MONTREAL — A Quebec coroner says all certified seniors' homes in the province, old and new, should be equipped with automatic sprinkler systems to avoid tragedies like the one that killed 32 people a little over a year ago.
Cyrille Delage said in his final report into the fire at the L'Isle Verte, Que. home that while sprinklers "don't solve all the problems," they can at least slow the progression of the flames.
Fire swept quickly through the home in the early morning hours of Jan. 23, 2014.
The residence housed 52 elderly people, including many who couldn't move around without the use of a walker or wheelchair.
The wing of the Residence du Havre that burned to the ground was not equipped with automatic sprinklers and that's where many of those with disabilities were housed.
That was one of several issues uncovered by Delage in his report, made public Thursday.
Delage said the building wasn't up to code.
Delage added that firefighters did not have an evacuation plan for the seniors' residence and they arrived late to the scene.
Moreover, he said that several volunteer firefighters were not adequately trained because they were subject to a "grandfather" clause that exempted them from new training requirements.
"We will say in polite terms that during this (fire) intervention, the lack of training and preparation were very evident," Delage said in his report.
Delage said that the evidence presented to him indicates that the fire was accidental, but it will be up to the Crown to decide if anyone should be charged criminally.
Delage called for a review of emergency procedures at seniors' residences across the province.
"We have to better the security rules in seniors homes in order to avoid similar tragedies like the one that occurred at the Residence du Havre," he said.
Delage said that smoke detectors in seniors' homes need to be loud and visible by both employees and the people who live there.
That wasn't the case at Residence du Havre, where the smoke detectors were not located in each room and were not connected to a central alarm system that alerts the local 911 call centre.
Delage recommended that provincial authorities encourage rural and urban cities and towns to centralize fire services and to regularly review fire-fighting procedures and have co-ordinated planning.
Quebec Premier Philippe Couillard said Thursday in Quebec City that his government will review the report "exhaustively."
"There are actions that will be announced very soon," he said. "There are clearly things that need to be done."
Public Security Minister Lise Theriault said families of the victims are also reviewing the report and the government will look at the recommendations attentively.
Theriault said the government has already taken steps to address some of the problems addressed in the report. She said her government announced over $19 million for training for volunteer and part-time firefighters.
The coroner also had strong words for some owners of seniors' residences and politicians across the province who he said might be angry his recommendations will cost money, as retrofitting older homes with sprinklers can be quite costly.
"Let them (be angry) up until the moment that another disaster like this one happens again," he said. "They'll have to explain to their constituents why they did nothing."
