L'Isle-Verte seniors' home fire: Coroner blames staffing, response time

In a sprawling, 141-page report released today, Quebec coroner CyrilleDelgepointed to six factors that contributed to the deaths of 32 people after a fire swept through a seniors' residence in L'Isle-Verte, Que., more than a year ago.

The Rsidence du Havrehoused 52 elderly people, including many whocouldn't move around without the use of a walker or wheelchair.

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The factors cited by the coroner are:

• Not enoughpersonnel on duty the night of the fire on Jan. 23, 2014, who were trained in helping residents in case of an emergency.
• A significant delay in the firefighters' arrival on the scene, as well as the request for backup from adjacent municipalities.
• Questionable management and execution of operations once the firefighters arrived on scene.
• Delay in the transmission of alarms.
• Co-ordinatedresponse plan and automatic support were not implemented.

The combination of all of these factors, as well as the fact the fire happened in the winter, led to the ultimate result, the coroner's report says.

CoronerDelgemade several recommendations to avoid such tragedies, including better fire-detection tools for seniors residences.

He pointed to the need for visible and audible smoke-detector alarms in seniors residences, as well as heat sensors, automated sprinklers and an alarm system linked to the regions 911 network.

Delgealso cited the need for properly trained staff in case of an emergency, as well as a sufficient number of staff members on duty, particularly overnight.

TheLIsle-Vertefirebegan just after midnight.

Long response times were criticized during the inquest, which wrapped up in December.

The co-ordinator for fire safety for the Rivire-du-Loup region, Christian Chnard-Guay, told the inquest that when he arrived on the scene about 45 minutes after the buildings fire alarm was triggered, he saw no measures in place to getthe residents out ofthe building.

Delgealso recommended the creation of emergency response networks in both rural and urban environments to better organize a concerted and simultaneous response to fires and other emergencies. He pointed out that a lack of co-ordination between regional fire services contributed greatly to slow response times.

There is no valid reason why Quebecwhich has just overeight million inhabitantsis served by just over 700 emergency services when Ontario, which has a population of more than 13 million inhabitants, is served by about 400 emergency services," the coroner wrote in his report.

Other recommendations include havingQuebecs Rgie du btiment, the provincial body responsible for building safety regulations, make automatic sprinklers mandatory in all certified buildings without exceptions.

Public Security Minister Lise Thriault commended Delge for his "incredible" work on the report.

She said the government would look to implement therecommendations as soon as possible. She saidwork hasalready begun to improvetraining for volunteer firefighters,

In December,Thriaultannounced the government would invest $19.5 million over five years into volunteer firefighter training.

Christian Morin, a local resident wholost his godmother and his uncle in the tragedy, saidthe one thing that'smissing fromthe reportis what caused the fireto start in the first place.

"Why did this happen? We'll still be with left with a feeling of doubt," Morin said.