Updated: Apr 15, 2021
Co-authored by Nareh Ghalustians
The Report on the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (the “Report”) was released on July 31, 2019, with 91 recommendations (the “Recommendations”) for improving the safety and security of residents in Ontario’s long-term care system, and for Ontarians receiving home care services. The Report was released following the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (the “Inquiry”). The commission to spearhead this Inquiry was established on August 1, 2017, after Elizabeth Wettlaufer pleaded guilty to and was convicted of eight counts of first-degree murder, four counts of attempted murder, and two counts of aggravated assault offences that she committed while working as a registered nurse in various long-term care homes in southwestern Ontario and as a nurse providing home care services in private homes. She has been sentenced to life imprisonment with no parole eligibility for 25 years.
This article reviews Volume 1 of the Report and identifies the mandate of the Inquiry and its key findings and summarizes the Recommendations affecting long-term care homes in Ontario. We anticipate that there will be broader implications across the entire health sector arising from these Recommendations.
The Report was dedicated to the victims and their loved ones. It notes that the regulatory regime that governs the system is not broken and imposes clear standards for long-term care homes, and a rigorous inspection regime to enforce those standards that can be built upon and improved. In that vein, the Report requires the Ministry of Health and Long-Term Care (the “Ministry”) to issue a report by July 31, 2020, describing the steps it has taken to implement the Recommendations coming out of the Report, and to table that report in the Ontario Legislature. In a recent news release, the Ministry stated its intention to meet this deadline.
The Report notes that the mandate of the Inquiry was to inquire into the events that led to the offences, circumstances, and contributing factors, and to make recommendations on how to avoid similar tragedies in the long-term care system. The mandate was not to conduct a general review of the long-term care system.
The Report highlights three main findings:
The offences would not have been discovered if Elizabeth Wettlaufer had not confessed.
The offences resulted from systemic vulnerabilities.
The long-term care system is strained, but not broken.
The Report was clear that change is required on a systemic level.
The Report recommends that long-term care home licensees must provide training to administrators and directors of nursing on hiring and discipline of staff, conducting workplace investigations, and on reporting obligations to the Ministry and the College of Nurses of Ontario (the “College”). Recommendation #3 suggests that this training be provided by the Ministry, the College, and the Office of the Chief Coroner/Ontario Forensic Pathology Service.
The Report also recommended that medical directors, attending physicians, and nurse practitioners of long-term care homes receive comprehensive, ongoing training on preventing resident abuse and neglect, a requirement from which they are currently exempted, unlike other staff such as registered nurses.
The Report also adds a specific Recommendation that Medical Directors complete the Ontario Long-Term Care Clinician’s Medical Director course within two years of assuming the role of Medical Director in a long-term care home.
Furthermore, the Report recommends additional training for staff, visitors, and residents about their obligations to report to the Ministry (not just to the long-term care home) regarding suspected abuse and neglect of residents that results in a risk of harm to the resident (see s. 24(1) of the Long-Term Care Homes Act, 2007 (the “Act”)).
Summary of Other Key Recommendations
Handling of Medication. Recommendations were made for improving the long-term care home’s medication administration and medication incident reporting systems, and how to use the recommended redesigned institutional Patient Death Record, once it is created.
Improved medication management in long-term care homes is recommended through a three-pronged approach directed at the Ministry creating new policies, improving the annual quality inspection process, and by long-term care homes modifying and improving the security of rooms in which medications are stored and using technology to support medication management.
Recommendations are made to the Ministry to permit long-term care homes to use the additional nursing and personal care funding to purchase or upgrade integrated automated medication dispensing cabinets and install cameras and/or glass doors in medication rooms.
It is recommended that long-term care homes improve their medication incident analyses (required by the Act) and treat the use of glucagon as a medication incident. Medication incidents, under the Act, would have to be reported and reviewed at least quarterly by the long-term care home’s medication management interdisciplinary team, composed of the Medical Director, administrator, director of nursing and personal care, and the pharmacy service provider. More details regarding medication management can be found in Recommendations #74-84 of the Report.
Recommendation #19 recommends that the Ministry expand the nursing and personal care funding envelope and permit long-term care homes to use these funds to pay for a broader spectrum of staff including porters, pharmacists, and pharmacy technicians.
Recommendation #76 goes further to recommend that long-term care homes use this funding to engage a staff pharmacist and/or pharmacy technician. The Report also recommends that the licensees use this new funding for training, education, and professional development of all staff, including the backfilling of positions for staff attending training. Further, the Report recommends that licensees be permitted to use the expanded or new funds for annual membership fees in AdvantageOntario and the Ontario Long-Term Care Association.
Agency Nurses, Service Providers, and the Role of the Ministry. Specific Recommendations are made regarding long-term care homes’ use of agency nurses (Recommendations #11-13); home care service provider obligations (Recommendations #14-18); and the role of the Ministry (Recommendations #19-31).
LHINS/Ontario Health, College, Coroner, and Ministry Recommendations. Recommendations #32-39 are directed toward Local Health Integration Networks (“LHINs”) and providers and coordinators of home care services, and thereby to Ontario Health, once it takes over this role. One of the Recommendations is for the LHINs to adopt a common electronic events reporting system and to train staff and service providers on its use. Recommendations #40-49 are directed to the College and Recommendations #50-61 to the Office of the Chief Coroner/Ontario Forensic Pathology Service. Recommendations #62-63 suggest an expanded leadership role for the Ministry and improved communication with the LHINs/Ontario Health.
Health Care Serial Killer Phenomenon. Building awareness of the “healthcare serial killer” phenomenon is addressed in Recommendations #64-73 (a phenomenon used to describe murders committed by individuals working as health care professionals). The Inquiry heard evidence that 90 healthcare serial killers have been convicted in the USA, Canada, and Western Europe since 1970, but the phenomenon has been documented since the 1800s.
Number of Registered Staff. It is recommended that the Ministry conduct a study to determine the adequate levels of registered staff in the long-term care homes on each of the day, evening, and night shifts, table the study in the legislature by July 31, 2020, and increase funding accordingly (Recommendation #85).
Detecting Deaths. Suggestions for improving the detection of intentionally caused resident deaths are covered in Recommendations #86-91.
The Report highlights the dedication and commitment of individuals working in the long-term care system under pressure and with limited resources. The Report highlights improvements that were implemented by stakeholders during the Inquiry and prior to the release of this Report, including the formation of a working group on medication management systems in long-term care homes, and the increase in the amount of information available from the College about nurses’ employment history, and stakeholder-led initiatives that predated the Inquiry, such as a medication safety pilot project and the clinical support tools program.
The Report expresses hope that the Inquiry and the Report can rebuild Ontarians’ shattered trust in the long-term care system.
 The Government of Ontario recently divided this Ministry into two, appointing a separate Minister of Long-Term Care in addition to what is now called the Ministry of Health. This blog post uses the language of the Report, which references both Ministries jointly.