Long-term care inspection system collapsed during deadly first weeks of COVID-19 pandemic, Ontario Ombudsman finds

September 7, 2023

7 September 2023

Ministry of Long-Term Care accepts all recommendations to improve preparedness for next crisis

(TORONTO – September 7, 2023) Ombudsman Paul Dubé today called for an overhaul of Ontario’s long-term care inspection system, after his latest investigation found it was completely overwhelmed during the first wave of COVID-19.

There were no inspections of long-term care homes for seven weeks in the spring of 2020 and no inspection reports issued for two months, the Ombudsman reveals in his investigation report, Lessons for the Long Term, released today. “Few knew that this oversight mechanism had fallen apart,” he writes.

“Tragically, the Ministry of Long-Term Care was unprepared and unable to ensure the safety of long-term care residents and staff during the pandemic’s first wave,” he states, noting that “it is crucial that the Ministry fully understand and learn from the failure of the Inspections Branch to adequately and quickly respond.”

The Ombudsman launched the investigation on his own initiative on June 1, 2020, shortly after Canadian Armed Forces personnel reported shocking conditions inside several long-term care homes where they had been called in to help in the early days of the COVID crisis.

Mr. Dubé’s office, which does not directly oversee long-term care homes but does have jurisdiction over the Ministry, also received 269 complaints and inquiries from families of long-term care residents, employees of long-term care homes and other stakeholders in the sector. Investigators conducted more than 90 interviews and reviewed thousands of emails and documents, among other evidence.

Since other probes were also under way, including by the Auditor General and Patient Ombudsman, as well as the government’s Long-Term Care COVID-19 Commission, Mr. Dubé focused his investigation on the Ministry of Long-Term Care’s inspection and enforcement-related activities. He found that the Ministry’s lack of planning and preparedness for the crisis was “unreasonable, unjust and wrong,” under the Ombudsman Act, and made 76 recommendations to the Ministry and government.

“The people of Ontario should be able to count on their public services to learn lessons from our experience with COVID-19 and be adequately prepared for the next threat to our collective health,” he says.

All of the Ombudsman’s recommendations were accepted, and the Ministry has agreed to report back to him every six months on its progress in implementing them.

The Ombudsman’s report details what one Ministry employee called a “complete system breakdown” at the outset of the pandemic, when inspections stopped because the Ministry had no plan to ensure inspectors’ safety. Inspectors had no personal protective equipment or training in infection prevention and control at the time.

Despite their role in enforcing compliance with legislation, inspectors were deployed to call and “support” homes. When inspections resumed, only those who volunteered were sent inside homes experiencing COVID outbreaks. Inspectors often gave homes reduced penalties for non-compliance, or let them have months to remedy issues that were causing serious harm to residents.

“We saw many examples where inspectors used their considerable discretion to lower the default enforcement action that would otherwise apply, even in very serious situations and with little to no explanation,” Mr. Dubé says in the report.

“We discovered that extremely serious COVID-related issues – such as infection prevention and control or personal protective equipment usage – were not inspected in a timely manner, or at all. The Inspections Branch also did little – often nothing – when homes did file reports about COVID-19 outbreaks.”

The report cites several stories of families who were affected, for example:

  • “Peter” contacted the Ministry four times between April 6 and May 5, 2020, about disturbing conditions in his mother’s long-term care home, but none were inspected until October 2020, many months after his mother died; one of 53 residents of that home who died during the first COVID wave.

  • “Gemma” complained in April 2020 that the long-term care home where both her parents contracted COVID was “severely short” on personal support workers. A Ministry inspector "reassured” Gemma over the phone and then closed the file without taking any action. One of Gemma’s parents died during the first COVID wave, along with 32 other residents at that home.

The Ombudsman’s recommendations are aimed at ensuring the province is prepared for the inevitable next pandemic. They include regular training for inspectors, ensuring adequate stockpiles of personal protective equipment, and establishing clear rules on when on-site inspections are required. He also recommended that the Ministry:

  • Ensure it always has staff with expertise in infection and control measures available for in-person inspections of long-term care homes;

  • Issue immediate compliance orders in situations where residents are at an ongoing risk of serious harm; and

  • Take a broad approach to its mandate – meaning it can inspect anything that leaves long-term care residents unsafe.

In addition, he calls on the government to:

  • Revise legislation to improve whistleblower protection;

  • Expand the circumstances in which homes must report critical incidents; and

  • Work with the Ministry to ensure the Inspections Branch has adequate staff.

Although several improvements have since been implemented by the government, including the new Fixing Long-Term Care Act, which strengthens enforcement of long-term care requirements and requires homes to be better prepared for future pandemics, “much more needs to be done to address the serious lapses in oversight I have detailed in this report,” the Ombudsman stresses.

“My investigation and recommendations have focused on evidence not revealed in other reviews, and the remedial action necessary to ensure Ontario is better prepared and its residents better protected when future crises arise,” he says.

“The Ministry’s goal should always be to confirm that homes are complying with legislated requirements, and if not, to bring them back into compliance as soon as possible while encouraging future compliance. Ensuring the safety of residents and staff must be the primary mission of the Branch and reflected in its work culture.”

He noted that he is “pleased” with the response from the Ministry, which said more than half of his recommendations have already been fully or partially implemented.

About the Office of the Ombudsman: The Ombudsman is an independent and impartial officer of the Ontario Legislature. Under the Ombudsman Act, the Ombudsman reviews and resolves complaints and inquiries from the public about provincial government organizations, as well as French language services, child protection services, municipalities, universities and school boards. The Ombudsman does not overturn the decisions of elected officials or set public policy, but makes recommendations to ensure administrative fairness, transparency and accountability. The Ombudsman's investigations have benefited millions of Ontarians and prompted widespread reforms, including better newborn screening, a more secure lottery system, more tracking of inmates in segregation, and improvements to the Landlord and Tenant Board.

For more information, contact:
Linda Williamson, Director of Communications