Questions and comments regarding this report may be directed to:

Geriatric and Long-Term Care Review Committee
Office of the Chief Coroner
25 Morton Shulman Avenue
Toronto, Ontario
M3M 0B1
occ.inquiries@ontario.ca

Message from the Chair

The following is the 2020 Annual Report of the Geriatric and Long-Term Care Review Committee (GLTCRC).  The delay in this report is due to the COVID‑19 pandemic.

The GLTCRC was established in 1989 and consists of members who are respected practitioners in the fields of geriatrics, gerontology, family medicine, psychiatry, nursing, pharmacology, emergency medicine and services to seniors.

The Office of the Chief Coroner (OCC), through the GLTCRC, has made it a policy to review all homicides involving residents of long-term care or retirement homes. The GLTCRC also reviews cases where systemic issues may be present or where significant concerns have been identified by the family, investigating coroner or Regional Supervising Coroner. 

Reviews conducted by the GLTCRC include a comprehensive and thorough review of the circumstances surrounding the death and if appropriate, the development of recommendations aimed towards the prevention of future deaths.  In 2020, the GLTCRC reviewed 19 cases, involving 19 deaths, and generated 46 recommendations.

Reviews and recommendations prepared by the GLTCRC are widely distributed to service and long-term care providers and other relevant agencies and organizations throughout the province. Our role is to provide information to relevant organizations that will subsequently lead to improvements in processes, policies and initiatives, with the goal of preventing future deaths in similar circumstances.

The COVID‑19 pandemic arrived in Ontario in 2020. It took a devastating toll on the elderly, especially those living in long-term care homes (LTCHs). Families were separated, some during their loved one’s last days. Staff were also affected by the disease and by the loss of cherished residents. The pandemic laid bare the weaknesses in long-term care and produced commitments to do better.

The OCC was privileged to assist LTCHs and hospitals in a small way through the implementation of the Managing Resident Death Response process. Although these deaths generally did not fall within the OCC mandate for investigation and hence were not reviewed by the GLTCRC, the committee members were intimately familiar with the impact of the pandemic as it affected their patients and colleagues.

I would like to take this opportunity to thank Ms. Kathy Kerr (Executive Lead) for her assistance with the ongoing administration and management of GLTCRC activities and data.

It is an honour to participate in the work of the GLTCRC and I am grateful for the commitment of its members to the people of Ontario. Readers who wish to obtain the redacted narrative reports can do so by contacting the OCC at: occ.inquiries@ontario.ca.

Dr. Roger Skinner
Regional Supervising Coroner, Modernization
Chair, Geriatric and Long-Term Care Review Committee