Thanks to the inept response that followed, 32 seniors – who had moved to an institutional setting in order to be safe and cared for, let’s not forget – died horrific deaths.

A year later, we need to wonder aloud if we actually learned anything from yet another preventable tragedy. The orgy of inaction and excuse-making that has followed suggests the answer is a resounding “No.”

There has been an extensive police investigation, but no criminal charges have been laid. The Crown prosecutors’ office is still mulling things over, but history suggests no one will be going to jail.

The obligatory coroner’s inquest, headed by Cyrille Delage, wrapped up just before Christmas. He heard testimony from 60 witnesses over eight days and, while Mr. Delage has not yet produced a final report, some key facts emerged. (And, remember, a coroner can only make recommendations, he cannot point fingers of blame.)

Initially, the fire was blamed on 96-year-old Paul-Étienne Michaud, an occasional smoker. But crime scene investigators found that the fire started in the kitchen just below Mr. Michaud’s room and he was, in fact, the first victim.

There was one worker responsible for the overnight care of the 52 residents of the nursing home, even though most were over 85 and suffering from mobility and cognitive challenges. The actions of that employee, Bruno Bélanger, on the fateful night were head-scratchingly bizarre.

After the fire started, he ran by the rooms of at least a dozen residents without notifying them, saying he was in a rush to get to the room of his employer/girlfriend at the opposite end of the complex, because that was “protocol.”

Mr. Bélanger, however, had never participated in a single fire drill and said he didn’t even know how to operate a fire extinguisher, even though he was a fire extinguisher salesman for 15 years – a palpable irony.

The front door of the nursing home was locked and could not be opened from the inside. Several bodies were found there; most others were found on balconies, where residents prayed for help that did not come fast enough. The bodies were so badly burned that they had to be identified by the serial numbers on their artificial hips and false teeth.

It took 18 minutes for volunteer firefighters to arrive on the scene and the fire chief did not call in reinforcements until 19 minutes after he arrived on-site, and the closest professional firefighting crew, in Rivière-du-Loup was never called. Once again, the excuse was “protocol.” Turns out that most of the firefighters didn’t have proper training either; the municipality said it didn’t want to impose on volunteers. (The insurance company for the property is suing L’Isle-Verte for $2.3-milliion, arguing the response was inadequate.)

The most disturbing testimony of all, however, came from Lise Veilleux of the Régie du bâtiment, the provincial agency responsible for building standards.

A key contributing factor to the disaster was that there was no sprinkler system in the part of the building where everyone died. When asked if sprinklers were mandatory, Ms. Veilleux gave such a Byzantine and bureaucratic explanation, that the mild-mannered Mr. Delage exploded with anger : “Does anyone understand these [rules] other than you?”

The law should be simple and straightforward: Every institutional facility like a nursing home should have an automatic sprinkler system. Period.

Mr. Delage first made that recommendation in 1969, when he conducted an inquest into the Repos du Vieillard nursing home fire in Notre-Dame-du-Lac that killed 38 seniors.

Since then there have been too many similar tragedies with mass casualties, including the Chafe’s Nursing Home fire in Petty Harbour, Nfld., on Boxing Day 1976 that left 21 people dead, and the 1980 fire at the Extendicare home in Mississauga that claimed the lives of 25 seniors. And that is without mentioning the incidents that occur all too often that claim “only” a couple of lives.

How much more carnage do we need before taking decisive action? There are more than 400,000 Canadian seniors living in institutional settings, and they deserve to be in a safe setting. Yet, in Quebec, fewer than half of nursing homes have sprinkler systems.

As Mr. Delage is fond of saying : “The best way to fight fires is with prevention.”

But there have been far too many inquiries and far too little action on their recommendations.