Two Quebec coroners are calling for new regulations in seniors homes following the death of three people in the same Gatineau residence last year.

In a report released on Thursday the coroners who investigated those cases said the problem isn’t limited to one facility, with a lack of generalized staff and adequately trained personnel in residences across the province.

The three deaths in question happened in July of last year and February of this year. One of the deaths followed a fall that was not reported by employees. When she was taken to hospital, the 90-year-old woman’s condition was found to have deteriorated, showing signs of dehydration and hypertension as well as a fractured pelvis. The woman died in hospital eight days later.

Another woman was found not to have received necessary clinical care. Coroner Francine Danais said it was unclear what care any of the dead had received, saying their files were incomplete.

The coroners wrote that a broader problem is people being sent to private residences where they may not receive the proper care while waiting for a spot in a CHSLD.

The pair recommended an investigation at the residence in question by the body that oversees auxiliary nurses in Quebec, as well as the establishment of a best practices guide for all seniors homes in the province.

“We need to review the standards and criteria to give accreditation to private homes to accept those types of patients because right now the criteria are the same for private homes for senior citizens,” said Danais. “However, this is not the clientele they are getting. The criteria should be revised and the ratio between the number of patients and healthcare providers needs to be revised. We need more people there.”

The office of Marguerite Blais, the cabinet minister responsible for seniors, said a review of the regulations for residences and criteria for certification is underway.