Open this photo in gallery The Quebec government is also facing questions over its response to the outbreak, with relatives – such as Keira Whitehead, seen here on April 12, 2020, whose father died two days ago – raising concerns that staffing at Herron remained inadequate even after officials got involved two weeks ago. CHRISTINNE MUSCHI/Reuters

The Quebec coroner, health authorities and the police have launched investigations in the wake of the deaths of 31 residents at a Montreal seniors’ home, where the owners allegedly withheld medical files and staff left their posts amid an outbreak of the novel coronavirus.

Relatives described a facility where only one or two orderlies remained on each floor, urine bags were left dripping on floors, residents struck by COVID-19 were not properly isolated and others lacked food or clean drinking water.

The deaths occurred since March 13 at Résidence Herron, a 154-bed private nursing home on Montreal’s West Island. The home is owned and operated by Gatineau-based Katasa Group.

Story continues below advertisement

Herron’s operators – Katasa chief executive Samir Chowieri and manager Katherine Chowieri, his daughter – didn’t return messages left during the weekend. But according to Le Journal de Montréal, Ms. Chowieri sent a letter to the government on Thursday, blaming regional health officials for stepping in and creating chaos.

Quebec Premier François Legault said the private operator had refused to comply with health authorities after they stepped in on March 29. “It certainly seems like gross negligence. When our people got there, the majority of the staff were gone,” Mr. Legault told reporters on Saturday. “It’s not acceptable, the way we treat our elderly in Quebec.”

The government is also facing questions over its response to the outbreak, with relatives raising concerns that staffing at Herron remained inadequate even after officials got involved two weeks ago.

Officials investigate after 31 die in Montreal nursing home during coronavirus pandemic

Five of the deaths at Herron were confirmed COVID-19 cases, while the causes of the others are still undetermined.

Details about the situation at Herron emerged as officials said that, instead of patients flooding hospitals, the heaviest impact of the pandemic has been in facilities for elderly people. At the start of last week, officials began dispatching more health care workers to understaffed public long-term care centres.

However, Health Minister Danielle McCann and local officials said that, because Herron’s owner was not co-operating, the government didn’t realize until Friday that 31 residents had died. Ms. McCann announced Saturday that teams would visit all of Quebec’s 40 private nursing homes.

Past complaints about Herron led the provincial Ombudsman to investigate in 2017. The Ombudsman’s report found that the centre was not properly staffed, employees were poorly trained, there was a shortage of incontinence pads and the food lacked variety.

Story continues below advertisement

Leane Conti said the home’s alleged mismanagement of the outbreak is consistent with the neglect she feels her mother, Carole Stewart, experienced while living there over the past two years. She said she had concerns that her mother wasn’t being properly fed or bathed, recalling one time that the 79-year-old had to have her hair cut because she was left lying in her own vomit for so long it had dried on her head.

Ms. Stewart, who is nearly paralyzed after a series of strokes, didn’t want to leave the home because she couldn’t face a move in her condition, Ms. Conti said. She is now in palliative care in the hospital after being infected by the coronavirus.

Natalie Nituch, whose husband has lived at Herron for a year because he has Parkinson’s disease, said she repeatedly complained in the past six months because he was only bathed once a week and wasn’t given his medications properly.

She said the staff told her they were short on linen, diapers and waterproof bed pads so the residents remained in soiled beds.

Once the outbreak began, “it all fell through,” she said. “They just didn’t come in … From other staff I’ve talked to, people were sick, some people were told to stay home because they had been in contact with other residents who were positive or staff who were sick, or they were afraid to come in.”

Quebec banned family visits to nursing homes on March 14 to try to prevent disease spread. Peter Wheeland, whose parents lived at Herron, said the decision made things worse because it cut off relatives, who could no longer support their loved ones or keep an eye on the quality of care. The lockdown made little sense to him when so many residents were already infected. “The wolf was already inside.”

Story continues below advertisement

Patrizia Di Biase-Leone, whose 97-year-old mother lives on the Herron’s 2nd floor, said she and her husband were powerless as e-mails came, informing them that three cases had been detected, then five, then 12.

A few doors down the hallway from her mother’s room was Mr. Wheeland’s 87-year-old mother, Connie. Her husband, Ken, was also a Herron resident until this spring when he was diagnosed with vascular dementia. Herron wanted to hike the monthly rent, Peter Wheeland said, from $3,200 to $5,000 to care for his father. The family couldn’t afford it, so they moved Ken to a public facility.

How many coronavirus cases are there in Canada, by province, and worldwide? The latest maps and charts

Coronavirus guide: Updates and essential resources about the COVID-19 pandemic

What are the coronavirus rules in my province? A quick guide to what’s allowed and open, or closed and banned

‘Can I take my kids to the park?’ And more coronavirus questions answered by André Picard

Ms. Wheeland told her son Peter that, with so much of the staff now gone, another female resident helped deliver food trays. Then, she said, that woman caught the coronavirus.

It is unclear whether Herron followed the proper practice of setting up a separate “red zone” for infected people and “yellow zone” for those awaiting test results. The infected woman stayed in her room, across the hallway from Ms. Wheeland’s, with a sign on the door indicating she had tested positive.

However, according to the letter obtained by Le Journal de Montréal, Ms. Chowieri said Herron did designate a red zone, which was later breached when outside help was called in by health authorities.

The letter also said Herron’s first COVID-19 case was recorded on March 27, but Ms. Conti’s recollections contradict that claim.

Story continues below advertisement

On March 20, despite the lockdown, Ms. Conti was able to visit her mother, who was complaining of feeling unwell. After Ms. Stewart ran a fever and fell out of bed later that day, she was taken to hospital, but was sent back to Herron, pending the results of a COVID-19 test.

Ms. Stewart began coughing up blood two days later and went to hospital again in an ambulance. She is now in palliative care.

Still, Herron’s staff didn’t seem aware of how sick she was, Ms. Conti said. She informed one nurse that Ms. Stewart had tested positive. “Oh my God, I didn’t know, I’ve been in and out of that room,” the nurse replied.

On March 29, no one brought breakfast, Mr. Wheeland said, and his mother, who uses a wheelchair, was left in her bed. Her children repeatedly phoned Herron, but no one answered. Eventually an orderly visited Ms. Wheeland in the afternoon and told her that there were only two staffers to handle about 60 residents on the floor. Her urine bag had burst and her diaper needed to be changed.

“We don’t have time to do much. Tell me what it is that’s the most urgent to do,” the orderly said. Ms. Wheeland understood it meant that she had to choose between dealing with the urine bag or the diaper. So the bag and its catheter were left dripping on the floor.

That same day, the local health authority, the CIUSSS de l'Ouest-de-l'Île-de-Montréal, decided to step in and dispatched help to Herron.

Story continues below advertisement

Loredana Mule, a registered nurse who had volunteered to help, received an urgent call to go to the Herron home. “They were begging me, saying it was dire straits,” she recalled. She arrived around 5:30 p.m. with three other health care workers.

“Patients were all sitting in urine and feces. Some dressings were a week old. Every single room was like this. I never saw anything like it in my career.”

Herron should normally have 11 to 15 daytime care staff, according to the Ombudsman report. Ms. Mule saw no more than three employees left in the building.

She and the other outside workers paired up and moved room by room to turn and change people. Sheets were blackened from dried feces. Once everyone was cleaned up, they went room to room offering yogurt and fruit cups. “When we finished, I went to my car and cried."

Two of the residents were found to be in critical condition. One was sent to the Jewish General Hospital and later died. The other patient died during the evening at Herron.

Even with the CIUSSS intervention, things remained chaotic, relatives said. Ms. Nituch said the new staff kept changing. “The next day somebody else is coming in and trying to figure things out. Everybody is asking ’where’s this, where’s that, how do we do this?’ So every day is still difficult there.”

Story continues below advertisement

She said residents weren’t given enough liquids last week and no one warned them to avoid drinking from the tap because the local water distribution network was being flushed.

Regional officials could only send workers in support to help fill understaffed shifts at Herron, but they didn’t have the immediate authority to take over, Lynne McVey, CEO of the local CIUSSS, said.

“The law in Quebec, the law of health and social services, is very clear on this,” she told reporters who asked why the CIUSSS didn’t assume control more promptly. “When there is a private organization, a private long-term care facility, it is the owners who have the responsibility to staff that long-term care facility.”

The letter from Ms. Chowieri blamed the CIUSSS for the confusion, faulting the outside staff for administering care without consulting medical charts, failing to consult the incumbent staff and not heeding the red zone.

Ms. McVey said the staff brought in by CIUSSS weren’t able to access clinical files or contact information for relatives because Herron’s management was not co-operating. She said CIUSSS sent two legal warnings to the owners, then obtained a court order on Thursday to look at the clinical records.

Ms. McCann, the Health Minister, said she first became aware of the possibility of dozens of deaths at the residence on Friday, from reading the Montreal Gazette newspaper. Herron had officially reported two deaths, but neighbours told the paper they often saw funeral vans at the residence.

Mr. Wheeland was skeptical how health officials didn’t realize that more than 30 people had died in less than a month. “There were body bags being wheeled out.”

His father, who had been moved to another facility, died on April 4. Mr. Wheeland and two siblings were allowed by his side. The next day, they were told that their father had tested positive so they had to be quarantined while their mother remained at Herron. “The thing that’s the hardest is that I can’t hug my sister, I can’t hug my mother … so that’s hard,” he said. The family was eventually able to transfer their mother to a hospital.

It was only Friday evening that the doctors who analyzed the files confirmed that there had been 31 deaths.

Ms. Di Biase-Leone already had an idea of the death toll. An employee had told her Friday that two dozen empty rooms at Herron now needed to be disinfected.

“You know what I mean,” the employee said.

Author and journalist Malcolm Gladwell discusses the far-reaching impact of the coronavirus pandemic on refugees, conflict and the economy. Gladwell was in conversation with Rudyard Griffiths from the Munk Debates. The Globe and Mail

Sign up for the Coronavirus Update newsletter to read the day’s essential coronavirus news, features and explainers written by Globe reporters.