Opposition leader calls for coroner's inquest into long-term care deaths

Ontario's official opposition is calling for a coroner's inquest into deaths from neglect in long-term care and to clarify if his office is investigating any of those deaths.

"Ontarians learned of the horrors of seniors who perished not from COVID-19 but from dehydration; they were neglected to death," said NDP Leader Andrea Horwath in a letter on May 12. "This has sparked appropriate outrage from Ontarians across the province."

To date, the coroner and solicitor general have not provided any information about how the province is responding to the disturbing notes from the Canadian Armed Forces about residents dying from neglect in two of the homes the military aided.

In the wake of the publication of those reports, Government House Leader Paul Calandra said in question period Tuesday the Office of the Chief Coroner (OCC) was engaged to review all deaths in long-term care. But asked to explain what the coroner is doing, Solicitor General Sylvia Jones, whose ministry includes the OCC, appeared not to know and gave incorrect information.

She replied that all deaths in long-term care are investigated.

"Those are done by the Office of the Chief Coroner," Jones said. "And if and when there are concerns about criminal activity, then the Office of the Chief Coroner works directly with the local police jurisdiction — that relationship has been long-standing and ongoing, and I'm sure that that is exactly what is happening."

That's not so, according to Jane Meadus, a lawyer with the Advocacy Centre for the Elderly.

She said coroners used to investigate all deaths in long-term care, but it hasn't been the case for years. Prior to 2013, coroners investigated every tenth death in a long-term care home but that was phased out. The coroner does, however, have a legal responsibility to investigate all deaths that fit certain criteria, including neglect.

Today, all long-term care deaths must be reported to the Office of the Chief Coroner, but whether or not an investigation is launched is based on a process that begins with paperwork filled out by the long-term care homes themselves.

That's a concern for Meadus.

“The biggest problem is the deaths require the home to complete the documentation,” she said. “Really, what are they going to be reporting? Who’s going to report, we were negligent, we let 26 people die?”

The documentation is called an Institutional Patient Death Record (IPDR) and it's based on a series of yes or no questions, such as: was the death suicide, was it homicide, "was the death both sudden and unexpected," "is the manner of death unclear," and "did the family or any care providers raise concerns about the care provided?"

"Yes" answers trigger a look by a coroner.

Meadus said she's concerned homes in crisis may not be forthcoming when they have something to hide. “That’s the biggest problem here. You’ve got the person who may be responsible having to report everything.”

That said, the OCC has the power to investigate any death in long-term care it sees fit, she added.

The process for coroners' involvement in long-term care deaths received significant scrutiny in the last inquiry into long-term care — the one sparked by the Elizabeth Wettlaufer murders and led by Justice Eileen Gillese.

Gillese recommended the OCC replace the IPDR with a redesigned evidence-based resident death record. She said it should be filled out by the nurse who was providing the most direct care to the resident prior to their death, in consultation with personal support workers, that it should include a broader set of questions, and that it be shared with the patient's other medical care providers.

In fact, of Wettlaufer's eight murder victims, only two had IPDRs filled out with "yes" answers. One by Wettlaufer herself and another by a nurse who noted a recent increase in deaths in the facility. The final report also details a third Wettlaufer murder victim, whose hospital physician contacted the coroner's office with a concern about the cause of death while the home replied "no" to all questions in the IPDR.

Early on in the pandemic, the province gave the province's chief coroner, Dr. Dirk Huyer, additional roles in the provincial response. First, he was named executive lead for COVID-19 testing, then co-ordinator of the provincial outbreak response, and then a member of the vaccine task force.

The coroner's office has yet to respond to questions from QP Briefing about the implementation of the Wettlaufer inquiry recommendations and for information about whether investigations have been launched into deaths from neglect, and if any information has been forwarded to police for a criminal investigation.

Huyer's office provided a brief statement: "The Office of the Chief Coroner is working with our ministry and agency partners to provide information or data they may require."

The two homes where the military notes said residents died from neglect are both located in Toronto — the Toronto Police Service has told QP Briefing it is not yet investigating, but noted it could be contacted by the coroner. Meanwhile, the NDP has also asked the OPP to undertake a review of deaths from neglect.

Horwath's latest letter includes a request to know if the long-term care homes in question have properly alerted the chief coroner's office.

"As it is your office’s role to investigate these deaths, I am writing to ask you to publicize how many investigations you have begun. I particularly want to know whether long-term care providers, in these public instances, have or have not properly alerted your office of these death notices. Ontarians deserve a full inquest into the deaths of each of those 26 seniors, as well as any other deaths that warrant investigation," she wrote.

"In light of the seriousness of what is public and what has been alleged to have taken place in report after report in long-term care homes during this pandemic, I ask for your office to conduct a full review of all of these deaths, as the neglect and mistreatment of seniors cannot pass without accountability."

Last May, a union representing personal support workers who died from COVID-19 sent a similar letter to the chief coroner. SEIU Heathcare asked for the deaths of the three PSWs who had died at that time to be investigated and for the coroner to determine whether or not an inquest is necessary.

The homes named by the Canadian Armed Forces maintain no residents died of neglect.

GEM Health Care, which owns the Downsview Long-Term Care Centre where the military notes allege 26 deaths from neglect, said that report is false. "Again, having co-operated fully with the OCC, and having reviewed our own records from last year, we are confident that this information will be confirmed by the OCC with the Ontario Ministry of Long-Term Care."

Responsive Group, which owns Hawthorne Place, said no investigations were launched into deaths at their facility and none of their residents' death certificates list neglect, dehydration or malnutrition as a cause of death.