COVID-19 Oversight Lapses Lead to Tragedy in Ontario Long-Term Care Homes


When the COVID-19 pandemic struck, the mechanisms of oversight for the Ministry of Long-Term Care substantially faltered, leading to a nearly two-month cessation of on-site inspection of long-term care homes during the initial pandemic wave, as discovered by an investigation initiated by Ontario’s ombudsman.

The investigative report, released on a recent Thursday, examines the Ministry’s inspection-related activities in care homes during the early stages of the global health crisis. Findings revealed that the ministry’s inspections sector halted on-site inspections completely across a seven-week span during the initial wave.

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The oversight process within the city of Hamilton experienced similar issues, with no physical inspections for three consecutive months. The report underlines an oversight system strained pre-pandemic, but one which was found to be entirely unprepared and incapable of handling the additional pressures of COVID-19.

The Ombudsman’s office examined several individual cases, one of which involved a man who lodged four complaints with the Ministry between April 6 and May 5, 2020, raising grave concerns about his mother’s long-term care home. Inspection of these concerns wasn’t carried out until October 2020, long after his mother had succumbed to COVID-19. Tragically, 53 residents lost their lives in this specific care home during the first wave.

Furthermore, the report noted a woman in April 2020 who lodged a complaint about her parents’ under-staffed long-term care home. She reported inadequate care of residents, who weren’t being cleaned, fed or given their medications. While one parent had already died from COVID-19, her other parent was battling the virus. However, a Ministry inspector ‘reassured’ her over phone, after which the case was closed without any follow-up action. This home’s death count during the first wave totaled 33 residents.

The report pointed out that inspectors were prevented from conducting inspections as they were untrained for infection prevention and control, and the Ministry failed to supply personnel with personal protective equipment. Once resumed, inspections were carried out only by inspectors who volunteered for the task, leading to drastically reduced inspection teams across several provincial areas. Rather than on-site investigations, the inspectors relied heavily on self-reporting by homes during the ‘periodic’ phone calls.

Furthermore, after resuming, the inspections saw lenient actions from inspectors even when they discovered legal violations. Care homes were allowed many months to address serious issues, posing significant harm risks to residents. This approach continued even when inspections restarted and serious violations were found, creating a lenient enforcement atmosphere.

When inspections eventually resumed, bureaucratic processes were slow and sluggish. For over two months during the initial wave of infections, the inspections sector refrained from issuing any inspection reports.

SEIU Healthcare, representing 60,000 frontline healthcare workers, commented that the report confirms longstanding knowledge of the lackadaisical efforts made to protect workers during the pandemic. Increased protections for residents and staff remained non-existent and negligent nursing home corporations were hardly penalized for not maintaining safe environments.

During the first wave, defined as the time between January 15, 2020 and August 2, 2020, the inspection hiatus saw the deaths of 720 long-term care residents, bringing the toll close to 2,000 COVID-related deaths in long-term care facilities.

To address the glaring issues uncovered by the investigation, the ombudsman made 76 recommendations, all of which have reportedly been accepted by the ministry. These recommendations stress the need for revisions in legislation to better protect whistleblowers, availability for on-site inspections, clarity surrounding off-site inspections during future pandemic scenarios, and maintaining sufficient staffing levels within the inspections branch. The Ministry is expected to report biannual updates on progress made in implementing these recommendations.

Critics react strongly to the report, suggesting that safeguards intended to protect the seniors failed entirely, and that inspectors were ineffective in holding the care homes accountable, resulting in preventable deaths.

Dubé emphasized the importance of learning from this tragedy to prevent future recurrences. The report concluded with the sobering reminder that the next pandemic may be more fatal, urging the need for stronger oversight and effective preparedness.