A Quebec coroner’s report on the L’Isle-Verte seniors home tragedy released Feb. 12 confirms virtually everyone involved contributed in some way to the tragedy.
Quebec Coroner Cyrille Delage released his report which contained harsh language and many recommendations about the deadly fire that killed 32 senior citizens just over a year ago.
While the 141-page report could not assign criminal blame to anyone, it did not hold back from highlighting failures from regulators, firefighters and nursing home staff.
Some of the findings of the report included:
- the nursing home staff working the night shift did not attempt to properly evacuate residents. Night supervisor Bruno Belanger woke the co-owner of the residence, and left all of the 32 residents to perish in the fire.
- local volunteer fire departments took a full 18 minutes to arrive on the scene. The report singled out volunteer fire chief, Yvan Charron, for failing to call in reinforcements from neighbouring communities to help fight the blaze. Instead the local volunteer unit was the only emergency service on the scene to help evacuate the building
- Charron was also made fire chief by being”grandfathered” into the position after serving as a volunteer fire fighting for many years. Delage suggests that stricter training and qualifications be put in place to better train volunteer fire departments to battle large fires
- sprinklers, which dramatically increase survival rates in residential fires, were not present in the older part of the nursing home where most of the victims perished. The report recommends that sprinklers become mandatory in all care facilities in Quebec.
- the residence was also missing key fire barriers which helped to contribute to the quick spread of the blaze. The report recommends that all residences that were built before fire barriers became mandatory be upgraded to comply with existing laws and regulations.
Quebec must merge fire departments
The report comes just weeks after fire officials and police released a statement saying that the exact cause of the fire will probably never be found.
The report also criticized the state of fire departments in Quebec. It noted that with 8 million people Quebec has over 700 fire departments. Ontario has just under 400 departments with a larger population.
Delage recommends merging fire departments to better serve the province, since there would be more firefighters per local unit. This also means that a centralized command centre would be established to help co-ordinate local departments to quickly reach a large blaze.
The coroner’s findings are not the end, but only the beginning of the process of assessing blame. It is now up to the Ministry of Health and Social Services in Quebec to determine what changes to regulators and health care standards are coming.