02/12/2015 08:22 EST | Updated 04/14/2015 05:59 EDT

L'Isle-Verte: Coroner blames staffing, fire response time in report

In a sprawling, 141-page report released Thursday, Quebec coroner Cyrille Delâge pointed to six factors that contributed to the deaths of 32 people living in a seniors' residence in L'Isle-Verte, Que.

The factors are:

- Not enough personnel 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.

- Coordinated response plan and automatic support were not implemented

More to come.