The Résidence du Havre burned on Jan. 23, 2014, killing 32 seniors. The fire rocked the small municipality of L’Isle Verte northeast of Quebec City.
Report follows inquest
The report follows a coroner’s inquest, which was mandated by the province’s Ministry of Public Security.
At the time, Public Security Minister Lise Thériault said she hoped the inquest would help provide closure for the families involved.
"I hope this inquiry will allow the families and loved ones of the victim to have a clearer picture concerning the nature and causes of this tragedy," she said.
Thériault said Delâge had the mandate of finding the cause and exact circumstances of the fire and to make recommendations.
"It’s not a criminal investigation. The police are continuing that. The mandate that we’ve given them is [to determine] why this happened and what we can do to ensure that it doesn’t happen again," she said.
Witnesses highlight safety concerns
At the 10-day inquest, witnesses testified to a multitude of problems that led to such a high number of deaths.
There was only one person on staff when the fire began, and according to witnesses at the inquest, neither he nor the owner evacuated the building.
As well, the chief firefighter did not call in reinforcements until 20 minutes after the fire was reported.
Provincial building codes as well as emergency protocols were also criticized.