Between 2004 and 2022, the GLTCRC reviewed a total of 395 cases and generated 931 recommendations aimed towards the prevention of future deaths. On average, the GLTCRC has reviewed 20.8 cases and generated 49 recommendations per year.

It is recognized that there is an inherent bias as to which cases undergo review (i.e. 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  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)
  • Training and education (emerged as a new theme in 2022 and has been reflected in the data)
  • Transfers (emerged as a new theme in 2022 and has been reflected in the data)
  • Other: includes recommendations that do not fall into any of the other listed themes, including recommendations that relate to research, data collection, the referral to another committee, ministry, legal/justice sector, or is case specific

The following statistical analysis of 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 help 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 help 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 One: Percent of major issues based on theme identified in GLTCRC cases from 2004-2022

Graph 1: full description is below

From 2004 until 2022, the GLTCRC has reviewed a total of 395 cases. 

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

Note: ‘Other’ includes recommendations that do not fall into any of the other listed themes, including recommendations that relate to research, data collection, the referral to another committee, ministry, or legal/justice sector, or is case specific.

Graph One demonstrates that in 32% of the cases reviewed by the GLTCRC from 2004-2022, issues relating to medical/nursing management were identified. This is followed by 23% of the cases where issues pertaining to the acute and long-term care industry (including MOH and MLTC) were noted and 18% of the cases where issues of communication/documentation were present. Other key themes included use of drugs in the elderly (12%), use of restraints (3%), training and education (1%), transfers (0.5%), determination of consent and capacity/DNR (3%) and other (7%). 

Training and education along with transfers has emerged as new themes in 2022. This has been reflected in the data.

Graph Two: Percent of major issues based on theme(s) identified in GLTCRC recommendations (2004-2022)

Graph 2: full description is below

From 2004 until 2022, the GLTCRC generated 931 recommendations aimed at the prevention of future deaths.

Notes: Some recommendations had more than one theme/issue attributed.
'Other' includes recommendations includes recommendations that do not fall into any of the other listed themes, including recommendations that relate to research, data collection, the referral to another committee, ministry, or legal/justice sector, or case specific.

Graph Two demonstrates the percentage of common themes/issues attributed to the individual recommendations made from the cases reviewed from 2004-2022. Some complex recommendations may have been recorded as having more than one theme or issue. It was found that 34% 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 (11%), determination of capacity and consent for treatment or DNR (3%), the use of restraints (4%), training and education (1%), transfers (1%), and other (6%).