One of the most terrible findings of the final report of Ontario's independent commission into long-term care is that some residents died, not of COVID-19 but of neglect and dehydration.
"Apart from fatalities due to COVID-19, residents died as a result of neglect due to staff shortages," the commission wrote in its final report, released Friday. "For example, the commission was told that malnutrition and dehydration occurred due to a lack of available staff to tend to resident needs. As a result of these conditions, some residents spent their final hours in complete isolation and ultimately died alone."
Long-Term Care Minister Merrilee Fullerton, who held a press conference Monday to respond to the report, declined to answer when she first learned that deaths from neglect were occurring in the seniors' homes she is responsible for.
Instead, she thanked the Canadian Armed Forces for their assistance in long-term care homes in the first wave of the pandemic and spoke about her work as a doctor before entering politics.
"We have to move forward, and I came to politics because of long-term care, the neglect of the sector," she continued. "And I came to fix it. Our government is fixing it. And we will move forward."
The commission was informed of the deaths from neglect by several sources, including the Canadian Armed Forces and registered dietitians who work in long-term care, said John Callaghan, the commission's chief counsel, in an interview with QP Briefing.
"We wanted to make sure that people understood that we knew that, and that we had seen evidence of that in our review," he said.
Callaghan pointed to the notes of one member of the Forces who said in one of the homes they came to assist, 26 people had died from neglect and dehydration before their arrival when "all they needed was water and a wipe down."
The commission was highly critical of delay in getting homes outside help, both in bringing in Canadian Armed Forces and assistance from local hospitals, once hard-hit homes began experiencing staffing collapses — when so many workers were off sick or scared that residents were neglected.
Doris Grinspun, CEO of the Registered Nurses' Association of Ontario (RNAO), said Fullerton and the Ford government should have known since the first wave of the pandemic that neglect was costing lives — Fullerton in particular, given her background as a doctor.
Grinspun also recalled an 11 p.m. call she received from Minister of Finance Peter Bethlenfalvy, back in April 2020, along with the President and CEO of University Health Network Dr. Kevin Smith, asking her to help get nurses to go to Orchard Villa LTC, in Bethlenfalvy's riding, "because there was no staff there and they were concerned and afraid about what was going on inside."
"And I said, 'My God, who is helping these people eat? Who is helping these people drink?'" said Grinspun. "So everybody ought to have known."
According to Grinspun, it is Fullerton who is ultimately responsible for the fact that residents died from neglect.
Callaghan, asked who bears responsibility, didn't offer an answer. "Well, we're precluded from making criminal or civil findings," he said, referring to the terms of reference that defined the commission's mandate. "So I think I should just leave it and let the report speak to that."
It's not clear from the report which of the initial five long-term care homes the military assisted experienced the 26 deaths noted by the CAF member. One of the homes the military aided was Orchard Villa and the commission's report was particularly critical of the provincial government's delay in bringing in assistance to the home, noting that the local medical officer of health, Dr. Robert Kyle, acted more swiftly with relatively limited powers, than the province.
The first resident case was detected there on April 9, 2020, and the commission reported that a staff member made an "unusual call" to a local hospital three days later to request support due to reduced staffing levels and a deteriorating situation. Kyle alerted the Ministry of Health of the outbreak the next day, and he deployed an infection prevention and control team to the home on April 17.
"By April 19, 80 per cent of the staff were infected and 98 residents had tested positive. Sixteen residents were already dead," the commission found.
On April 21, Kyle issued an order for Lakeridge Hospital to assist the home.
"The possibility of military intervention had been on the table as early as mid-April, yet the first shift of Canadian Armed Forces personnel did not begin work at Orchard Villa until April 28," the commission found, noting that was 12 days after Fullerton first made a personal note that military intervention would be needed.
"Though Orchard Villa was particularly hard-hit by COVID-19, it was not alone in its challenges," it wrote. "Racing to keep up with the virus during the first wave, the province was still refining its response structure throughout April — as COVID-19 raged through long-term care. Because of its lack of preparation, the province was chasing the virus rather than heading it off."
The report continues to say that after the hardest-hit homes, like Orchard Villa, were stabilized there was "a lull in the storm."
"It did not last," it says. "The province’s preparations did not protect residents from the second wave. In fact, the second wave was worse."
The commission report identified areas where the government could have taken stronger, faster actions to prevent the tragedies of the second wave. A major one was "decanting" residents, which means moving infected or exposed residents out of overcrowded homes to other facilities where they can be cared for and infection prevention and control practices can be maintained, as other jurisdictions did routinely.
The government also didn't move effectively over the summer to boost staffing levels, as Quebec did, and while it put in place a plan for hospitals to partner with long-term care homes to help them with infection prevention and control, it was in place until late November, when the second wave was well underway.
The commission also noted that while the government surveyed homes to identify which would be at highest risk of a tragedy in the second wave but seemed to do nothing to help the homes that were identified as high risk, and didn't share the evaluations with other bodies, such as public health units, that could have helped.
One question the commission never really found an answer to was why the Ford government didn't take stronger and faster action on those areas that could have prevented loss of life, according to Callaghan.
"It's difficult to say exactly what stopped them. Whether it was a belief that wave one had been resolved, and that those things at the end of the wave one worked, and they didn't have to do other things — I don't know?" said Callaghan, adding that the government did create a facility to decant residents to, which had been recommended in both of the commission's interim report, but not until December when the second wave was raging.
"But why it wasn't done earlier, it's not clear," he said. "We know it wasn't done earlier. And the commissioners believe it should have been done earlier."
The provincial government is moving now to increase staffing levels in long-term care, aiming for an average of four hours of hands-on care for residents by 2025. The commission has recommended it accelerate that plan on an urgent basis, and to ensure that there are more skilled staff — registered practical nurses and registered nurses — as part of the staffing mix, aligning with recommendations from the RNAO.
According to Grinspun, legislating the staffing complement and staffing mix is one way the government can ensure that the neglect of residents never happens again, by this government or any of the next ones.
It will only be possible to recruit and retain the staff needed, according to Grinspun as well as the health-care unions that represent front-line long-term care workers, with improved pay and working conditions.
Fullerton suggested there will be something done.
"We all know, wages and working conditions matter," she said. "We need to ensure that we attract and keep workers in the sector, and we fully acknowledge that more needs to be done. And with the commission's final report to inform us, we're going to move forward on these issues."
But asked for details, including when workers could see a wage increase, Fullerton had none and said only that the government has concerns that boosting wages in long-term care could have unintended consequences in another part of the health-care system — a concern the government has raised since the last inquiry into the province's long-term care homes, prompted by the Elizabeth Wettlaufer serial killings.
Fullerton was also asked if she or her government would apologize to people for what happened in long-term care. She did not.
"You know, I think as a society we need to do some soul searching and understand why it took a pandemic to address the capacity issues in long-term care, the staffing issues in long-term care," she said, adding that she became a minister in order to address those long-standing issues and Ontario was "overdue" for a pandemic when she took office.
Callaghan echoed those concerns. Giving one message he hopes policy-makers take away from the report, he said, "You can't ignore these problems any longer."
He said that applies to two things: the needs of the "tsunami" of seniors ageing in Ontario, which includes a healthy long-term care system, as well as ensuring the provincial government is prepared for another pandemic.
Despite the experience of SARS in the early 2000s, and several infectious disease warnings in the interim, the province only ever paid attention to its preparedness in fits and starts and let it fall behind other priorities again and again, falling prey, he said, to the "tyranny of the urgent."