Cases reviewed in 2020

In 2020, the GLTCRC reviewed a total of 19 cases involving the deaths of 19 elderly individuals (eight females and 11 males), including residents of long-term care and retirement homes; one case involved a 31-year-old male who lived in a residential group home. Of the 19 cases, three were mandatory reviews resulting from homicides that occurred in long-term care facilities.

Of the cases reviewed in 2020, one of the deaths occurred in 2016, four in 2017, six in 2018 and eight in 2019.

[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 2020 is included in Appendix A.

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

Average age of decedent in cases reviewed in 2020:

• From the cases reviewed in 2020, the average age of all decedents was 79.2 years.
• Female: 82 years
• Male: 77.1 years

Graph three: 2020 GLTCRC reviews based on manner of death and sex of decedent

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In 2020, the GLTCRC generated a total of 46 recommendations aimed at preventing future deaths.  There were three cases that did not result in any recommendations.  Although the GLTCRC may not have generated recommendations in these cases, the analysis of the circumstances and subsequent discussion contributed significantly to the larger coroner’s investigation of the deaths.

Recommendations made by the GLTCRC are distributed to relevant individuals, facilities, ministries, agencies, special interest groups, health care professionals (and their licensing bodies) and coroners. Agencies and organizations in a position to implement recommendations are asked to respond to the OCC within six 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 four: Percent of major issues based on theme(s) identified in GLTCRC recommendations made in 2020

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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 LTCHs 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 2020: 

• In 2020, there were 19 cases involving 19 deaths reviewed by the GLTCRC. There were 46 recommendations made. Of the 19 cases reviewed, three resulted in no recommendations.
• One case involved the death of a 31-year-old man with a severe developmental delay characterized by autism, a seizure disorder, and bipolar spectrum disorder, who lived in a group home. 
• Of the 19 cases reviewed in 2020, the breakdown for manners of death were:
  • Natural — 5 (three males and two females)
  • Accident — 7 (four males and three females)
  • Homicide ^{footnote 1[1]} — 3 (three males)
  • Undetermined — 4 (one male and three females)
• Medical/nursing management issues were identified in 35% of the recommendations made.
• Communication and documentation issues were identified in 24% of the recommendations made.
• MOHLTC and/or LTC industry issues were identified in 28% of the recommendations made.
• ‘Other’ (including recommendations to police services and Regional Supervising Coroners, etc.) was identified in 4% of the recommendations made.
• Use of drugs in the elderly was identified in 9% of the recommendations made.
• The use of restraints in the elderly was identified in 9% of the recommendations and determination of consent and capacity / DNR in 7% of the recommendations.
• Some of the recommendations touched on more than one issue.
• There were three cases that did not have any recommendations.
• Of the 19 cases (involving 19 deaths) reviewed, 11 involved female deceased persons and eight male deceased persons.
• The average age of all decedents (i.e. male and female combined) in cases reviewed in 2020 was 79.2 years.
• Of the cases reviewed in 2020, the manner of death for each of the 19 deceased persons was: natural (5), accident (7), homicide (3) and undetermined (4). There were no cases of suicide reviewed in 2020.