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MONTREAL (Reuters) - A 2014 fire that killed 32 people at a Quebec nursing home was made worse by inadequate staffing, delays by rescuers and a section of the building that failed to meet provincial codes, a coroner's report said on Thursday.
Quebec Coroner Cyrille Delage's report was based on the testimony of more than 50 witnesses at hearings into the fire at the Residence du Havre home in L'Isle-Verte, located about 230 km (143 miles) northeast of Quebec City.
The nearly total destruction of the residence on Jan. 23, 2014, prevented experts from knowing the specific cause of the blaze.
Delage said the fire started near the ground-floor kitchen and was probably accidental, but he noted many contributing factors.
Part of the home did not "satisfy the legal norms and regulations" required for physically dependent residents, Delage wrote.
There were not enough staff members, and they were not adequately trained to help residents in an emergency. The report also pointed to lengthy delays before firefighters arrived and requested help from neighboring municipalities.
"It was the combination of all these factors, during the winter on top of that, that led to the result we knew," the coroner wrote.
The fire shocked Canada because of the number of vulnerable, elderly victims, and it raised calls for the installation of mandatory sprinklers in such facilities.
In his report, Delage also called for automatic sprinklers, as well as better training for staff and heat-and-smoke detectors connected to a central alarm.
Editing by Jeffrey Hodgson and Lisa Von Ahn