Military team asked for deaths from neglect in long-term care to be raised up the chain of command: Full report

The now infamous warning that 26 residents of an Ontario long-term care home died of neglect when all they needed was "water and wipe down" was raised at a Canadian Armed Forces meeting last June, where the team that mentioned it asked for it to be relayed to higher-ups.

But it wasn't made public until nearly a year later, on April 30, 2021, when Ontario's Long-Term Care COVID-19 Commission released its final report and criticized the government for being too slow to bring in the Canadian Armed Forces (CAF) to help the province's hardest-hit homes. The report included snippets of two military reports detailing the "deplorable conditions" CAF members found when they finally arrived at two long-term care homes in northwest Toronto.

The mention of 26 deaths at Downsview Long-Term Care Centre was contained in notes on a meeting held on June 4, 2020, under the heading, "Was there any issue you feel should be raised to higher?"

It says: "'Large concern with the timing of arrival. It was noted by ACCT [augmented civilian care team] that 26 residents died due to dehydration prior to the arrival of the CAF team due to the lack of staff to care for them. They died when all they [needed] was 'water and a wipe down.'"

Notes on a May 18, 2020 meeting about the other home, Hawthorne Place, say: "The ACCT described that when they first arrived at the LTCF there was 'feces and vomit on floors and on the walls.' One ACCT member discovered that two of the residents had dried feces under their fingernails for a prolonged period of time. The ACCT Team reported that there had been resident deaths due to dehydration and malnourishment."

The ministry of long-term care has officially reported 65 residents of Downsview died with COVID-19, as did 51 residents of Hawthorne Place.

The full copies of the notes include more disturbing allegations.

Both are highly critical of the homes' management. On Hawthorne Place, the meeting notes are particularly harsh, alleging the home's director wanted to cut back on the hours of temporary staff to save money and would rather use the CAF as "free labour." They also allege the management denied the military teams access to medical charts, leaving them without crucial information about the residents' care, resulting in an incident that caused harm to one person.

"[Many] of the ACCT feel this has been done out of fear that if the ACCT had access, it would be discovered that there were serious issues in the legality of what has been, or not been properly documented," the notes say.

"The facility should be shut down, competent staff should be placed in isolation and then moved, incompetent staff should be fired, and management should be charged," said one CAF member, according to the notes.

Some members believe what was happening at Hawthorne Place "is criminal," the notes say.

The notes also decry the homes' physical conditions, noting a cockroach infestation at Downsview and a raccoon falling through the roof "Mission Impossible-style." Hawthorne Place, also infested by cockroaches, is described as "terrible," a "shit-pit" and "horrifying."

The Ministry of Long-Term Care first received these meeting notes on May 6, after requesting them from the commission, a spokesperson for the minister said when she released them to QP Briefing Monday. The Globe and Mail also obtained the notes and first revealed the identity of those two homes on Monday.

On Monday, the provincial government confirmed the coroner will review all long-term deaths.

"The chief coroner has been engaged to look at all deaths in long-term care, as I'm sure all members would expect," said Government House Leader Paul Calandra in question period. He also said the ministry has reached out to the long-term care commission to provide supporting documentation.

The Toronto Police Service says it is not yet investigating the two homes. Meanwhile, the Ontario NDP has asked the Ontario Provincial Police (OPP) to review information about deaths from neglect to determine if charges are warranted. The commissioner of the OPP responded Monday to say the request is being reviewed.

QP Briefing reported last week that Long-Term Care Minister Merrilee Fullerton would not confirm when she became aware of deaths from neglect or if any of them, including those mentioned in the military reports, were under investigation. The coroner's office said last week it could not confirm if it was investigating those deaths due to "privacy reasons."

"The release of the Commission’s report is the first the ministry learned of these 26 deaths allegedly due to dehydration," Fullerton's office said in a statement Monday. "These reports were not separately reported to the ministry or minister’s office by the Canadian Armed Forces, nor through testimony or documents posted by the Commission, nor by the home where the deaths were noted as having occurred, nor through the course of our robust inspections of these homes."

But there were earlier warning signs that residents had died from neglect.

That includes testimony from the CEO of Humber River Hospital when she spoke about problems in both of those homes to the long-term care commission seven months ago. A transcript was published online shortly afterwards.

Barbara Collins laid out the circumstances that led her hospital to assist the Downsview home prior to the military's arrival. She said that "food and water challenges" had contributed to the deaths at that home and suggested the military knew that was the case at Hawthorne Place was well.

Collins said there were "significant challenges" at both homes. She had "shared a number of experiences with the Army" and said that both homes experienced many of the same things. She said that while her hospital's physicians were able to help a lot of residents at Downsview, "there was still a lot of death."

"And some of that was food and water, and if your condition has deteriorated as a result of food and water challenges, you probably cannot fight COVID," she continued.

(Downsview Long-Term Care Centre is pictured in a file photo. Andrew Francis Wallace / Toronto Star)

Collins went on to compare the situation Humber River Hospital found at Downsview, a for-profit home owned by Nova Scotia-based GEM Health Care, with that of Villa Columbo, a non-profit that was also very hard-hit by large COVID-19 outbreaks that decimated their staffing, which the hospital also assisted.

The difference, according to Collins, was that a charity affiliated with Villa Columbo engages in significant fundraising to boost the non-profit home's budget and the home "spent a fortune" on temporary agency staff during their outbreak. As a result, their residents were "well looked after, well cared for, despite a shortage of staffing."

"And I think those patients were in better health to battle COVID and many of them did battle it," said Collins.

Downsview was assisted first by Humber River Hospital, and then also by the CAF as part of its second deployment. The hospital first began assisting the home on April 23, according to Collins, but it took another five weeks before the province issued a mandatory management order directing the management of the home to be taken over by the hospital on May 30. Before that point, the province had secured voluntary management orders with some long-term care homes.

During that time, personal support worker Sharon Roberts tested positive for COVID-19 and died. Her union, the SEIU, called publicly on the province to provide more support to the home on May 14.

"It was five weeks from the time we first knew Downsview was in trouble until we could get to actually having an order, and I feel that there was challenges during that period of time for the home," Collins said. "Had we moved quicker, perhaps they would have benefited."

On June 2, the military deployment began. The government had signalled the week before, on May 26, that it would like to see military support transferred from homes that had begun to recover, to Downsview.

Collins also offered her view on why the home's ownership may have resisted a voluntary management order, contributing to the delay: "when you call the owner of a private home who doesn't know you as anybody and only thinks you are the CEO of the big grand hospital, they are not listening to you, and you can understand that, and I understand where they are coming from. They were very surprised in Nova Scotia when I told them about the problems they were having in their home because what is their resource? The [Ministry of Long-Term Care] Inspections Branch has said everything is okay, and [the executive director of the long-term care home] has told us everything is okay."

Collins also noted other problems that contributed to the home's problems: unhelpful remote inspections by the ministry of long-term care and the home's physicians abandoning the home and conducting online-only visits, if any at all.

But primarily, it was a lack of people to care for the residents: "They were down 60 per cent of their staff because of the [provincial order that directed staff only work at one long-term care home, rather than part-time at more than one], but also because of a number of people that were sick and a number who were not sick but were terrified."

It wasn't only the lack of staff, however. The province's decision to bar access of family members contributed to the crisis, as the hospital learned that 50 families had been coming to the home twice a day, prior to the pandemic, to feed residents, said Collins.

QP Briefing has reached out to Humber River Hospital to request an interview with Collins.

James Balcom, Chief Operating Officer of GEM Health Care Group, which owns the Downsview Long Term Care Centre, said in a statement the allegation about deaths from dehydration is false but did not answer a list of detailed questions sent by QP Briefing.

Hawthorne Place, the other home where the military reported on neglect and deaths from dehydration and malnourishment, is owned by Responsive Management Group. In a statement, it said at no time were concerns raised with it about "mould, fungus, dehydration, malnutrition."

Those issues were raised, however, when another hospital leader testified to the long-term care commission in January. Susan Kwolek, of the North York General's effort to aid long-term care homes, told the commission that residents "were weren't getting fed or weren't getting hydration" before temporary staffing was brought in, after the home's usual staffing collapsed. She also noted mould in the kitchen and a cockroach infestation.

"When you went down to the basement and kicked a cardboard box, as I did, there were thousands and thousands of cockroaches. Horrible. And not only that, they were in the kitchen where the food was being prepared," Kwolek said.

North York General assisted Hawthorne Place after the military support.

Responsive Group also said the government inspectors couldn't substantiate the CAF's claims.

"Following the issuance of the CAF report last spring, the Ministry of Long-Term Care initiated an inspection to review the CAF’s findings at Hawthorne Place," the company said in its statement. "Both the Ministry of Long-Term Care’s follow up inspection as well as our own investigation found many instances where allegations were not shared with Hawthorne Place’s leadership team at the time, could not be substantiated, or members of the CAF could not recall a date or time an incident occurred."

Kwolek and one of her colleagues from the hospital criticized the inspection regime for not being comprehensive — for focusing on specific metrics and resident complaints while missing the broader picture, such as the lack of cleanliness and cockroach infestation.