Geriatric and long-term care review committee

Message from the chair

The following is the 2021 Annual Report of the Geriatric and Long-Term Care Review Committee (GLTCRC). The COVID-19 pandemic contributed to delays in assembling our committee reviews that form the basis of our committee reports.

The GLTCRC was established in 1989 and consists of members who are respected practitioners in the fields of geriatrics, 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 2021, the GLTCRC reviewed 16 cases, involving 18 deaths, and generated 49 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 further deaths in similar circumstances.

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. Kathy retired in February 2022 after 35 years with the Ontario Public Service, most of those with the OCC. Kathy was an integral part of our organization, especially with the expert review committees for which she provided both lead and support services. We miss her and wish her health and happiness in the years to come.

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

Committee membership (2021)

• Dr. Roger Skinner — Regional supervising coroner, committee chair
• Ms. Kathy Kerr — Executive lead
• Ms. Julie Cavaliere — Registered dietitian
• Dr. Barbara Clive  — Geriatrician
• Dr. Margaret Found — Family physician/coroner
• Dr. Sid Feldman — Family physician
• Dr. Dov Gandell — Geriatrician
• Dr. Barry Goldlist — Geriatrician
• Dr. Mark Lachmann — Geriatric psychiatrist/coroner
• Dr. Andrea Moser — Chief medical officer
• Dr. Joel Ross — Family physician/coroner
• Ms. Anne Stephens — Clinical nurse specialist

Executive summary

The Geriatric and Long-Term Care Review Committee 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
• services to seniors

In 2021, the GLTCRC reviewed 16 cases involving 18 deaths and generated 49 recommendations directed toward the prevention of future deaths. Of the 16 cases reviewed, one resulted in no recommendations.

Of the 18 deaths that were reviewed in 2021, the breakdown for manners of death were:

• natural — 5 (1 male and 4 females)
• accident — 7 (5 males and 2 females)
• homicide (for the purposes of a coroner’s investigation, the finding of “homicide” does not imply a finding of legal responsibility or culpability) — 1 (female)
• undetermined — 5 (3 males and 2 females)

Of the 18 deaths reviewed:

• 9 were male and 9 were female
• the average age of men whose deaths were reviewed was 84.8 years
• the average age of women whose deaths were reviewed was 68.1 years
• the average age of all deaths reviewed in 2021 was 73.5 years

In 2021, the most common areas for improvement identified by GLTCRC through their case reviews and resulting recommendations consisted of:

• medical and nursing management
• acute care and long-term care industry in Ontario, including the Ministry of Health (MOH) and Ministry of Long-term Care (MLTC)
• communication and documentation
• use of drugs in the elderly
• use of restraints
• other (for example, quality reviews, referrals to other organizations)

Chapter 1: Introduction

The annual GLTCRC report is intended to provoke thought and stimulate discussion about geriatric and long-term care deaths in Ontario and contains statistical information about cases reviewed and the resulting recommendations from those reviews.

Aims and objectives

The aims and objectives of the GLTCRC are:

1. To assist coroners in the province of Ontario with the investigation of deaths involving geriatric and elderly individuals and others receiving services within long-term care homes.
2. To provide expert review of the circumstances of the care provided to individuals receiving geriatric and/or long-term care in Ontario prior to their death.
3. To produce an annual report that is available to doctors, nurses, healthcare providers, social service agencies, and others, for the purposes of death prevention awareness.
4. To review cases and help identify whether there are any systemic issues, trends, risk factors, problems, gaps, or other shortcomings in the circumstances of each case, in order to facilitate the development of appropriate recommendations to prevent future similar deaths.
5. To conduct and promote research where results and a comprehensive understanding may lead to recommendations that will prevent future similar deaths.

Note: The above-described objectives and committee activities are subject to limitations imposed by the Coroners Act of Ontario and the Freedom of Information and Protection of Privacy Act.

The OCC has made it a policy to submit all coroner’s investigations involving homicides in long-term care or retirement homes in the province to the GLTCRC for further review. Other cases involving the deaths of elderly individuals (regardless of whether they are in a long-term care or retirement setting), may be referred to the GLTCRC for review if systemic issues or implications may be present.

Structure and size

The GLTCRC consists of respected practitioners in the fields of:

• geriatrics
• pharmacology
• family medicine
• emergency medicine
• psychiatry
• nursing
• services to seniors

This committee membership reflects practical geographical balance and representation from various levels of institutions providing geriatric and long-term care.

The chair of the GLTCRC can either be a regional supervising coroner or deputy chief coroner. Committee support is provided by the executive lead, committee management, OCC.

Other individuals with specific expertise may be invited to committee meetings as necessary on a case-by-case basis (for example, investigating coroners, regional supervising coroners, police officers, other specialty practitioners relevant to the facts of the case, etc.).

Membership is reviewed regularly by the committee chair and by the chief coroner as requested.

Methodology

Cases are referred to the GLTCRC by a regional supervising coroner when expert or specialized knowledge is needed to further the coroner’s investigation, and/or when there are significant concerns or issues identified by the family, investigating coroner, regional supervising coroner, or other relevant stakeholders. All homicides that occur within a long-term care setting are referred to the Committee for review.

A minimum of at least one member of the committee reviews the information submitted by the regional supervising coroner, and then presents the case to the other committee members. Following committee discussion, a final case report is produced that includes a summary of the events, the committee’s collective findings and recommendations intended to prevent future deaths. The report is sent by the chairperson to the referring regional supervising coroner, who may conduct further death investigation if necessary.

When a case presents a potential or real conflict of interest for a committee member, a substitute member may be asked to participate in the review or the committee may review the case in the absence of the member with the conflict of interest.

When a case requires expertise from another discipline, an external expert may be asked to review the case, attend the meeting, and/or participate in the discussion and drafting of recommendations if necessary.

Limitations

The GLTCRC is advisory in nature and makes recommendations through the chairperson. While the committee’s consensus report is limited by the data provided, efforts are made to obtain all available and relevant information. It is not within the mandate of the committee to re-open other investigations (e.g., criminal proceedings) that may have already taken place.

Information collected and examined by the GLTCRC, as well as its final report, are for the sole purpose of a coroner’s investigation pursuant to section 15(4) of the Coroners Act and subject to confidentiality and privacy limitations imposed by that Act and the Freedom of Information and Protection of Privacy Act. Accordingly, individual reports, review meetings, and any other documents or reports produced by the GLTCRC are confidential and may not be released publicly. Redacted versions of reports are publicly available by contacting OCC.inquiries@ontario.ca.

Each Committee member has entered into and is bound by the terms of a confidentiality agreement that recognizes these interests and limitations.

Members of the committee do not publicly give opinions about cases they have reviewed. In particular, committee members will not act as experts at civil trials for cases that the GLTCRC has reviewed. Additionally, members do not participate in discussions or prepare reports of clinical cases where they have (or may have) a conflict of interest, or perceived conflict of interest, whether personal or professional.

It is recognized that the GLTCRC only reviews deaths that meet the criteria for mandatory referral (such as, homicides in long-term care or retirement homes), or discretionary referral (such as, where systemic issues or implications may be present). Discretionary referrals may be based on concerns or issues identified by the investigating coroner, regional supervising coroner or family.

Statistics generated from GLTCRC reviews, particularly as they relate to themes and trends, may be inherently biased due to the selection criteria for cases referred to the committee. It is also recognized that there is a certain level of subjectivity when themes are assigned during analysis.

Recommendations

One of the primary goals of the GLTCRC is to make recommendations aimed at preventing further deaths. Recommendations are distributed to relevant organizations and agencies through the chairperson.

Organizations and agencies are asked to respond to the executive lead, committee management, OCC on the status of implementation of issued recommendations within six months of receiving them. Similar to recommendations generated through coroner’s inquests, GLTCRC recommendations are not legally binding and there is no legal obligation for agencies and organizations to implement or respond to them.

Recommendations made to cases reviewed by the GLTCRC in 2021 are included in Appendix A.

Responses to recommendations are part of the public record and are available by contacting OCC.inquiries@ontario.ca.

Chapter 2: Statistical overview 2004–2021

Between 2004 and 2021, the GLTCRC reviewed a total of 382 cases and generated 882 recommendations aimed towards the prevention of future deaths. On average, the GLTCRC has reviewed 21.2 cases and generated 49 recommendations per year.

It is recognized that there is an inherent bias as to which cases undergo review (meaning, most cases are discretionary referrals sent to GLTCRC due to the presence of identified concerns and issues). There is also the possibility of researcher bias in attributing certain themes to cases and recommendations. It is also recognized however, that regardless of these potential biases, there are certain recurring themes that have emerged over the years. These themes can be applied at a broader level to cases and more specifically to focused recommendations.

The themes identified include:

• medical and nursing management
• communication and documentation
• use of drugs in the elderly
• use of restraints
• determination of capacity and consent for treatment/DNR
• the acute care and long-term care industry in Ontario, including the Ministry of Health (MOH) and Ministry of Long-Term Care (MLTC)
• other: includes other Ontario ministries, justice and legal systems

The following statistical analysis on themes has been broken down into two distinct sections:

• an analysis of themes based on individual cases reviewed
• an analysis of themes based on individual recommendations made

By breaking the analysis down into cases vs. recommendations, it is possible to observe general trends relating to themes that emerge throughout cases that have been referred and reviewed by the GLTCRC, compared to themes that have emerged from specific recommendations.

Trends based on themes in cases helps to identify what issues or themes are present in the cases that are being referred to the GLTCRC for review. These findings help to identify if there is a trend in the types of cases that are being referred and reviewed.

Trends based on themes in recommendations helps to identify what specific themes/issues have been identified and addressed in recommendations aimed toward the prevention of future similar deaths. A trend in themes of recommendations helps to identify specific areas where the need for change, action or attention has been suggested.

Graph 1: Percent of major issues based on theme identified in GLTCRC cases from 2004–2021

From 2004 until 2021, the GLTCRC has reviewed a total of 382 cases.

Many cases had more than one theme/issue attributed to the recommendations.

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Graph 1 demonstrates that in 32% of the cases reviewed by the GLTCRC from 2004–2021, issues relating to medical/nursing management were identified. This is followed by 24% of the cases where issues pertaining to the acute and long-term care industry (including MOH and MLTC) were noted and 19% of the cases where issues of communication/documentation were present. Other key themes included:

• use of drugs in the elderly (13%)
• use of restraints (3%)
• determination of consent and capacity/DNR (3%)
• other (6%) (** other includes recommendations to other ministries or in the legal/justice sector)

Graph 2: Percent of major issues based on theme(s) identified in GLTCRC recommendations (2004–2021)

From 2004 until 2021, the GLTCRC generated 882 recommendations aimed at the prevention of future deaths.

Note: Some recommendations had more than one theme/issue attributed.

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Graph 2 demonstrates the percentage of common themes/issues attributed to the individual recommendations made from the cases reviewed from 2004–2021. Some complex recommendations may have been recorded as having more than one theme or issue. It was found that 35% of all recommendations made were related to medical or nursing management while 22% of the recommendations touched on the acute and long-term care industry, including the MOH and MLTC. The other themes/issues that were present, but that were less frequently assigned to the recommendations, were related to:

• communication/documentation (19%)
• use of drugs in the elderly (12%)
• determination of capacity and consent for treatment or DNR (2%)
• the use of restraints (4%
• other (6%) (** other includes recommendations to other ministries or in the legal/justice sector)

Chapter 3: Cases reviewed in 2021

In 2021, the GLTCRC reviewed a total of 16 cases involving the deaths of 18 elderly individuals (9 females and 9 males), including residents of long-term care and retirement homes. Of the 16 cases, one was a mandatory review resulting from a homicide that occurred in a long-term care facility.

Of the cases reviewed in 2021:

• 1 of the deaths occurred in 2016
• 4 in 2018
• 6 in 2019
• 7 in 2020

Note: The OCC has made it a policy to submit all coroner’s investigations involving homicides in long-term care or retirement homes in the province to the GLTCRC for further review. Other cases involving the deaths of elderly individuals (regardless of whether they are in a long-term care or retirement setting), may be referred to the GLTCRC for review if systemic issues or implications may be present, or if concerns were identified by the family, investigating coroner or regional supervising coroner.

A summary of cases reviewed, and recommendations made in 2021 is included in Appendix A.

Full, redacted reports and responses to recommendations may be obtained by contacting the OCC at occ.inquiries@ontario.ca.

From the cases reviewed in 2021, the average age of all decedents was 73.5 years, the average age for females being 68.1 years, and males 84.8 years.

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Graph 3: 2021 GLTCRC reviews based on manner of death and sex of decedent

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Graph 3 demonstrates the breakdown of cases reviewed by the GLTCRC based on manner of death and sex of the decedent. Of the 18 cases reviewed:

• 5 were natural (4 females and 1 male)
• 7 were accidents (3 females and 4 males)
• 1 homicide (female)
• 5 were undetermined (2 females and 3 males)
• none were suicide cases

In 2021, the GLTCRC generated a total of 49 recommendations aimed at preventing future deaths. One case resulted in no recommendations. Although the GLTCRC may not have generated recommendations in this case, the analysis of the circumstances and subsequent discussion contributed significantly to the larger coroner’s investigation of the death.

Recommendations made by the GLTCRC are distributed to:

• relevant individuals
• facilities
• ministries
• agencies
• special interest groups
• health care professionals (and their licensing bodies)
• coroners

Agencies and organizations in a position to implement recommendations are asked to respond to the OCC within 6 months. These organizations are encouraged to report on the implementation status of recommendations assigned to them.

Recommendations are also shared with chief coroners and medical examiners in other Canadian jurisdictions and are available to others upon request.

Graph 4: Percent of major issues based on theme(s) identified in GLTCRC recommendations made in 2021

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Note: Some recommendations had more than one theme/issue attributed.

Graph 4 demonstrates the distribution of themes/issues for the recommendations made for the cases reviewed in 2021. The most commonly identified themes/issues were related to:

• the acute and long-term care industry (30%)
• communication and documentation (20%)
• medical or nursing management (17%)
• use of drugs in the elderly (7%)
• determination of consent and capacity (2%)
• “other” (including recommendations to the police and Regional Supervising Coroners, and/or **recommendations to other ministries or in the legal/justice sector) (13%)
• use of restraints (11%)

It is recognized that the issues identified and any resulting trends, are based on the cases that are referred for review. Other than the reviews of homicides within long-term care homes which are mandatory (based on the policy of the Office of the Chief Coroner), all other cases are referred for review based on a discretionary, and therefor subjective, decision to do so. It is acknowledged that the discretionary nature of some referrals may result in trends based on issues or concerns that have been identified as areas requiring further attention and analysis.

Overall summary of cases reviewed, and recommendations made by the GLTCRC in 2021:

• In 2021, there were 16 cases involving 18 deaths reviewed by the GLTCRC. There were 49 recommendations made. Of the 16 cases reviewed, 1 resulted in no recommendations.

• Of the 16 cases reviewed in 2021, the breakdown for manners of death were:
  • natural — 5 (1 male and 4 females)
  • accident — 7 (5 males and 2 females)
  • homicide — 1 (female)
  • undetermined — 5 (3 males and 2 females)
• Medical/nursing management issues were identified in 17% of the recommendations made.
• Communication and documentation issues were identified in 20% of the recommendations made.
• MOH and MLTC and/or long-term care industry issues were identified in 30% of the recommendations made.
• ‘Other’ (including recommendations to police services and regional supervising coroners, etc.) was identified in 13% of the recommendations made.
• Use of drugs in the elderly was identified in 7% of the recommendations made.
• The use of restraints in the elderly was identified in 11% of the recommendations and determination of consent and capacity / DNR in 2% of the recommendations.
• Some of the recommendations touched on more than 1 issue.
• One case did not have any recommendations.
• Of the 16 cases (involving 18 deaths) reviewed, 9 involved female deceased persons and 9 male deceased persons.
• The average age of all decedents (meaning, male and female combined) in cases reviewed in 2021 was 73.5 years.
• Of the cases reviewed in 2021, the manner of death for each of the 18 deceased persons was:
  • natural (5)
  • accident (7)
  • homicide (1)
  • undetermined (5)
• There were no cases of suicide reviewed in 2021.

Chapter 4: Learning from GLTCRC reviews

Recurrent themes from the GLTCRC include violence in long- term care, elder abuse and medical management, including:

• medication use
• restraints
• consent and capacity
• the management of dementia and psychiatric illness

A prominent theme in this year’s reviews was, again, the challenges associated with transitions of care. When the decision is made that a person requires long-term care, they should be placed in a long-term care home, not temporarily housed in a setting that cannot provide the requisite care. Once there, they require the prompt attention of the care team, including the physician, in order to ensure a safe and successful move. This settling in period is recognized as being a time of risk for delirium, behavioural changes and for violent interactions with other residents. A coordinated, proactive approach can reduce this risk.

The elderly as a population present challenges in the management of complex medical and psychiatric conditions; they are best served by a multidisciplinary team of providers with specialized skills. This starts at the level of training and finishes with oversight and effective quality review.

The GLTCRC appreciates the many Ontarians involved in the provision of care to the elderly. These individuals have taken on the responsibility for this valuable, and at times vulnerable, segment of our population, and they do so with considerable skill and dedication. It is hoped that the work of this committee will be of assistance to them and to the families of those whose deaths have been reviewed.

Appendix A: Summary of 2021 cases and recommendations

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