prompted her to call police at 1:29 a.m. on April 11.

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In the days following, the CIUSSS scrambled to compile the full list of the deceased, along with when and how they died, as journalists circled and senior ministry officials demanded answers of their own.

On April 11, Claire Roy, the chief of communications for the CIUSSS, reported to the department of health and social services that there had been 31 deaths at the Herron between March 13 and that day.

“Of the 31 deaths, the CIUSSS has managed to confirm the exact dates for 29 of them and the research is continuing for the other two,” she wrote. “The CIUSSS is documenting the causes of death and that will be the subject of another update. The families will be notified today.”

According to one graph compiled by the administrators, 26 residents died at the Herron between March 29, the day the CIUSSS first showed up there, and April 11, when the police were called. Fourteen of them died on or after April 7, the day the health authority legally gained control of the home after procedural wrangling.

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Another chart exchanged among CIUSSS officials contained the names and causes of death of 24 patients at the Herron who perished between March 27 and April 10. The majority are listed as COVID-19 or suspected cases. However, for one person who died on April 1, the cause was listed as hypomagnesemia, an electrolyte disturbance. For another, who perished on April 7, the cause of death was recorded as acute aspiration of vomitus, an infection that develops when food, saliva, vomit or mucus is inhaled into the lungs. In two other cases, hypernatremia, another electrolyte problem caused by high sodium concentrations in the blood, was named as the cause.

No charges ultimately resulted from the police investigation.

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Larente, a doctor from the CIUSSS who brought in her own children to help feed residents when the health authority was alerted to the humanitarian catastrophe on March 29, filed additional information in writing to the coroner in the wake of her testimony last fall. After her initial efforts stabilizing patients, she did not return to the Herron until after the Gazette exposé was published on Good Friday, wrongly assuming Dr. Hermon and the other GPs were present.

“No nurses from the CIUSSS were trained to do these constats de décès. I believe this contributed to a pile of SP-3s being discovered all at once,” she said.

Once it became clear they couldn’t get the nurses to do the declarations of death, Larente said she eventually created a list of doctors to call on for that purpose.

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“I don’t recall exactly when this coverage started, but I think it was around Easter weekend or shortly after,” she added.

Kamel was incredulous during McVey’s testimony at the inquest that no one was keeping track of the residents that were dying.

“It was Herron’s responsibility to collect the death reports,” McVey insisted. “The statistics were not our first priority.”


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