It was 11:30 on a night in early May when Louisa Mussells Pires first walked into a long-term care home in Lachine and learned some hard truths about the health-care system in one of the richest countries in the world.
Pires, 31, had almost finished nursing school. There was a crying need for extra staff in Quebec’s long-term care network, which had been decimated by COVID-19 infections. So she volunteered to help and readily agreed to grab a night shift at the CHSLD Nazaire-Piché.
Pires can still recall in vivid detail what it was like to walk through its halls for the first time.
It was dark. The common areas were roped off. At a nursing station, a television blared news about the dizzying death toll at CHSLDs across the province.
She eventually found the only other person working on the floor, a tired-looking nurse. “Tell me what needs to be done,” Pires said to her.
The nurse replied: “Make sure everyone is breathing. And then come back and we’ll take things from there.”
Scattered throughout the ward were large piles of pink plastic bags that held the final possessions of the residents who had succumbed to COVID-19.
Over the next few weeks, until military reinforcements arrived, Pires and the rest of the skeleton staff were able to offer a minimum level of care. The residents were cleaned, fed and given medication; little else.
When an infected resident began to hyperventilate, Pires knew the end was near and provided what comfort she could. But make no mistake, she said, these were lonely deaths, away from family and friends, away from those who loved them the most.
“It was a reminder that even in a high-income country, that is supposed to be well off, you can have a humanitarian crisis of this scale,” Pires said in a recent interview.
“It might be quickly forgotten. But it happened. I mean, how can you have people dying of dehydration in Canada?”
Last spring, 5,000 people in the province died of COVID-19, more than anywhere else in Canada. And the sense that Quebec’s health-care system failed is as widespread among many frontline workers as it is among the families of the dead.
But it is less clear how the system’s administrators could have acted differently, faced with an unprecedented situation.
CBC News conducted a series of interviews with both frontline workers and managers to get a better understanding of how one part of the system — the health authority covering Montreal’s West Island — responded at the outset of the pandemic.
What emerged was a portrait of a system under severe strain, exposing some to uncommon horrors while others had to make ethically fraught, complex decisions.
WATCH: One year later, front-line workers reflect on how they responded in the first weeks of the pandemic
‘We had to improvise’
The top officials in the West Island health authority — the Integrated University Health and Social Services Centre (CIUSSS) — began planning for a pandemic in January of 2020, as evidence began to accumulate that a novel coronavirus was spreading around the world.
In those early plans, any West Island cases of COVID-19 were to be transferred to the Jewish General Hospital, which has several negative pressure rooms, ideal for treating infectious diseases.
The lone hospital in the West Island, Lakeshore General, was built in 1965 and doesn’t have the same up-to-date equipment. It also has one of the city’s busiest emergency rooms.
By mid-March it was apparent that Quebec was seeing more cases than initially anticipated. The West Island CIUSSS leadership began meeting every morning in a large boardroom on the fifth floor of Lakeshore General Hospital.
They were carefully monitoring the hospital’s capacity. The hospital serves a territory dotted with homes for the elderly and long-term care centres, and suspected COVID cases kept coming into the ER.
When the Jewish General hit capacity in the third week of March, those cases could no longer be transferred downtown.
“We had no choice. Somebody had to take those patients,” said Dr. Guy Bisson, Lakeshore’s medical co-ordinator.
Plastic dividers were thrown up and a makeshift COVID ward was fashioned out of a short-term stay ward. “We couldn’t close the door. We had to improvise,” said Bisson.
Herron and the CHSLD disaster
On Sunday, March 29, the morning meeting of the CIUSSS West Island’s leadership was interrupted by a call from CHSLD Herron. They needed staff, urgently.
It was unclear, at first, how bad the situation was, said Najia Hachimi-Idrissi, the associate CEO of the CIUSSS. Two colleagues were dispatched to investigate.
“The conditions were disgusting. The patients were drenched in urine and feces,” Loredana Mule, a nurse who was assigned to help at Herron that night, told CBC News last April. “It was quite appalling.”
The health authority placed Herron under trusteeship on March 29. But that was not enough to prevent at least 47 residents from dying last spring — deaths that will be the subject of a coroner’s inquiry this fall.
“It was very difficult emotionally for everybody,” Hachimi-Idrissi said. “In a society like ours, we would like to be more organized. Nobody knew the virus could be that destructive.”
The situation at Herron prefigured similar staffing situations at CHSLDs elsewhere in the province. Underpaid staff were getting sick; others were too frightened to show up to work.
Their managers, meanwhile, were overstretched, racing to different locations, said Anne-Marie Chiquette, who works for an organization, APER, that represents health-care managers.
In 2015, Health Minister Gaétan Barrette amalgamated dozens of local medical establishments into a handful of super-agencies. At the same time, he eliminated around 1,300 management positions in the health-care system.
Chiquette said those reforms — which left fewer managers responsible for larger areas — contributed to the scale of the tragedy in the CHSLD network.
“When you have a pandemic, you need to have a link with employees to reassure them, because they are scared. But in this case the managers couldn’t be there,” Chiquette said.
At one point while Pires was working at CHSLD Nazaire-Piché, the building ran out of apple juice. The staff spent several hours trying to identify who was responsible for replenishing their stock. Eventually they gave up.
“There was no clear person in charge,” she said. “”There was a lack of leadership. I don’t think it was due to personal shortcomings. It was due to the structure of the system.”
As the virus continued to spread within the long-term care network, the ER at Lakeshore went through periods when it was effectively overwhelmed.
Nathan Friedland, an ER nurse at the hospital, recalled one day in early May when in the span of 15 minutes five ambulances arrived, each carrying ailing patients from long-term care homes.
The ER was already jammed. The incoming stretchers were placed in a waiting area. Among them was a woman in severe respiratory distress. All he could do was get her a blanket.
“I had a line of patients, five in a row, with this woman dying in front of me and I had to go to the next patient,” he said in a recent interview.
The hospital’s morgue eventually filled up and the dead had to be stored in a refrigerated truck parked behind the hospital. “It was deeply disturbing,” Friedland said.
At the height of the first wave, nearly half of the Lakeshore’s 265 beds were occupied by COVID-19 patients.
That required making difficult decisions about who received the limited amount of personal protective equipment available. They also had to choose which non-urgent surgeries would be cancelled and which patients would be transferred to other hospitals.
Hachimi-Idrissi rejected the suggestion that the health-care system in the West Island collapsed in the spring. “But we did have to make choices about where we concentrated the resources that we had,” she said.
“It was risk management everyday.”
Is anyone to blame?
The staggering death toll from those first critical months of the pandemic has left many of those who had to witness it up close demanding accountability.
Frontline health-care workers have complained for years about staffing shortages, ramshackle long-term care homes and overcrowded ERs. They feel that if only their warnings had been heeded, the outcome could have been different.
“The virus made a mockery of our health-care system,” said Friedland.
Legault has also called for accountability, though he denies any of his government’s decisions contributed to the scale of the disaster.
In recent interviews marking the anniversary of the first case, Legault has suggested there were major shortcomings in the management of the health-care system.
At one point in the pandemic, Legault mused about firing half of the health authority CEOs in Montreal, according to a new book by Alec Castonguay.
But the eagerness to lay blame may also obscure the unprecedented nature of the crisis that Quebec confronted last year.
Those who administer the province’s large, complex health-care system have difficulty identifying what they could have done differently, given what they knew at the time and the resources they had available.
“The problem is not the hospitals. It’s not the CHSLDs,” said Bisson. “The problem is COVID. That’s the true culprit. We have to remember that.”