Speech by the Québec Ombudsperson on the occasion of the publication of her Progress Report concerning handling of the first wave of COVID-19 in CHSLDs

  • December 10, 2020

(Check against delivery)


Thank you for joining me for the presentation of the Protecteur du citoyen’s progress report. 

In order to protect my staff’s health and safety and that of anyone who would have attended in person, this morning I’ve opted for a virtual gathering. Thank you for your understanding.

Last May 26, I announced that there would be an investigation into the COVID-19 crisis in CHSLDs and how the government handled it during the first wave of the pandemic. This special intervention, based on in-depth analysis of the events and of systemic issues, will be completed in the fall of 2021.

Meanwhile, faced with an unprecedented crisis, it became obvious very quickly that we should give the floor to those who were in the thick of the fray last spring, namely, CHSLD residents, their families, and healthcare staff. Many of them filed complaints with us or answered our call for witness statements and input. 

The goal of this progress report is to determine the priorities for action.

In a nutshell, the Protecteur du citoyen’s mandate is to ensure that the rights of people are upheld whenever they interact with Government of Québec departments and agencies, as well as with the health and social services network. It also handles disclosures of wrongdoing regarding public bodies and reprisal complaints stemming from these disclosures.

Before going further, please remember that not all CHSLDs in Québec – even those in the most heavily affected zones like the Montréal region – experienced an acute crisis. The ones that were spared managed to find means of action that we should emulate.

One thing is sure: the testimonies are unanimous in saying that healthcare teams showed immense dedication

To give you some background, from September 2 to October 2, 2020, 1,355 people responded to our request for input and, from September 2 to October 16, 2020, we received some 15 briefs from unions, researchers, organizations and users’ committees. Add to this the complaints and reports that we received starting from the beginning of the pandemic.

Also, we conducted nearly 250 interviews with people who had experienced the crisis directly and we consulted a wealth of documents.

All of these sources corroborate the statements we collected and this has enabled the Protecteur du citoyen to make various observations

Here is a summary of these findings:

  • First, the CHSLDs were the blind spots in bracing for the pandemic, while massive efforts were made to prepare hospitals.

  • The danger was underestimated because so little was known about the virus. No one could have foreseen such rampant contamination that spread to users and staff. 

  • Personal protection equipment was insufficient and was distributed too late and unequally. 

  • Staff mobility, whether it be from one CHSLD to another, or from a cold zone to a hot zone, caused the virus to spread. 

  • The ban on visits by informal caregivers had harmful consequences in terms of anxiety and major stress for residents and their families. 

  • Care and services were postponed or cancelled: it was often a question of basic care such as hygiene, hydration, and help with eating, mobility and dressing. Residents’ physical and mental health may well have been affected irreversibly. 

  • We cannot forget that relief workers were dispatched to CHSLDs from outside. Their assistance was indispensable, generous and appreciated. Nonetheless, many of them did not have the training to respond in such a context and they were not given the supervision they needed. What’s more, they arrived when outbreaks were already well underway. 

  • On the administrative level, decisional power in CHSLDs, often those most heavily affected, was far from where events were being played out, resulting in disorganization that sometimes paralyzed action. 

  • The witness statements insist on the load that staff had to bear during the first wave. Between March 1 and June 14, 2020, 13,581 healthcare workers from all parts of the network contracted COVID-19, fully a quarter of the cases reported during the first wave. Eleven of them died. Most workers experienced fear of the unknown virus, distress in connection with their feeling of powerlessness, and exhaustion because of the pressure they were under. 

At this point, what must we learn from what occurred in CHSLDs during the first wave? What changes must be made so that the rights and dignity of residents are respected? 

At this stage of the investigation, the Protecteur du citoyen has identified 5 main lessons and the priorities for action that accompany them.

  1. First of all, CHSLDs must maintain humane care that is centered on the residents – no matter what the health context. First and foremost, CHSLDs are living environments. Contact between the people who live there and their informal caregivers is essential and contributes to this humanization.
    ▶ Public and private CHSLDs must put in place training, supervision and the material resources needed so that informal caregivers can play their role as partners, in times of outbreak and in normal times alike. This is a priority for action. 
  2. Secondly, understaffing in CHSLDs was a key factor in the failings in ensuring quality care. 
    ▶ Systemic staff shortages, especially the lack of orderlies and nursing staff, must be remedied. Authorities will now be expected to use financial and other incentives that acknowledge and highlight the essential worth of the jobs these workers do. This is a priority for action. 
  3. Thirdly, it was seen that CHSLDs which had a manager on-site to support and supervise staff were better equipped to deal with the crisis. 
    ▶ Authorities must continue to put a local manager in every CHSLD who can exercise strong local leadership with his or her clinical and administrative team. This is a priority for action. 
  4. The first wave also taught us that CHSLDs whose decisions and actions were solidly based on infection prevention and control dealt better with the pandemic. 
    ▶ Each CHSLD must be able to maintain a culture of prevention and infection control everywhere with its staff, informal caregivers, visitors and anyone involved in the living environment. Every CHSLD must be equipped accordingly. This is a priority for action. 
  5. Lastly, the first wave showed that to ensure care and service continuity, information and knowledge transfer are crucial. 
    ▶ Strengthening of local, regional and Québec-wide communication channels is necessary in order to convey clear information and directives, as is the sharing of best practices. This is a priority for action.

Today, December 10, the pandemic is still among us and continues to claim victims. The figures are not comforting. The lessons learned during the first wave must contribute to reliable and sustainable changes for protecting and reassuring CHSLD residents, who are vulnerable.

In closing, I would like to thank the many people who opened up to the Protecteur du citoyen to talk about what they experienced in CHSLDs last spring. I also want to extend thanks to all the workers who remained despite the extent of the outbreak so that no one would be left behind.  

I’ll take your questions now.

Québec Ombudsperson Marie Rinfret