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OCC Geriatric and Long-Term Care Report Dec 2013

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Publications & Reports

2012 Annual Report of the Geriatric and Long-Term Care Review Committee

Print version, PDF – 1.98 MB

Message from the Chair
Executive Summary

Committee Membership

Chapter One: Introduction

Chapter Two: Analysis of cases and recommendations (2004-2012)

Chapter Three: 2012 Case Review Summary

Chapter Four: Case Reviews - 2012





















Chapter Five: Learning from GLTCRC Reviews

Message from the Chair

It is my pleasure to present to you the 2012 Annual Report of the Geriatric and Long-Term Care Review Committee. Each year, a small percentage of the deaths of elderly persons investigated by the Office of the Chief Coroner have issues identified by Regional Supervising Coroners who, in turn, bring them to the attention of the committee which has been providing expert reviews and recommendations for over twenty years. Through the publication of its annual report, this information is shared with service providers throughout the province Our role is to provide information to service providers that inform improvements in their processes, with the goal of preventing future deaths in similar circumstances

It is an honour to participate in the work of the Geriatric and Long-Term Care Review Committee and I am grateful for the commitment of its members to the people of Ontario.

I would like to acknowledge Ms. Kathy Kerr, Executive Lead. Without her efforts, the work of the committee and the production of this report would not be possible.

Roger Skinner, MD, CCFP(EM)
Regional Supervising Coroner and
Chair, Geriatric & Long Term Review Committee

Executive Summary

  • The Geriatric and Long Term Care Review Committee (GLTCRC) was established in 1989 and consists of members who are respected practitioners in the fields of geriatrics, gerontology, family medicine, psychiatry, nursing, pharmacology, emergency medicine and services to seniors.
  • In 2012, the GLTCRC reviewed 20 cases, involving 21 deaths and generated 58 recommendations directed toward the prevention of future deaths. Of the 20 cases reviewed, five resulted in no recommendations.
  • Total number of cases reviewed: 20
  • Total number of deaths reviewed: 21
  • Manner of death:
  • Natural 5
  • Accident 11
  • Homicide 3
  • Undetermined 2
  • Suicide 0

* For the purposes of a coroner’s investigation, the finding of “homicide” implies one person causing another person’s death; there is no culpability or responsibility assigned.

  • In 2012, common issues identified by the GLTCRC were:
  • medical and nursing management
  • use of drugs in the elderly
  • communication between healthcare practitioners regarding the elderly
  • the use of restraints in the elderly
  • medical/nursing documentation.

Committee Membership (2011)

Dr. Roger Skinner
Regional Supervising Coroner, Committee Chair

Ms. Kathy Kerr
Executive Lead

Ms. Elaine Akers

Dr. Barbara Clive

Ms. Sheila Driscoll
Ministry of Health and Long-Term Care

Dr. Sid Feldman
Family Physician

Dr. Margaret Found
Family Physician/Coroner

Dr. Heather Gilley

Dr. Barry Goldlist

Dr. Mark Lachmann
Geriatric Psychiatrist

Ms. Margaret Leaver-Power
Registered Dietician

Ms. Anne Stephens
Clinical Nurse Specialist

Chapter One



The GLTCRC was established in 1989 to assist the Office of the Chief Coroner in the investigation and review of deaths of elderly persons and development of recommendations towards the prevention of future similar deaths relating to the provision of services to elderly individuals and/or individuals receiving geriatric and/or long-term care within the province.

Aims and Objectives

The aims and objectives of the GLTCRC are:

  1. To assist coroners in the Province of Ontario with the investigation of deaths involving geriatric and elderly individuals and/or individuals receiving services within long-term care homes and to make recommendations that may prevent future similar deaths.
  2. To provide expert review of the care provided to elderly individuals and/or individuals receiving geriatric and/or long-term care in Ontario.
  3. To produce an annual report that is available to doctors, nurses, healthcare providers and social service agencies, etc. for the purpose of preventing future deaths.
  4. To help identify whether there are systemic issues, problems, gaps, or shortcomings in each case in order to facilitate appropriate recommendations for prevention.
  5. To help identify trends, risk factors, and patterns from the cases reviewed to make recommendations for effective intervention and prevention strategies.
  6. To conduct and promote research where appropriate.
  7. To stimulate educational activities through the recognition of systemic issues or problems and/or:
  • referral to appropriate agencies for action;
  • where appropriate, to inform in the development of protocols with a view to prevention;
  • where appropriate, to disseminate educational information.

Note: The above described objectives and attendant committee activities are subject to limitations imposed by the Coroners Act of Ontario Section 18(2) and the Freedom of Information and Protection of Privacy Act.

Structure and Size

The GLTCRC membership consists of respected practitioners in the fields of geriatrics, gerontology, pharmacology, family medicine, emergency medicine, psychiatry, nursing and services to seniors. The membership is balanced to reflect practical geographical balance and representation from all levels of institutions providing geriatric and long-term care, including teaching centres to the extent possible.

The GLTCRC Chairperson is a Regional Supervising Coroner and/or Deputy Chief Coroner. Executive support is provided by the Executive Lead, Committee Management, Office of the Chief Coroner.

Other individuals with specific expertise may be invited to committee meetings as necessary on a case by case basis (e.g. investigating coroners, Regional Supervising Coroners, police, other specialty practitioners relevant to the facts of the case, etc.).

Membership is reviewed regularly by the Committee Chair and by the Chief Coroner as requested.


Cases are referred to the GLTCRC by a Regional Supervising Coroner when expert or specialized knowledge is needed to further the coroner’s investigation, and/or when there are significant concerns or issues identified by the family, investigating coroner, Regional Supervising Coroner, or other relevant stakeholders. All homicides that occur within a long-term care setting are referred to the committee for review.

At least one member of the committee reviews the information submitted by the Regional Supervising Coroner and then presents the case to the other members. Following committee discussion, a final case report is produced that includes a summary of events, discussion and recommendations (if any) intended to prevent deaths in similar circumstances. The report is sent by the chairperson to the referring Regional Supervising Coroner who may conduct further investigation (if necessary).

When a case presents a potential or real conflict of interest for a committee member, a temporary member may be asked to participate in the review. Alternatively, the committee will review the case in the absence of the member with the conflict.

When a case requires expertise from another discipline, an external expert may be asked to review the case, may attend the meeting, and participate in the discussion and drafting of recommendations, if necessary.


The GLTCRC is advisory in nature and makes recommendations through the chairperson. While the committee’s consensus report is limited by the data provided, efforts are made to obtain all available,relevant information. It is not within the mandate of the committee to re-open other investigations (e.g. criminal proceedings) that may have already taken place.

Information collected and examined by the GLTCRC, as well as its final report, are for the sole purpose of a coroner’s investigation pursuant to section 15(4) of the Coroners Act, R.S.O. 1990 Chapter c.37, as amended.

All information obtained as a result of coroners’ investigations and provided to the GLTCRC is subject to confidentiality and privacy limitations imposed by the Coroners Act of Ontario and the Freedom of Information and Protection of Privacy Act. Unless and until an inquest is called with respect to a specific death or deaths, the confidentiality and privacy interests of the decedents, as well as those involved in the circumstances of the death, will prevail. Accordingly, individual reports, review meetings, and any other documents or reports produced by the GLTCRC, are private and will not be released publicly.

Each committee member has entered into, and is bound by the terms of a confidentiality agreement that recognizes these interests and limitations.

Members of the committee do not give opinions outside the coroners’ system about cases reviewed. In particular, members do not act as experts at civil trials for cases that the GLTCRC has reviewed.

Members do not participate in discussions or prepare reports of clinical cases where they have (or may have) a conflict of interest, or perceived conflict of interest, whether personal or professional.

Medical records, draft and consensus reports and the minutes of committee meetings are confidential documents.

This annual GLTCRC report is intended to provoke thought and stimulate discussion about geriatric and long-term care deaths in Ontario. It contains case summaries which have been redacted to remove identifying information about the decedent, those involved in their care or in the circumstances of their death, and the institution(s) in which care was provided.


One of the primary goals of the GLTCRC is to make recommendations aimed at preventing deaths in similar circumstances. Recommendations are distributed to relevant organizations and agencies through the Chair.

Organizations and agencies are asked to respond to the Executive Lead, GLTCRC on the status of implementation of recommendations within one year of distribution. Similar to recommendations generated through coroners’ inquests, GLTCRC recommendations are not legally binding and there is no obligation for agencies and organizations to implement or respond to them.

Chapter Two

Analysis of cases and recommendations: 2004-2012

Over the years, the GLTCRC has identified specific themes that have consistently emerged. These include issues relating to:

  • Medical and nursing management
  • Communication and documentation
  • Use of drugs in the elderly
  • Use of restraints
  • The acute care and long-term care industry in Ontario, including the Ministry of Health and Long-Term Care (MOHLTC).

Chart One is an analysis of cases (based on area of concern or theme), reviewed by the GLTCRC from 2004-2012. It is recognized that some cases touch on multiple issues and therefore more than one theme or concern may be identified for each case. NB: In this and the charts that follow, the numbers exceed the total number of cases, as many cases involve multiple themes or issues.

Chart One – Number and % of GLTCRC cases based on theme (2004-2012)











# of cases reviewed












Medical / nursing management




















Communication / documentation




















Use of drugs in the elderly




















Determination of capacity and consent for treatment / DNR




















Use of restraints




















Acute and long-term care industry, including MOHLTC





















Chart Two - % of GLTCRC cases based on theme (2004-2012) demonstrates that consistently over the past several years, the majority of cases reviewed by the GLTCRC involved medical and nursing management and/or matters relating to communication and documentation and/or the Long-Term Care industry in general.

Chart Two: % of GLTCRC cases based on theme (2004-2012)

Chart 2: see summary below

Chart Three: % of GLTCRC recommendations based on theme (2004-2012)











# of recommendations












Medical / nursing management




















Communication / documentation




















Use of drugs in the elderly




















Determination of capacity and consent for treatment / DNR




















Use of restraints




















Acute and long-term care industry, including the MOHLTC





















Chart Four - % of GLTCRC recommendations based on theme (2004-2012) demonstrates that consistently over the past several years, the majority of recommendations made by the GLTCRC addressed issues pertaining to medical and nursing management.

Chart Four – % of GLTCRC recommendations based on theme (2004-2011)

Chart 4: see summary below

Summary of Statistical Analysis – GLTCRC reviews 2004-2012

  • Based on cases reviewed by the GLTCRC from 2004-2012, the most common themes have consistently been medical and nursing management, communication and documentation, long-term care, MOHLTC issues and the use of restraints.
  • The focus of recommendations generated by the GLTCRC from 2004-2012 is generally reflective of the themes of the cases. Consistently over the past several years, the majority of recommendations made by the GLTCRC addressed issues pertaining to medical and nursing management and/or matters regarding communication/documentation.

Chapter Three

2012 Case Review Summary

In 2012, the GLTCRC reviewed a total of 20 coroners’ cases involving 21 deaths, involving the elderly, including residents of long-term care homes. Upon reviewing the cases, the committee generated a total of 58 recommendations aimed at preventing future similar deaths.

These recommendations were 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 were asked to respond to the Office of the Chief Coroner within one year. These organizations were encouraged to self-evaluate the status of implementation of recommendations assigned to them.

Recommendations were also shared with Chief Coroners and Medical Examiners in other Canadian provinces and territories and are available to others upon request.


Major Issue/Theme

Number of Cases


Number of recommendations


Medical / nursing management



Communication and documentation



Use of drugs in the elderly



Use of restraints



Determination of capacity and consent for treatment/DNR



Acute care and long-term care industry,

including the Ministry of Health and Long-Term Care



Note: Some cases had recommendations that touched on a variety of issues or themes and some recommendations touched on multiple themes.


Chart Five: % of recommendations based on area of concern – 2012 case reviews

Chart 5: see summary below

Note: some recommendations touched on more than one issue.

Summary of cases based on Manner of Death – 2012 GLTCRC reviews:

Total number of cases reviewed: 20

Total number of deaths reviewed: 21

Manner of death:

  • Natural 5
  • Accident 11
  • Homicide 3
  • Undetermined 2
  • Suicide 0

Summary of recommendations made by the GLTCRC in 2012:

  • 20 cases were reviewed and 58 recommendations were made.
  • 23 (40%) of the recommendations from 2012 case reviews involved medical/nursing management issues.
  • 16 (28%) of the recommendations involved communication/documentation issues.
  • Four (7%) of the recommendations touched on the use of drugs with the elderly.
  • 13 (22%) of the recommendations touched on issues involving the use of restraints.
  • 10 (17%) of the recommendations involved MOHLTC and/or LTC industry issues.
  • Some of the recommendations touched on more than one issue.
  • Five cases did not have any recommendations.
  • Trends or themes may exist due to a selection bias of cases that are referred to the GLTCRC for discretionary review. More specifically, Regional Supervising Coroners were asked to refer all cases involving the deaths of elderly individuals where restraints may have been a factor, to the GLTCRC. This resulted in an increase of restraint-related reviews and subsequent recommendations.
  • Similarly, trends or themes may exist due to the selection bias of mandatory referrals of homicides in long-term care homes.

Chapter Four

Case Reviews - 2012

The following cases were reviewed by the GLTCRC in 2012. All recommendations have been distributed to agencies and organizations that may be in a position to effect implementation. Agencies and organizations are asked to provide a response within one year of receipt as to the status of implementation.

Case: 2012-01

OCC file: 2011-11941

Date of Death: September 14, 2011
Age: 89 years

Documents for Review

  • Coroner’s Investigation Statement
  • Post mortem report
  • Community Care Access Centre (CCAC) report and medical records
  • Medical records from General Hospital (GH)
  • Family physician records

Reason for Review

The GLTCRC was asked to independently review the circumstances surrounding the death of this 89-year-old man. The hospital medical staff expressed concerns about possible elder abuse and/or care provided by family and the CCAC agencies.


The 89-year-old male decedent was born in Iraq and educated in the United States. He spoke English very well. His medical history included hypertension and diabetes mellitus. His medications included: glicazide, amiloride, indapamide, atorvastatin, nifedipine, perindopril and aspirin.

The family physician notes provided for this review date back to 1999. The decedent was seen by the family physician monthly in 2000. From 2001 to 2005, he was seen one - five times a year. An echocardiogram in 2002 reported borderline concentric left ventricular hypertrophy (LVH) with diastolic dysfunction and moderate mitral regurgitation. A right inguinal hernia was diagnosed in 2004. There was no record that the hernia was repaired. From March 21, 2006 until April 21, 2006 he was admitted to hospital (GH1) for a cerebellar stroke. After the stroke, from 2006 to 2009, he was seen by doctors approximately five – eight times per year. In 2010, he was seen four times.

He was seen in November 2010 and then again in June 2011 when an ulcer was noted on his lower back. His aspirin was stopped due to his fall risk. Records indicated that his creatinine ranged between 95- 169 between 1999 and 2009. His HbA1c ranged from .076 to .095 during this same time period.

On August 23, 2010 a referral was faxed to the CCAC by the family physician for bathing assistance, mobility aids and fall prevention as he was becoming more frail and the family needed assistance. The notes from CCAC indicated that there was difficulty reaching the family due to phone numbers and addresses not being up-to-date. The referral was re-faxed on September 23, 2010. CCAC was able to assess the patient on October 20, 2010. A personal support worker (PSW) provided assistance for one hour per week. On December 7, 2010, CCAC increased the care provided to two hours per week.

In May 2011, the family agreed to look at long-term care, but closed this application process on July 14, 2011 as they wanted to care for the decedent at home. On May 13, 2011 a daily PSW was provided. On May 27, 2011 the PSW reported to the case manager that the decedent had a reddened area on his lower back. A nursing assessment was done on May 30, 2011. The decedent was noted to have a Braden scale score of 16 and a Stage 2 ulcer that measured 1.2 cm square. On July 17, 2011, the ulcer was Stage 2 and was 2 cm by 3.2 cm. On July 18, 2011, three ulcers were reported (no measurements were noted in the records). The next report on August 4, 2011 indicated that the ulcers were healed and that the client (i.e. the decedent), was discharged from nursing care.

The PSW was increased to twice daily visits on Monday to Friday and the family was to help with care on the weekends. On August 11, 2011, the PSW was unable to provide care. The case manager was having difficulty reaching any family member as the phone numbers changed or were not in service. There was also some difficulty with the return of equipment (e.g. the hospital bed) from the family.

On September 2, 2011, there was a meeting in the home involving the family, case manager and occupational therapist. The PSW was providing routine care and on that day, the decedent was noted to have multiple bed sores on all bony prominences. Nursing care was reinstated.

Nursing staff had difficulty reaching family so the decedent was not seen again until September 9, 2011. The nurse found the decedent alone in a dark basement, covered in feces (old and new). There were no other family members present in the house. The decedent was in a contracted position and wanted water. A family member arrived home and was informed that the man needed to be turned every two hours.

On September 12, 2011 the decedent was admitted to GH1 after family members found him unresponsive. Upon admission, the decedent had profound hypovolemia, multiorgan dysfunction and dry gangrenous wounds. His creatinine was 451, urea 56.9 and hemoglobin of 105. His EKG showed atrial fibrillation at 136. He was covered in feces. His legs and arms were contracted and his skin was mottled.

The history given by the family did not match the presentation of the decedent. Another family member arrived at the hospital and questioned why the decedent was so sick. She felt that the decedent was not cared for by the other family members.

The family had agreed to a ‘Do Not Resuscitate’ (DNR) order on admission. When the decedent arrested, the family requested ’a full code’ (i.e. resuscitation). The man was revived, but arrested again and could not be resuscitated.

The Intensivist involved in the care of the decedent requested that a coroner be notified as there were concerns about possible elder abuse and/or neglect. The investigation by the coroner indicated that police had interviewed family members and there were no concerns about the care provided by the family. The Regional Supervising Coroner and the investigating coroner had a meeting with the CCAC to discuss issues regarding the care and services provided to the decedent.

The police report indicated that since 2009, the decedent had lived in the basement of his son and daughter-in-law’s house. Prior to that time, the decedent had lived with his daughter. Another son had not seen the decedent since 2008.

The basement where the decedent lived was found to be tidy and clean and the decedent utilized a hospital bed. The decedent had been able to care for himself until June 2011. He then became confined to his bed in the basement and had to be assisted by family to go to the bathroom and shower. In August 2011, he became bedridden and wore diapers and was bathed in bed.

Post mortem

The decedent weighed 72.6 kilograms and was 162 cm tall. Body habitus noted that he was normally nourished. A 15 cm right groin scar was noted.

Signs of recent injury included:

  1. Circumferential ulcer around glans penis
  2. 2.0 x 3.0 cm area of erythema right mid back
  3. 2.0 x 4.0 cm area of erythema in the sacrum
  4. 8.0 x 10.0 cm area of erythema and decubitus ulceration on the right hip
  5. 8.0 x 10.0 cm area of ulceration on the left lateral hip area
  6. 1.0 x 2.0 cm area of ulceration on the left medial thigh
  7. 1.0 x 2.0 cm hematoma right anterior lower leg
  8. 3.0 x 2.0 cm ulcer on the medial aspect of the right toe.
  9. 1.0 x 1.0 cm ulcer on the lateral aspect of the right malleolus
  10. Diffuse reddish discolouration and swelling of the left lower leg.

Also noted on post mortem:

  1. Mild atherosclerotic coronary artery disease with 60 % stenosis of epicardial vessels;
  2. Severe atherosclerosis of the aorta and large vessels;
  3. Benign prostatic hypertrophy (adenocarcinoma on histology) with dilatation of the urinary bladder with mucosal trabeculation and bilateral hydronephrosis.

The medical cause of death was attributed to septic shock with coliform bacilli (antemortem blood culture report) with the source of sepsis likely being urinary bladder or fecal contamination of the described decubitus ulcers.


This is a case of an 89-year-old man who lived at home with his son and daughter-in-law and their children from June 2009 to September 2011. He was cared for by family and when he required more support, the family physician requested CCAC assistance in August 2010. CCAC had difficulty contacting a family member to arrange the initial visit which eventually took place in October 2010. The decedent was eligible for one hour per week of personal care and this was increased to two hours per week in December 2010.

In May 2011, a PSW noted a reddened area on the decedent, so nursing care was added until August 2011 when the ulcers had healed. At this time, the PSW hours were increased to twice daily visits, five times a week. PSW notes were not provided for this review.

The CCAC had records of multiple phone calls that were made to the family regarding visits and issues with equipment. The phone numbers often changed and the primary contact was not consistent. In September 2011, the PSW noted a bed sore and a nurse was brought into assess once again. The decedent was covered in bed sores, was unclean and was in a contracted position. The decedent was sent to hospital on September 12, 2011 and died on September 14, 2011 from sepsis.

The police investigated the home after the death and found the basement clean and tidy. The coroner’s report indicated that the care provided by CCAC was not optimal and that certain steps should be followed to prevent future similar cases. The care provided by the family and the CCAC was inconsistent in the last months of decedent’s life.


To Community Care Access Centres in Ontario:

  1. Community Care Access Centres should strive to work with family physicians in a collaborative way particularly when there is a transition in care involving patients/clients in common. It is recognized that physicians may need to visit patients/clients at home in order to assess changes in the health status of the patient/client.
  2. Community Care Access Centres are reminded that it is important to document the goals of treatment for the patient/client and to share these goals with other healthcare providers, as well as the family.
  3. Community Care Access Centres should ensure that family are included and made aware of the goals of treatment for the patient/client. The family should know and understand the role they play in supporting the established goals.
  4. When interacting with the family of a patient/client, the Community Care Access Centre should ensure that there is a primary point of contact that is accessible and available for consultation when necessary.
  5. Community Care Access Centres should encourage Personal Support Workers to seek support and/or guidance from a registered health professional when the health status of a patient/client changes. Personal Support Workers may require additional training to recognize changes in health status.
  6. Community Care Access Centres should be aware that different cultures may have different expectations and experiences pertaining to care. These expectations should be discussed with the patient/client and their families when establishing treatment goals.

Case: 2012-02

OCC file: 2011-4118

Date of Death: April 4, 2011
91 years

Reason for Review

The Regional Supervising Coroner referred this case to the GLRCRC as there were concerns about the possible fall of a patient resulting from the use of a mechanical lift during transfer.

Documents Reviewed

  • Referral letter from Regional Supervising Coroner
  • Coroner’s Investigation Statement
  • Post mortem report
  • Documentation from the long-term care home
  • Police reports and photographs
  • Acute care hospital records
  • MOHLTC Inspection Report


The decedent was a 91-year-old female who was admitted to the long-term care home in 2006 with advanced Alzheimer’s disease. As a result of her dementia, she was dependent in all of her activities of daily living (ADLs) and she required a mechanical lift for transfers.

Her past medical history included cardiac dysrhythmia, bilateral mastectomies in 1966 and 1996 for malignancy, cerebrovascular accident and hypercholesterolemia.

Her medications at the time of death included: atorvostatin, ASA, furosemide, potassium chloride, paroxetine, rabeprazole and risperidone.

On March 19, 2011, she appeared well and in good health.

On March 20, 2011, she was washed, dressed and prepared for breakfast. With the assistance of two Personal Support Workers (PSWs), she was transferred from her bed to a wheelchair and taken to the breakfast area.

Later that morning, she was found sitting slumped in her wheelchair in her room. There was a small amount of emesis on the floor next to her. PSW 1 tried to sit her upright, but she slumped forward again. Without any other assistance, PSW 1 transferred the woman back to bed using a mechanical lift.

The woman had her lunch in bed that day. At 1400 hours, the Registered Practical Nurse (RPN) noted that the woman’s right thigh was swollen and bruised. Later that evening, the woman vomited. Upon assessment by the Registered Nurse (RN), the woman’s right leg was significantly more swollen than the left. The woman did not seem to be in distress or discomfort. A note was made for the physician to assess the woman on the next visit.

On March 21, 2011, further bruising and swelling of the right thigh was noted. The woman’s daughter was notified about the swelling later that afternoon.

On March 22, 2011, the Nurse Practitioner (NP) did an assessment and documented the bruising and swelling of the right thigh and suggested the woman be on bed-rest until further assessment by the physician. The NP requested an x-ray of the hip, thigh and knee and suggested Tylenol® as needed for pain.

On March 23, 2011, the physician evaluated the woman and recommended transfer to hospital for assessment of the right leg. The hospital x-rays subsequently showed evidence of a fracture of the distal femur. A Zimmer splint was applied and the woman was returned, with a Foley catheter in place, to the long-term care home via ambulance.

On March 23, 2011 the woman’s daughter notified police regarding a possible assault on her mother at the long-term care home.

On March 24, 2011, the house physician assessed the woman again as there were concerns about possible deep venous thrombosis. The physician expressed frustration that the emergency department had not forwarded any information, including the x-ray reports, physiotherapy instructions or Foley catheter instructions, along with the woman when she was returned back to the facility. The nurse practitioner documented that she would follow-up with the emergency department regarding the transfer of information.

The physician was able to organize a venous doppler to be carried out at the long-term care home. The doppler studies were carried out on the morning of March 25, 2011 and the presence of a deep venous thrombosis was noted. The physician contacted the pharmacist responsible for the long-term care home. The pharmacist advised that because of the woman’s poor renal function, she was not a suitable candidate for the use of low molecular weight heparin. The doctor requested transfer to the acute care facility for assessment and monitoring. The woman was transferred back to the long-term care home on March 25, 2011 with no medication record, blood work or report from the hospital.

The woman’s daughter had been at the acute care hospital all day and told staff that the hospital physician stated that there was no treatment for her mother at this time. Laboratory investigations were eventually faxed to the long-term care home from the emergency department showing sodium elevated at 150, potassium 3.9, chloride 111, HC03 29 and creatinine elevated at 109.

On March 26, 2011, the woman’s daughter changed the advance care directive to comfort measures only. Over the next several days, the woman was cared for in her room. She was alert at times and fed by staff. The Foley catheter remained in place.

On March 28, 2011 the local police service contacted the long-term care home asking to speak to staff regarding the woman’s reported fall. The police carried out a full investigation of the incident, including interviews of staff and physicians. The MOHLTC Compliance Inspector was contacted and advised of the change in resident status and the police involvement.

The woman remained on comfort measures and passed away on April 4, 2011 at 0830 hours.

Post Mortem

Post mortem examination showed that the right femur was fractured in two locations. Note was made of marked osteoporosis. There was evidence of inflammatory response in the area of the fracture indicating the age of the fracture was in the range of days.

There was also evidence of adenocarcinoma, most likely of colonic origin, with involvement of the lung, pancreas and spleen; acute bronchopneumonia; pulmonary thromboembolism with thrombus identified in the vein of the right thigh; findings in the brain of Alzheimer’s disease; cardiovascular changes of hypertension.

Of note, there was no evidence of metastasis of malignant neoplasm to the bone.

The cause of death was given as complications of osteoporosis related femoral fracture.


The decedent was a 91-year-old female who suffered from advanced Alzheimer’s disease and required assistance with all of her activities of daily living. A mechanical lift was necessary to transfer her from bed to wheelchair. She died as a result of complications of a right femoral fracture.

This case involved an in-depth police investigation, as well as a review by an MOHLTC, Compliance Inspector, regarding the care provided to the woman at the long-term care home.

Pathologists involved in the autopsy subsequently answered questions regarding the mechanism of injury. In their response, they indicated that they “were unable to infer or exclude an intentional injury, based on autopsy findings. However the osteoporosis would have made the bones brittle and vulnerable to fracture.” The pathologists stated that they could not “reliably determine the precise date of injury” and that “the osteoporosis would have made her vulnerable to sustain fractures either accidentally or inflicted.” It was felt that the lift device used “could apply a force to the lower extremities that could result in a fracture, since osteoporosis was present.”

The mechanism of injury leading to the right femoral fracture cannot be determined from this review. It is clear that the PSW, in transferring the decedent from wheelchair to bed by herself, did not comply with the long-term care home policy.

It is not clear whether the woman’s injuries were caused by a fall (or if a fall ever occurred), or if the injuries resulted from the simple lifting action combined with her severe osteoporosis.

The safety of mechanical lifts remains an on-going issue and the proper use of these lifts must be reinforced with staff at all times.

The police carried out a full criminal investigation of this case. The PSW involved was initially charged with criminal negligence causing death and failure to provide the necessities of life. These charges were subsequently withdrawn.

The MOHLTC carried out a compliance inspection of the long-term care home one week after the death, on April 11, 2011. The specific goal of the review was to ensure compliance with the Long-Term Care Homes Act.

The MOHLTC found that the long-term care home was non-compliant with the Act as they had not adhered to the decedent’s advanced directive signed on March 1, 2010 which indicated Level 4 care i.e. transfer to acute care with CPR, if needed.

There was no indication that the plan of care was revised when the care needs of the woman changed on March 23, 2011. The MOHLTC Inspector also felt that the MOHLTC was not notified of the change in status related to the critical incident in a timely manner in accordance with the legislation.


No recommendations.

Case: 2012-03

OCC file: 2011-10723

Date of Death: August 30, 2011
71 years

Reason for Review

The decedent was a 71-year-old woman who died of complications of femur and humerus fractures sustained during a transfer from bed to chair at the long-term care home where she resided. A mechanical lift was being used to transfer her. The long-term care home involved has since reviewed the professional practice of the health care staff involved in this incident and completed education with all staff regarding proper use of this particular type of mechanical lift. An MOHLTC Compliance Officer was also involved and completed an investigation. The Regional Supervising Coroner felt that this case should be reviewed by the GLTCRC with a view to developing broader recommendations for the long-term care sector to prevent similar incidents in the future.

Documents Reviewed

  • Coroner’s Investigation Statement
  • Health record of decedent from local acute care general hospital
  • Partial health record of decedent from long-term care home.


The decedent was a 71-year-old woman who was a resident of a long-term care home where she had lived since January 2002. Her medical conditions included:

  • Chronic atrial fibrillation
  • Stroke with dense left hemiparesis
  • Diabetes mellitus
  • Chronic obstructive pulmonary disease (COPD)
  • Seizure disorder
  • Dementia
  • Renal mass – noted on CT scan February 2002, not investigated further
  • Anemia
  • Intermittent vaginal bleeding.
  • Congestive Heart Failure
  • Remote Deep Vein Thrombosis left leg.

Her medications at the long-term care home included: Insulin lispro by sliding scale, amiodarone 400 mg daily, dalteparin, furosemide 40 mg daily, ramipril 2.5 mg daily, digoxin .0625 mg daily, fluticasone 500 mcg/ salmeterol 50 mcg inhaler twice daily, salbutamol inhaler as needed, escitalopram 10 mg daily, valproic acid 500 mg twice daily, and a nutritional supplement.

Functionally, she was fully dependent on the staff. She required two persons to move in bed, dress, bathe and complete personal hygiene. She was able to feed herself with the assistance of one staff member. Transfers were completed with two persons using a mechanical ceiling lift. Her care plan for transfers indicated:

Left side weakness, stiffness and contracted, non-weight bearing. Ceiling lift is being used. Intervention: Two + person physical assist, lifted mechanically with ceiling lift; Total dependence. Full staff performance of activity during entire shift; ….one staff to operate the lift, the other to guide and support safety transfer from bed to chair, vice versa.

On August 21, 2011, the following information was noted in the deceased’s record at the LTCH:

At 1505 PSW D [Personal Support Worker “D”] states that she heard the call bell in R 257. PSW entered room and inquired as to what resident needed. She stated to PSW that she wanted a glass of water. PSW stated that she will transfer her to geri chair so the bed will not get wet. PSW stated that when she attempted to lift resident’s left arm to place in sling, resident began to scream in pain. PSW asked resident what happened she began to cry. As per PSW upon assessing resident left shoulder was swollen and feels hard when touched. Resident screamed off and on in pain. Also complained of pain in the left leg. Tylenol #2 was administered as per RPN for pain, no effect. 911 was called. Resident was transferred to (local acute care general) hospital via stretcher accompanied by three ambulance attendants.

In the emergency department at the hospital, the decedent was found to have two new fractures: an impacted, slightly angulated fracture of the surgical neck of the left humerus, and an obliquely oriented fracture of the left distal femur. This fracture commenced medially within the distal femoral shaft, and extended inferolaterally, likely through the lateral femoral condyle. There was mild angulation.

In discussion with the substitute decision-maker (SDM) for the woman, the decision was made to treat both fractures non-operatively. The left arm was placed in a sling, and a posterior slab applied to the left leg. Follow-up was arranged in the hospital two weeks later. The woman was then returned to the long-term care home.

On arrival at the long-term care home, she had an ice pack placed between her legs, left arm in a sling, and had a temperature of 37.9 C. Her oxygen saturation on room air was 68% - 72%. She was placed on supplemental oxygen at two litres per minute by nasal prongs, and her oxygen saturation improved to 90%. The following day, she was noted to be persistently febrile (temp. 38-39 degrees C), and still requiring oxygen to maintain oxygen saturation greater than 90%. She was sent back to the emergency department of the local acute care general hospital. She was tachypneic (with a respiratory rate of 28), hypoxic on room air and tachycardic (heart rate 114 beats per minute). She was admitted to hospital.

The woman was found to have a urinary tract infection with extended spectrum beta-lactamase (ESBL) producing bacteria. She was drowsy and not swallowing safely and required a modified diet. She was treated with antibiotics, but unfortunately over the ensuing days, she continued to decline and passed away on August 30, 2011.

The Coroner’s Investigation Statement stated that the deceased was being transferred using a “Sit to Stand” lift. The transfer was being done by only one staff member using the left arm. During the attempt to transfer, the decedent fell and sustained the injuries to her left arm and leg. Apparently, this particular type of lift requires that the resident have some ability to stand and bear weight in order to transfer safely. Subsequent to this incident, the long-term care home has reviewed the professional practice of the health care staff involved in this incident, and completed education with all staff regarding proper use of this particular type of mechanical lift. The MOHLTC Compliance Officer was also involved and completed an investigation.

Post Mortem

A post mortem examination was not conducted.


This 71-year-old woman died nine days following injuries sustained when she fell at the long-term care home during a transfer with mechanical lift that was being attempted by only one staff member, rather than the two staff members required to do this safely.


  1. Long-term care homes are reminded of the importance of all staff adhering to the guidelines and care plans for safely transferring residents using mechanical lifts.

Case: 2012-04

OCC file: 2011-5942

Date of Death: May 13, 2011
83 years

Reason for Review

The Regional Supervising Coroner requested review of the use of restraints in this 83- year-old retirement home resident who died when she became entrapped in her bed rail.

Materials Reviewed

  • Coroner’s Investigation Statement
  • Post mortem report
  • Police report
  • Clinical records from the retirement residence


The decedent was an 83-year-old female who was admitted to the retirement residence in November 2005 after transfer from an in-patient rehabilitation unit.

Past medical history included a left hip revision, hip fracture 2005, left knee contracture (despite intensive rehabilitation treatment), spasticity (on baclofen), healed left heel ulcer, rheumatoid arthritis, left hemiparesis secondary to right hemispheric stroke (1975), dyslipidemia, left leg pain due to contracture and patellar pressure, chronic obstructive pulmonary disease (COPD), stress incontinence, history of spinal stenosis, peptic ulcer disease, depression, osteoporosis, esophageal reflux, bullous pemphigoid and chronic peripheral edema. In 2009, it was felt she may have developed diabetes mellitus. Hemoglobin A1C was slightly elevated at 6.5%. It was felt that this may be contributing to her ongoing skin problems. She periodically received treatment with topical antibiotic ointment for recurrent cellulitis.

Rehabilitation discharge notes indicated the functional status as: “assist of one person for transfers, independent wheel chair mobility, assist with personal care.” Notes on admission at the retirement residence indicate that the resident received morning and evening assistance for grooming and dressing. The decedent attended the main dining room for lunch and dinner. It was noted that she required two-person assistance for transfers at night because she was very stiff.

The decedent’s care challenges over the years included recurrent episodes of skin breakdown and recurrent cellulitis related to ongoing incontinence and immobility. She required ongoing monitoring and management of leg ulcers by CCAC nursing. She was referred for assessment by a vascular surgeon in January 2011. She was noted to have areas of redness on the lower leg consistent with cellulitis. The decedent suffered from urinary incontinence and long-standing episodes of loose stools, often requiring management with loperimide. She would often become quite acutely confused with episodes of cellulitis. Mental status testing in 2009 showed MMSE 26/30 with 3/3 recall. The decedent was known to consume alcohol and over-the-counter medications, including acetaminophen. Staff met on several occasions with the decedent’s family to discuss their concerns about the woman’s consumption of alcohol and other medications.

Care challenges also included multiple falls. Even within the first month of admission, she was found on the floor. These falls usually occurred as a result of trying to transfer independently to the toilet, slipping out of her wheelchair and on one occasion in 2008, rolling out of bed onto the floor. The decedent would require two-to-three person assistance or a mechanical lift, to be placed back in bed.

Care challenges also included demanding behavior. The decedent would frequently call staff to her room, even urgently using her emergency call bell, just to have a pen picked up off the floor.

Progress notes leading up to the day of death were last made on April 17, 2011 when the decedent was found sitting on the floor by her bed at 2310 hours. She was confused and stated that she wanted to get back up. She was put back to bed with a mechanical lift with the assistance of two people. On May 10, 2011, she had an episode of screaming. There were scratches noted on her face.

On May 13, the night of her death, the decedent called for a drink at about 0100 hours and was given a drink of ginger ale. She was in bed and seemed well. At about 0300 hours, a staff person came into the room and found the decedent trapped between the bedrail and mattress. Emergency Medical Services (EMS) were called and resuscitation was initiated. When it was determined that the woman had a ‘Do Not Resuscitate’ order, resuscitation attempts were discontinued.

At the time of her death, the decedent was on the following medications: alendronate 70 mg by mouth weekly; ASA 81mg by mouth once a day; duloxetine 30mg by mouth once a day; darifenacin hydrobromide 7.5 mg by mouth once a day; furosemide 40mg 2 tabs by mouth every morning; ramapril 2.5 mg by mouth once a day; L-thyroxine 0.088 mg by mouth once a day; vitamin D 1000 IU once a day; acetaminophen 325 by mouth four times a day scheduled; baclofen 20 mg 3 tabs by mouth three times a day; Advair 250 1 puff twice a day; calcium carbonate 1250 mg by mouth daily; trazodone 50mg by mouth four by mouth every night at bedtime; hydromorphone 1 mg by mouth every night at bedtime; simvastin 20 mg by mouth every night at bedtime; Tylenol® 3 as needed; hydrocortisone to lower legs with dressing.

Post Mortem

The post mortem examination revealed an area of abrasion from the left ear to jaw line associated with swelling, and blood was present in the left ear canal. There was a bruise on the temporo-parietal scalp and a bruise on the dorsum of the left hand. Examination of the coronary arteries showed severe atheromatous narrowing of several arteries with greater than 80% stenosis. There were no acute infarcts. Toxicology report was negative for all substances including hydromorphone, codeine and alcohol.

Cause of death: positional asphyxia with coronary artery atheroma as a contributing factor.


The decedent was an 83-year-old resident of a retirement home. She had suffered a previous stroke leading to a hemiparesis. She also had significant leg contractures from multiple hip operations leading to immobility. She required two-person assistance or a mechanical lift for transfers and mobilized with a wheelchair. There was a well recognized history of multiple falls. She also had ongoing challenges with recurrent skin breakdown and infections which at times led to an acute confusional state. Fall prevention strategies included a short bed rail as well as night checks. On the night of her death, the decedent was not seen for two hours prior to being found trapped in the bed rail. It is unclear what other alternative prevention strategies were in place, including the use of a bed alarm or low bed. It is not clear whether this equipment would have been available in a retirement home setting. Although the Care Plan indicated “night check” it is not clear how often the resident was to be checked on a scheduled basis while in bed.

It is not clear from the care plan if the bed rail was used as a Personal Assistance Services Device or a restraint. Alternatives to the bed rail, if used as a restraint, were not documented in the resident’s care plan. Bed rails place residents at risk of bed entrapment. Factors contributing to entrapment include mattress compressibility, lateral shift of the mattress or rail and the degree of play from loosened rails.

The decedent was also receiving numerous medications at bed time that may have contributed further to nighttime confusion.

Caregivers are reminded that a bed rail is a form of restraint and is not without risk. Fall prevention strategies need to be discussed and well documented. Supervision of residents in restraints needs to be consistent with the resident’s care needs no matter what the setting.


To the Ministry of Health and Long-term Care, Ontario Association of Long-term Care Homes and the Ontario Association of Long-term Care Physicians and Ontario Retirement Communities Association:

  1. Long-term care providers are reminded that positional asphyxia is a real risk with any type of restraint. All acute care and long-term care facilities, both licensed and unlicensed, should have a detailed policy regarding the use of restraints (chemical and physical, including bed side rails). All staff caring for patients should review these policies (i.e. inservices) on a regular basis. New staff should be oriented to these policies prior to commencing patient contact. These policies should include detailed instruction on the various types of restraints, their application, and ways to maximize safety. These policies should be consistent with the Long Term Care Homes and Retirement Homes Acts.
  2. Fall prevention strategies need to be discussed and well documented. Risks associated with the use of restraints should be well understood, and the risks and benefits should be discussed with the patient or the substitute decision-maker. Staff should be educated on these risks and their remediation. Supervision of residents needs to be consistent with the resident’s care needs, no matter what the setting.
  3. Health care professionals should be reminded of the importance of documenting alternative strategies considered and attempted prior to the usage of restraints.
  4. Health care professionals should be reminded that the use of restraints to prevent injuries should only be used after all other fall prevention strategies have been utilized and deemed to be ineffective.
  5. Health care professionals and institutions providing care to the elderly should ensure that the policies and procedures for the use of restraints are in compliance with the provincial legislation Bill 85 – “An Act to minimize the use of restraints on patients in hospitals and on patients of facilities” and the Long-Term Care Homes Act, Ontario Regulation 79/10.
  6. Health care professionals and institutions providing care to the elderly should ensure that policies and procedures pertaining to hospital beds are consistent with the Health Canada Guidance Document entitled: “Adult Hospital Beds: Patient Entrapment Hazards, Side Rail Latching Reliability, and Other Hazards” (March 17, 2008) (available online at:

Case: 2012-05

OCC file: 2010-12069

Date of Death: September 24, 2010
75 years

Documents for Review

  • Referral letter
  • Coroner’s Investigation Statement
  • Post mortem report
  • Police reports
  • Medical records from long-term care home

Reason for Review

The GLTCRC was asked to independently review the circumstances surrounding the death of this 75-year-old long-term care home resident who died as a result of entrapment in a wheelchair restraint.


The decedent’s past medical history included: dementia, stroke, alcoholism, type I diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD) and depression.

As of September 2010, the decedent was on the following medications:

  1. galantamine hydrobromide 8 mg daily
  2. mirtazapine 15 mg every night at bedtime for sleep and irritability
  3. enteric coated acetylsalicylic acid 325 mg on Monday and Thursdays
  4. Novolin ® 30/70
  5. ramipril 10 mg daily
  6. risperidone .75 mg every night at bedtime
  7. trazadone 175 mg by mouth every night at bedtime plus 25 mg every four hours as needed for agitation or insomnia.

The decedent was admitted to the long-term care home in August 2006 from another long-term care home. His admission weight was 67 kg and his weight in July 2010 was 70 kg. He had a tendency to roam the halls at night. On admission, the decedent was exit-seeking and a room alert was placed in his room. At the time of admission, he was using a cane or walker, but needed constant reminders to use these devices. By September 2007, for the safety of the decedent and other residents, he was occasionally put in a wheelchair or “geri-chair” with a seatbelt.

In February 2009, the decedent had been placed in a wheelchair with a seatbelt for his “safety”. On July 8, 2010, the order for a wheelchair was amended with a restraint system (single point release) that included a buckle which could only be unlocked with the use of a pointed object (like a pen).

The decedent was known to become agitated at night and the first course of intervention was to restrain him in his wheelchair so he could move freely, but be safe from falling. When the decedent was up, everyone was aware as he would wheel around the entire unit being very vocal.

On September 24, 2010, at around 0130 hours, the decedent left his room and walked down the hallway without his briefs on. He was escorted back to his room and new briefs were put on. He was then placed in his wheelchair and the seatbelt was fastened as per normal procedure. The decedent was then left in his wheelchair in his room with the brakes off. This allowed him to move around the unit, stay in his room or move to the back hallway.

The decedent was not checked, repositioned or released from his seatbelt until he was discovered at 0530 hours on September 24, 2010. He was last seen by staff at 0500 hours and then found deceased in his room at 0530 hours.

When the staff entered the decedent’s room, they found him slouched all the way down with the seatbelt underneath his chin. His body was on the floor with just his hand and leg on the chair. The staff member got help and used a pen to undo the seatbelt. The decedent let out a gasp and they thought he was alright, but soon realized he was not. CPR was not started as he had a ‘Do Not Resuscitate’ order. Staff commented that the decedent “slides all the time in his wheelchair.”

The nurse on another unit arrived on the scene and called the coroner. The coroner attended and requested the police attend.

Multiple comments throughout the record commented on aspects of the restraints used on the decedent. These comments included:

February 21, 2007

Physicians orders “seatbelt for safety while in WC and rear locking in tilt WC when extremely agitated for safety as well.”

June 11, 2009

An EMR typed entry from the physician stated, “the rear locking seatbelt arrangement is probably not good for him because he has stopped walking.”

June 11, 2009

Physician orders “no rear-locking seatbelts”

August 2009

On the Quarterly Physician’s Order Review order list it is noted, “seatbelt for safety –(no rear-locking seatbelts) while in WC.”

March 2, 2010

Required cushion covers for wheelchair cushion arrived and in place and working as expected.

May 20, 2010

Front locking pen release applied to decedent since resident is able to undo belt and ++ risk of injuring himself from falling.

July 8, 2010

The attending physician wrote “front pen release seat belt for safety please- clarification.”

August 11, 2010

Decedent required supervision of staff while ambulating due to weak lower extremities and impaired balance. He used a wheelchair and foot propels to get around unit as he is too unsteady while walking.

August 30, 2010

Decedent was observed by the occupational therapist foot propelling the chair on the unit. There was not a cushion cover on the wheelchair cushion with a tendency to slide on the cover.

The facility was aware that new regulations came into effect on July 1, 2010 and that the restraining devices should have been removed from service. On that date, the facility reported that they had 21 similar devices still in use. By the time of the incident involving the decedent on September 24, 2010, seven devices were still in use. All of these devices were subsequently removed by September 28, 2010.

The occupational therapist, whose role was to assist the physiotherapist and provide safe mobility options for residents, reported that the decedent was able to “propel” himself in his chair and was not initially using the seatbelt. Seatbelts (i.e. restraints) cannot (or should not) be removed by residents themselves.

Seat covers help to protect the plastic wrap on the cushions used on wheelchairs. The cover has two strips of Velcro that adhere the cushion to the seat to help prevent sliding. Cushions are custom made to fit to the resident and need to be positioned properly in order to be effective and safe.

The cushion on the decedent’s wheelchair was placed backwards. A temporary cover was used because the appropriate cover had not yet been delivered. As a result, the cushion and temporary cover were both positioned incorrectly.

Post Mortem

A post mortem examination revealed:

The conjunctivae contained multiple petechiae. There were florid facial petechiae. There was an area of indentation under the right side of the chin 4 X 1 cm. No bruising of strap muscles was identified and the hyoid bone and laryngeal cartilages were intact.

The description of the scene and the presence of an indentation on the neck and florid petechiae above the level of compression indicate that the medical cause of death was due to neck compression as a consequence of being suspended on the seat belt.


The decedent was a 75-year-old male with dementia. He had been a resident at the long-term care home from 2006 until his death in 2010. He had a habit of wandering the halls and being very vocal, often disrupting other residents.

In 2009, he was put in a wheelchair that he could propel around the facility. The wheelchair had a seatbelt (i.e. restraint), but he was able to remove it. He was known to slip out under the restraints.

In July 2010, the restraint was changed to a device that required another mechanism (such as a pen), in order to open it. Under legislation that took effect on July 1, 2010, the use of these restraints was prohibited in long-term care homes.

The decedent died as a result of neck compression that was caused when he slipped down his wheelchair and his neck got caught on the seatbelt.

An investigation by the MOHLTC Care Compliance Review Committee found the facility to be non-compliant with respect to several aspects of their restraint procedures as mandated by the Long Term Care Homes Act 2007.

The MOHLTC issued Compliance Orders on October 12, 2010 that included:

  1. The Licensee shall not use any prohibited devices that limit movement within the Long-Term Care Home as identified in O.Reg.79/10,8.112, including front pen release seat belt.
  2. The Licensee shall monitor residents that are being restrained by a physical device at least every hour by a member of a registered staff or by another member of staff and release those residents from the physical device and reposition them at least once every two hours
  3. The Licensee shall prepare, submit and implement a plan for achieving compliance to meet the requirements related to the documentation of every use of a physical device as it relates to: consent, person who applied the device and the timing of the application; assessment and monitoring including the resident’s response; every release of the device and all repositioning and the time of removal of the device.

Since September 24, 2010, the facility has met all the requirements of the Long-Term Care Homes Act (2007).


To MOHLTC, Ontario Long-term Care Association and Ontario Long-Term Care Physicians Association:

  1. Long-term care homes should be encouraged to explore alternatives to physical restraints. The risk of physical restraints most often outweighs the benefit. The use of restraints is for treatment of life threatening issues and for short periods of time only.
  2. The MOHLTC, Ontario Long-Term Care Association and Ontario Long-Term Care Physicians Association need to work together to explore the multi-facetted, inter-professional approach to minimize the use of physical restraints as per Long-Term Care Homes Act, Ontario Regulation 79/10 and the Patient Restraints Minimization Act.
  3. Long-term care homes need to appreciate the least restraint legislation and improve their compliance with the goal of being restraint-free.
  4. The quality indicator statistics regarding restraint use in long-term care homes should be made known to the public through HQO/Residents First initiative.

Case: 2012-06

OCC file: 2011-2219

Date of Death: February 18, 2011
87 years

Documents for Review

  • Coroner’s Investigation Statement
  • Health record from family physician
  • Health record from long- term care home
  • Health record from local acute care general hospital

Reason for Review

The decedent died from complications following a hip fracture. The fracture was sustained when she fell onto the floor from a standing position at her long-term care home. There was a suggestion that she had been pushed by another resident just prior to the fall.


The decedent was an 87-year-old woman who was admitted to a long-term care home on November 10, 2010 from a retirement home where she had been living. Due to her dementia, her care needs had progressed to a point where they could no longer be met in the retirement home. It was noted on her CCAC application assessment that she preferred to be alone, and spent long periods of time at the retirement home by herself in her private room. She could be resistive and would sometimes strike out at people caring for her.

The woman’s health history included coronary artery disease with myocardial infarction (1994), congestive heart failure, “senile” dementia, osteoarthritis with remote right total knee arthroplasty, chronic atrial fibrillation, hypertension, squamous cell carcinoma left 5th digit managed with intermittent liquid nitrogen, and a remote breast lumpectomy for cancer.

Her medications at the time of admission to the long-term care home were: donepezil 5 mg daily, furosemide 60 mg twice daily, potassium 20 MEq daily, oxazepam 15 mg daily at bedtime, fosinopril 10 mg twice daily, warfarin 4 mg daily, metoprolol 50 mg twice daily, and digoxin 0.25 mg daily.

When admitted to the facility, the woman was fully assessed by the inter-professional team. She had an increase in her disorientation after the move from the retirement home into the long-term care home and required frequent re-direction to find her room and reminders that this was her new home. Her admission Folstein MMSE score was 12/30. Functionally, she was fully mobile independently and fed herself, but required support for all other activities of daily living and was incontinent. One of the admission nursing notations indicated that the woman became “agitated or physically aggressive when startled or unsure of what is being asked of her.”

The woman had difficulty adjusting to sharing her new semi-private room in the long-term care home. She exhibited territorial behaviours, would frequently shout at her roommate to leave the room and became agitated with the general presence of the roommate. Several times in the first month, staff members had to separate the two roommates as they were shouting at one another. The woman was moved to a new semi-private room, but the same behaviours continued.

On November 17, 2010, nursing notes indicated that the woman was very agitated and continued to demand that the roommate leave “her” room. The woman was under the impression that she and her son owned the place and had lived there for a long time. She made it very clear that she was not happy sharing her room with another person. Nursing staff intervened by explaining to the woman that she had just recently relocated and that the LTCH was her new home. It was also explained to her that there were no private rooms and that she would have to share her space in a semi-private room.

On November 20, 2010, the woman was again very agitated and demanded that the roommate get out of “her” room. Staff once again re-oriented the woman to the long-term care home and explained that she must now share a room.

On November 26, 2010, the attending physician ordered quetiapine 25 mg every six hours as needed for agitation. On December 15, 2010, this was changed to quetiapine 12.5 mg at noon and 1800 hours and on December 29, the quetiapine dose was increased to 25 mg at 0600 and 1200 hours daily, and 25 mg once more each day as needed. The physiotherapist prescribed a walker for balance and stability.

On January 11, 2011, the woman was started on zanamivir (Relenza®) 75 mg once daily due to an outbreak of influenza at the LTCH.

On January 12, 2011, staff heard yelling and shouting coming from the woman’s room. Upon arrival at the room, the staff member (a PSW) reported that she witnessed the woman’s roommate push the woman (i.e. the decedent) who then fell to the floor. The woman immediately complained of pain in her right hip area, and asked the staff member “how did I get here?” She was taken to the local acute care general hospital where an X-ray demonstrated a displaced subcapital fracture of the right hip.

On January 14, 2011, the woman had surgical repair of the hip with a dynamic hip screw. Her post-operative course was complicated by pneumonia (treated with moxifloxacin), a urinary tract infection with E.Coli, and Clostridium difficile bowel infection. She did not do well mobilizing with physiotherapy post-operatively.

On February 3, 2011, she was transferred back to the long-term care home.

The woman continued to decline physically and cognitively after her transfer back to the facility. She had ongoing pain in her hip, did not walk, and her intake of food and fluids declined. She became weaker and her diet was changed to modified texture with thickened liquids. On February 16, 2011, a palliative plan of care was implemented.

On February 18, 2011, the woman died at the long-term care home, 15 days after being released from hospital.

A coroner was not immediately notified about this death. The local coroner came across the information about the death when he was asked to sign the cremation certificate. As there was the possibility that the woman could have been pushed by another resident of the long-term care home, the police were notified.

Upon investigation by police, it was determined that no staff members had actually witnessed the woman being pushed or fall to floor. During the course of the investigation, the roommate who had allegedly pushed the woman, died. The police investigation was terminated. As it could not be determined if the woman fell or was pushed, the manner of death was classified as “undetermined.”

Post Mortem

A post mortem examination was not conducted.


This 87-year-old woman died from complications of a hip fracture. It could not be determined whether the decedent fell spontaneously, or was pushed by another long-term care home resident.

The placement of this private, territorial woman with dementia in a semi-private room may have contributed to her death. It is clear from the records that there were numerous episodes of verbal aggression between the woman and her roommate.

The decedent was on medications that could have increased her risk for a fall (i.e. oxazepam, quetiapine and relenza).


To MOHLTC, Ontario Association of Long-Term Care Physicians and Ontario Association of Long-Term Care Homes and the Canadian Geriatric Society:

  1. Residents with a history of territorial behaviour and aggression - whether physical or verbal - should be considered for location in a private room. This would minimize the chances of escalation of aggressive behaviour.
  2. Health care providers are reminded that neuroleptics and anti-viral medications increase the risk of falls. This risk should always be considered when prescribing these medications.
  3. Health care providers are reminded that all deaths that occur following an occurrence that is non-natural (like a push or a fall), must be reported to a coroner.

Case: 2012-07

OCC file: 2012-462

Date of Death: January 9, 2012
99 years

Documents Reviewed

  • Coroner’s Investigation Statement
  • Correspondence from the decedent’s family
  • Acute care records from hospital admission
  • Long-term care home records.

Reason for Review

The Regional Supervising Coroner referred this case to the GLTCRC after concerns were raised by the family regarding the care provided to their mother, particularly as it pertained to the duration of time between a fall she had in the long-term care home where she lived and transfer to hospital for further medical attention.

The family had specific concerns regarding the nature of the fall and subsequent responses by staff, including decisions made and timing of those decisions.


The decedent was a 99-year-old woman who was admitted to the long-term care home on January 29, 2009. She suffered from a dementia of the Alzheimer’s type for approximately 10 years prior to her death. The woman ambulated with a walker and there were no recent falls recorded on file. She was active in programs at the long-term care home and had a supportive family with whom she communicated daily.

The woman’s past medical history included: Alzheimer’s disease, hypertension, colon cancer with a colectomy (2009), atrial fibrillation, depression, esophageal reflux, fractured wrist, osteoporosis, and scoliosis. She did not smoke or drink.

Medications at the time of hospital transfer were: quinapril 5mg (by mouth, once daily), citalopram 20mg (by mouth, once daily), mirtazapine 30mg (by mouth, once daily), lansoprazole 30mg (by mouth, once daily), l-thyroxine 0.025mg (by mouth, once daily), domperidone 10mg (by mouth, twice daily) and vitamin D 1000U (by mouth, once daily).

At 0545 hours on January 6, 2012, the woman sustained an unwitnessed fall in her room at the long-term care home. A PSW heard a noise and ran to the room. The PSW found the woman lying on the floor on her left side; the woman was complaining of pain in the right groin. The registered nurse on duty immediately came to assess the situation and found that the woman’s right leg did not appear to be shortened or externally rotated and that she was able to weight bear on her legs. The woman was placed back in bed and given Tylenol® for pain relief.

At 0650 hours, the woman ambulated with assistance to the bathroom. Staff noticed that she was dyspneic, so she was returned to her bed and an ambulance was called for transfer to hospital. The woman’s family was contacted and arrived at 0730 hours as the ambulance was preparing for transport to hospital.

The ambulance documentation indicated that the woman complained of right hip/groin pain and had increased pain with movement, but there is no comment about leg rotation or leg length discrepancy. Notes provided by the family indicated that the ambulance attendants reported external rotation and leg length shortening.

Upon arrival at the acute care hospital, the woman’s vital signs were: HR 104/per min and regular, respiratory rate 24, blood pressure 120/74 and O2 saturations were 77% on 5L nasal prong oxygen. The woman’s supplemental oxygen was increased to 50% by face mask with improvement in the O2 saturations to 92%.

Emergency department records indicated that the woman received an IV of normal saline (to keep veins open -TKVO), an appropriate dose of intravenous morphine for comfort, and dimenhydrinate. There was a discussion with the family regarding a ‘Do Not Resuscitate’ order and it was the family’s wishes that CPR, intensive care admission and/or intubation, not be administered.

Records indicated that the woman was examined by a medical student who was covering for the orthopedic service. The note documented a right hip bruise, external rotation and tenderness to palpation; there was no comment on leg length. The student noted that the woman was breathing with “pursed lips” and that a chest examination revealed “vesicular sounds.” Initial plain films of the right hip in the emergency department showed a fracture of the femoral neck with superior subluxation of the femoral shaft; there was no dislocation or angulation.

Further notes from the orthopedic service indicated that there appeared to be a well defined lytic lesion in the femoral neck. Further plain films indicated that “there is a slightly impacted fracture through the sub-capital region of the right hip. No fracture or bone lesion is seen throughout the distal femur. A portion of the fracture margins are not well visualized raising concerns for possible pathological fracture.” A CT scan of the hip was carried out later that day and showed a “comminuted fracture is present in the right femoral neck with evidence of bone destruction, consistent with pathologic fracture. There is anterolateral angulation of the fracture fragments with moderate impaction and superolateral displacement.”

Initial chest x-ray (single view) in the emergency department showed the woman’s lungs to be clear with some increased density and a rounded contour on the right side. Enlargement of the paratracheal region had been present before and was likely vascular in nature; there was an unfolded aortic arch.

Over the next 24 hours, the woman required increasing amounts of oxygen. By January 7, 2012, her O2 saturations were dropping into the 80’s on 50% oxygen by mask. She was placed on high flow oxygen with improvements in saturation. Her respiratory rate was 20-22 per minute and she was treated with IV furosemide. A medical consultation was requested.

A chest x-ray on January 7, 2012 confirmed developing heart failure with “mild increased interstitial markings and upper lobe diversion consistent with mild degree of pulmonary edema.” An Internal Medicine consult diagnosed the woman as having a non-STEMI and congestive heart failure. Despite the fact that she had diuresed one litre of fluid through the night, her respiratory status continued to worsen. The medical team recommended that she was not stable enough for surgery.

By the early hours of January 8, 2012, O2 saturations were dropping on 90% oxygen by face mask and the woman was becoming increasingly congested. Orthopedic notes documented that her troponin had been elevated on admission with initial levels of 0.10ug/L (N<0.03ug/L) on January 6, 2012; creatine kinase (CK) was 283U/L (N <167U/L). Serial troponins dropped to 0.06 and 0.05 and CK improved to 160 by the morning of January 8, 2012.

By January 9, 2012, the woman was not responding to treatment. She had increasing oxygen demands and it was recommended that the palliative care team be asked to see her.

At 1717 hours on January 9, 2012, the woman was found without vital signs.

At the time of her death, the woman was on the following medications:

furosemide 60mg IV (twice daily), acetaminophen (as needed), ASA 81mg (by mouth, once daily), atorvastatin 40mg (by mouth, once daily), bisacodyl 10mg (as needed), Vitamin D 3 1000U (once daily), citalopram 20mg (by mouth, once daily), dalteparin 5000u (subcutaneous, every night at bedtime), dimenhydrinate 25mg (every four hours as needed), docusate sodium 100 mg (by mouth, twice daily), domperidone 10mg (by mouth, twice daily), lactulose (once daily as needed), lansoprazole 30mg (by mouth, once daily), l-thyroxine 0.025mg (by mouth, once daily), milk of magnesia 30ml (by mouth, once daily, as needed), metoclopramide 5-10mg by mouth or IV, every six hours as needed, mirtazapine 30mg (by mouth at bedtime), morphine 2-5mg subcutaneously every three hours, as needed), nitroglycerine patch 0.4mg per hour, ondansetron 4-8mg IV (every eight hours as needed), quinapril 5mg (by mouth, once daily), senna (by mouth at bedtime), sodium phosphate enemas (once daily, as needed), zopiclone 7.5mg (by mouth, at bedtime, as needed), Dilaudid 0.25-0.5 mg (subcutaneously every three hours, as needed).

The coroner was notified as the woman had recently sustained a fall and because there were concerns expressed by the family to hospital staff about the care provided at the long-term care home prior to hospital transfer.

Post Mortem

A post mortem examination was not conducted. The coroner’s investigation concluded:

  • Medical Cause of Death: Congestive heart failure, Myocardial infarction
  • Due to/as a consequence of: Right hip fracture
  • Contributing factors: Dementia


This 99-year-old woman sustained an unwitnessed fall leading to a right hip fracture. Initial nursing assessment did not indicate definite signs of a fracture. The woman was noted to be dyspnoeic while being mobilized to the bathroom and was then transferred to an acute care facility. While in hospital, she was noted to have evidence of a pathologic fracture of the hip as well as worsening congestive heart failure unresponsive to therapy. She was placed on comfort measures under the direction of her family and passed away peacefully.

On initial assessment after the fall, the nurse did not feel there was sufficient evidence to support the presence of a hip fracture. Symptoms of hip fracture may typically include hip pain, swelling, ecchymosis and leg deformity. Significant bruising may not be visible if the fracture is intracapsular. The injured leg will only be shortened and externally rotated if the fracture is displaced. Some patients with minimally impacted fractures may be able to weight bear. It is clear from the initial x-rays in this case that the right hip fracture had only slight impaction and there was no major disruption of the joint.

At the hospital, there was evidence of congestive heart failure with increasing hypoxia, chest congestion and radiologic evidence of pulmonary edema. There was no definite evidence of an acute myocardial infarction. There was no evidence that walking the woman to the toilet on her broken hip precipitated a myocardial infarction. ECGs throughout the hospital admission showed sinus rhythm with premature atrial contractions and non-specific T-wave abnormalities. Cardiac troponin is a highly sensitive test and may become positive even in the absence of thrombotic acute coronary syndrome. The slight elevation of troponin was consistent with the presence of congestive heart failure and renal impairment.

Although the committee questioned the diagnosis of an acute myocardial infarction, it is recognized that mortality is increased, even in non-thrombotic syndromes, when associated with a rise in troponin. This woman was likely developing heart failure over a period of days or weeks prior to her hospitalization. Notes by the medical student and family indicated that the woman had shortness of breath, increasing weight and peripheral edema for several months prior to the fall. The woman’s weight was regularly monitored at the long-term care home and there was no evidence of a significant change over the months preceding her death; in July 2011 she weighed 49.5 kg and in January 2012 she weighed 49.1kg.

It is also recognized that the presence of congestive heart failure may have been a contributing factor to the fall.

With respect to the care and assessments at the long-term care home, the committee is of the opinion that the delay of transfer did not contribute to the outcome. The initial decision not to transfer to hospital was based on the nursing assessment that did not show definitive evidence of a fractured hip. There was no evidence to support concerns by the family that the long-term care home was under pressure to reduce transfers to hospital.

While fall prevention strategies for the elderly are important and worthy initiatives, this woman had a pathologic fracture and her fall likely could not have been prevented even with hands-on assistance while mobilizing and having multiple safety factors in place.

The family of the deceased woman expressed concerns that staff at the long-term care home was not readily communicating and sharing information with them. The family has indicated that they would have appreciated a more thorough discussion in order to better understand the assessment of the fall and of subsequent decisions made. The committee (through recommendation 2 noted below), supports the family’s recommendation that critical incident reviews, including debriefings to families, be conducted by the MOHLTC, as well as long-term care homes.


  1. Healthcare providers are reminded that a hip fracture may be present even in the absence of leg shortening and rotation of the hip. A person may be able to weight bear even in the presence of a fracture. Healthcare providers should, however, have a high index of suspicion for fracture in frail, elderly persons even in the absence of physical findings of definitive fracture.
  2. The MOHLTC and Long-Term Care Facilities should develop a process for critical incident reviews and family debriefing in a blame-free environment to provide improvement in the quality of care in long-term care homes based on learning from incident reviews.


1. Jeremias, A., Gibson, M.. Narrative Review: Alternate Causes for Elevated Cardiac Troponin. Annals of Int. Med. 2005;142(9) 786-791

2. McLaughlin, M.A., Orosz, G.M., Magaziner, J. et al. Preoperative Status and Risk of Complications in Patients with Hip Fracture. Journal of Gen. Int. Med. 2006; 21:219

Case: 2012-08

OCC file: 2012-929

Date of Death: January 22, 2012
: 74 years

Documents for Review

  • Letter from Regional Supervising Coroner
  • Coroner’s Investigation Statement
  • Long-term care home notes (incomplete) from both facilities
  • CCAC assessment for long-term care
  • Adult mental health notes (incomplete)


The decedent was a 74-year-old male who first came to the attention of adult mental health services in 1992 after one of his parents died and he was treated for a psychotic depressive disorder and anxiety. In December 1995 (at age 58 years), he was admitted to an acute care hospital with confusion and auditory hallucinations. The admission note indicated that he had a past history of schizo-affective disorder. He was living alone and driving a car. He was supported by a community work group where staff noted his confusion and referred him to hospital. His medications at that time were: ranitidine 300 mg at bedtime, lorazepam 1 mg every six hours as needed, benztropine 2 mg daily, fluvoxamine 50 mg at bedtime, and propriomazine 50 mg at bedtime. It was felt that poor medication adherence and recent poor nutrition might have been factors in his deterioration. Further hospital records were not available.

The decedent’s next psychiatric assessment was on June 30, 1999 when his main complaint was hearing voices. The voices were in the form of news broadcasts and generally occurred during thunderstorm season (i.e. July, August and September). He stated that he was well during the rest of the year. The psychiatrist felt that the patient may have had some sort of psychotic disorder. At that time, the deceased was on the following medications: haloperidol 2 mg daily, benztropine 2 mg twice a day, and lorazepam .5 mg four times a day. The plan was to taper his haloperidol and re-assess his psychiatric condition.

The next psychiatric note available was from October 3, 2000. The decedent had deteriorated after hearing about a severe thunderstorm, which provoked a short-term increase in his auditory hallucinations. His medications had been increased, and he had improved. At that time, his medications were: olanzapine 10 mg at bedtime, lorazepam 0.5 mg three times a day and 2 mg at bedtime, and oxazepam 30 mg at bedtime. The psychiatrist felt that the decedent had a psychotic disorder and that once this acute episode had settled down, consideration should be given to lowering the amount of benzodiazepines he was taking. There were no further psychiatric notes.

In May 2010, the decedent was admitted to an acute care hospital because of weakness and failure to cope. His discharge note indicated that his diagnosis was schizophrenia and that the major cause of his hospitalization was functional impairment (in particular, not eating well) rather than psychotic features. He had C. difficile infection either in hospital or just before, as this was mentioned in his CCAC application for long-term care. His CCAC assessment in June 2010 noted normal gait and balance and occasional incontinence, but he was otherwise independent in his basic activities of daily living. A depression screen revealed a score of 2/14, indicating minimal depressive symptoms.

On June 24, 2010 he was discharged to long-term care home 1. His stay there was uneventful, but he remained on neuroleptic treatment with a dose of olanzapine of 25 mg/day (10 mg twice a day and 5 mg at bedtime). His other medications included furosemide, potassium supplement, iron supplement, lorazepam 0.5 mg every eight hours, risperidone 0.25 mg twice a day, and a bowel protocol.

On June 2, 2011 he was transferred to long-term care home 2 (likely his original first choice). He seemed to settle in quite well, and no behavioural concerns were noted. The patient fell on June 11 and his family took him to hospital where a broken nose was diagnosed. His left arm was painful, but no fractures were detected. He was seen by the attending physician on June 13, 2011, and his olanzapine was decreased to 5 mg twice a day. He was using Tylenol® for his arm pain. On July 4, 2011 his olanzapine was decreased to 2.5 mg twice a day and an MMSE performed July 12, was 22/30.

In mid November 2011, inappropriate behaviour was observed and medication (illegible in the record) was restarted. After November 7, 2011, he received much less lorazepam than previously. He was feeling better by November 25, 2011, but was agitated on November 28 so the dose of olanzapine was increased. By mid-December, he was much better and once again performing his own basic activities of daily living.

On January 2, 2012, physiotherapy was commenced to decrease fall risk and increase mobility. From admission to November 7, his weight was stable, but from November 7, 2011 to January 17, 2012, he lost about 3.2 kg.

Unexpectedly, on January 17, 2012, the deceased rang his call bell at 0645 hours and informed the PSW that he had tried to commit suicide by drinking half a bottle of dandruff shampoo as well as a significant amount of mouthwash. He was upset that it did not work and said “I don’t want to live anymore. Why didn’t it work?” He was assessed by the nurse who in turn, contacted the doctor and the Poison Control Centre. The man was transferred to an acute care hospital. While in the emergency department, he vomited and aspirated. He was admitted for treatment and subsequently died on January 22, 2012.

Post mortem

A post mortem examination was not conducted.

Cause of death was noted to be: aspiration pneumonitis.


This 74-year-old man was receiving a drug commonly administered in long-term care homes (i.e. olanzapine), but for an uncommon indication: a primary psychotic illness. Most long-term care residents are on neuroleptic medications, such as olanzapine, to control the behavioural and psychiatric symptoms of dementia (BPSD). In these cases, the benefit is relatively small, and the risks significant. In such circumstances, a significant fall as this man experienced in June 2011 would appropriately be followed by a concerted attempt to decrease, and if possible discontinue, the offending medication(s). However, the deceased had a true psychotic illness (likely schizophrenia), and the risk versus benefit of neuroleptics in this case was different1, probably favoring maintenance treatment.

There is no evidence on the chart of a psychiatric consultation to help in determining whether the olanzapine should have been tapered and it is impossible to determine whether this was because it was not felt to be necessary, or whether it was because such consultation was not available. It is possible that an expert opinion might have been helpful in this case.


To MOHLTC, Ontario Association of Long Term Care Physicians, Ontario Long-Term Care Association and the Retirement Homes Regulatory Authority :

  1. A multi-disciplinary team approach should be taken to addressing the complex needs of geriatric and long-term care patients/residents. All long-term care homes should have access to expert psychiatric consultation. Such consultation could be helpful for BPSD and other less common psychiatric illnesses.
  2. Health care providers are reminded that neuroleptic treatment strategies depend on the underlying diagnosis. Long-term care physicians need to identify the underlying disorder and document the risks and benefits of treatment.
  3. The increasing number of geriatric patients with primary psychiatric illnesses should be considered in the development of health care provider education programs.


Leucht, S. et al. (2012). Antipsychotic drugs versus placebo for relapse prevention on schizophrenia: a systematic review and meta-analysis. Lancet 2012; 379:2063-71.

Case: 2012-09

OCC file: 2012-1461

Date of Death: January 29, 2012
71 years

Documents for Review

  • Coroner’s Investigation Statement
  • Medical records from hospital
  • Correspondence from family

Reason for Review

The Regional Supervising Coroner requested a review by the GLTCRC as possible issues related to supervision and communication were identified by family of the deceased.


The decedent was a 71-year-old man who lived with his wife in the community. He was admitted to hospital due to falls. His past history included: ischemic stroke (2005), hemorrhagic stroke (2007) with craniotomy (2007), complex partial seizures, hypertension, ischemic heart disease with myocardial infarctions (1986 and 1988), coronary artery bypass graft (1999), left lung injury during bypass surgery, type 2 diabetes, osteoarthritis of his left hip, bilateral knees and shoulders and throat cancer (radio and surgical therapy 2007).

Medications at the time of admission included: furosemide 40 mg daily, amlodipine 5 mg daily, phenytoin (dose unclear), metformin 500 mg twice daily, ramipril 5 mg daily, paroxetine 40 mg daily, metoprolol 12.5 mg twice daily, divalproex 250 mg twice daily and rosuvastatin 10 mg daily.

The man was admitted to hospital on December 29, 2011. He had a history of physical aggression towards his wife and this emergency visit was prompted after he physically assaulted her. She was unable to care for him and brought him to hospital. In the emergency department, he was found to be confused with word-finding difficulty and some disorientation, but he did not appear aggressive. He was admitted to hospital as it did not appear safe to have him return home with his wife.

In psychiatric consultation, he was felt to be suffering from an “organic brain disease on a vascular basis” with significant dementia and frontal lobe-related disinhibition. There was also comment about past, but not current, alcohol use as a contributing factor.

He was transferred to restorative care on January 6, 2012.

Progress notes included a comment that he ‘showered independently” on January 8, 2012.

On January 10, 2012 a call was received from the man’s family reinforcing the wife’s concerns that she felt unsafe with him being returned home and concern about why long-term care papers had not yet been completed. A family conference was planned for the next day (January 11, 2012) to discuss the issues.

An occupational therapist assessed the man’s ability to shower on January 10, 2012. The occupational therapist noted that the man was able to gather his towel and washcloth and turn on the water and regulate temperature. He was able to gather his toiletries and undress and dress following the shower. The man needed some cuing to use his walker. He demonstrated a forward shuffling gait with difficulty controlling speed. He would often leave his walker and ambulate short distances without aids. The occupational therapist indicated that the man managed the shower independently, but required supervision for ambulation. The occupational therapist was to monitor activity of daily living activities.

At the family conference on January 11, 2012, it was decided that it was not safe for the man to return home. There was some consideration of retirement home placement versus long-term care application. The decision was made to explore retirement home placement.

On January 13, 2012, the man fell while walking in the hallway. The fall caused a large hematoma on the back of his head.

On January 18, 2012 a progress note indicated that the man did not want assistance with getting washed and dressed. He appeared to be managing well with no direction and his independence was encouraged.

A further note on that date indicated that the man had been “quite calm since on restorative care and says he feels ‘better’.” A meeting took place with the man’s wife and the plan for transfer to a long-term care home was confirmed.

On January 19, 2012, the man had a fall while ambulating with his walker. No injuries were noted.

On January 20, 2012, the occupational therapist did another shower assessment. The man was assisted into the shower by the occupational therapist, but then he closed the door to the shower as he did not want assistance. He was able to shower without assistance, but had some difficulty manipulating his walker.

On January 21, 2012, the man’s wife reported to staff that her husband sounded very confused during a telephone conversation she had with him. Staff noted that he had intermittent “periods of confusion” and required support and redirection.

On January 23, 2012, the man showered independently. Later that day, the man’s wife spoke to staff and expressed her concern that “he calls me upset all the time, but won’t tell the nurses. He is talking about guns and thought he was going to jail.” The decedent however, appeared quite settled and was watching TV in bed.

On January 24, 2012, the man complained of abdominal pain. He was given soup and fluids and settled easily.

At 2148 hours on January 24, 2012, the man was found in a distressed state, walking with his walker outstretched in front of him stating, “I’m going to jail. I want to go to the jail.” He tipped over sideways and fell onto his right side. He was given Tylenol® and his usual trazadone dose was administered early. There was a reddened area on the right side of his head.

On January 25, 2012, he showered independently.

On January 27, 2012, a family conference was held and it was decided that it was not safe to return the man home, and the original plan to transfer him to a retirement home was no longer an appropriate option. He was designated as requiring Alternative Level of Care and the long-term care application process was initiated.

On January 28, 2012 at 1400 hours, the man was found lying on this stomach on the floor of the tub/shower. He did not respond verbally and was bleeding from his left eyebrow. His level of consciousness was reduced, so an urgent CT scan of his head was performed. The scan revealed bilateral frontal hematomas and a left parietal hematoma. There was considerable mass effect and a midline shift from right to left.

After a discussion with the man’s family, a decision was made to transfer him to palliative care. A ‘Do Not Resuscitate’ order was obtained and the man was treated palliatively until his death on January 29, 2012.


The decedent suffered from vascular dementia on the basis of multiple strokes. Behavioural issues at home (i.e. physically striking his wife) necessitated hospital admission. As per the Home First Strategy, the healthcare team considered return to home as an option, though notes from the physicians indicated that this was always felt to be a very low probability unless his condition significantly improved while in hospital. The next consideration was a retirement home, but this also proved to be unfeasible and ultimately the man was designated as requiring an Alternative Level of Care and long-term care placement was initiated.

There is documentation acknowledging family concerns and a series of meetings to review the plan of care.

In addition to behavioural issues, the man was prone to falls; multiple falls were documented while he was in hospital. An occupational therapist was regularly involved and attempted to reduce the risk of falls in a reasonable manner. The man’s ability to shower independently was assessed on a number of occasions and it was felt that although there were some risks involved, he valued and expressed his desire for independence in the shower. Although it was acknowledged that he was at some risk due to his unsteady balance, it was reasonable for him to shower independently.

The committee did not identify any serious concerns regarding the care provided.



Case: 2012-10

OCC file: 2011-11010

Documents for Review

  • Letter from the Regional Supervising Coroner
  • Coroner’s Investigation Statement
  • Post mortem report
  • Nursing home records
  • Police report

Reason for Review

The GLTCRC was asked to review the circumstances surrounding the death of this 87-year-old woman who died as the result of injuries received following an assault by another resident in a licensed long-term care home.


The woman was admitted to the long-term care home on March 27, 2011. Her admitting diagnoses included advanced dementia, ischemic heart disease and congestive heart failure.

The woman was on the following medications: lorazepam 1 mg (daily as needed); carvedilol 25 mg (twice daily); multivitamin (daily); enalapril 10 mg (daily); furosemide 20 mg (daily); nitro spray .4 mg (sublingual as needed); risperidone .25 mg (daily); potassium chloride 8 mEq (daily).

At the time of admission, the woman was using a walker to ambulate and required some assistance with her activities of daily living. She did not understand why she was admitted to the facility; she did not feel she had any health issues and wanted to go home. Sometimes she would refuse care by staff.

The woman had several falls prior to her admission to the long-term care home. It was noted by her physiotherapist that she would fall when she tried to pull herself up onto the rollator walker with the brakes off. On April 6, 2011 she had a witnessed fall and did not sustain any injuries. Two more falls were recorded on May 8, 2011 and June 7, 2011. Each time, the woman stated that she had lost her balance. Her blood pressure was approximately 110/60 after each fall.

On April 1, 2011, the woman was seen scratching a male resident, so she was redirected. On April 5, 2011, the family requested that the woman be transferred to another unit as she was expressing fear of the male residents. On May 11, 2011, a male resident wandered into the woman’s room and climbed into her bed. The male was removed and the woman would not settle for the rest of the night. On May 15, 2011, she spent the night wandering in and out of other residents’ rooms.

On August 4, 2011, she was transferred from a mixed ward to a female-only ward.

On August 31, 2011, at 2000 hours, the woman was ambulating using her walker in the hallway. Staff witnessed her stop to talk to another resident and during the conversation, she was pushed. The woman fell, striking her head on the wall and hitting her hip on the railing. She remained on the floor with a shortened and externally rotated left hip. The physician at the long-term care home ordered that the woman be transferred to hospital for assessment. The woman’s family reported the August 31, 2011 assault to police.

The woman was admitted to the local hospital on August 31, 2011 and had a surgical repair of the fractured hip on September 2, 2011. She suffered perioperative hypotension and elevated troponins and was thought to have had a myocardial infarction.

The woman died on September 4, 2011.

The resident who pushed the woman was another female resident, aged 70 years. She had been admitted to the long-term care home in 2009 and her medical history included dementia with paranoid episodes, multiple falls and hypothyroidism. She was ambulatory and her medications included: rivastigmine, mirtazipine, risperadol and rabeprazole.

January 17, 2011 was the first recorded incident of the 70-year-old female pushing another resident. Her family arranged for an outside agency to sit with her for an hour twice weekly, which seemed to help settle the woman. On April 7, 2011, she passed the same resident she had pushed earlier in the year, and made that resident angry. The woman was redirected. On May 13 and 15, 2011, the woman pushed two different residents to the floor.

Reports were submitted for these incidents, as well as times when the woman hurt staff members who were helping her with activities of daily living. The woman was given quetiapine as needed. The quetiapine was helpful on some occasions, but at other times, she became more agitated.

Post Mortem

Cause of death was severe coronary artery disease with evidence of congestive heart failure as a complication. The hip fracture was considered a significant contributing factor due to the trauma and major surgery.

Manner of death was homicide.


This is the case of an 87-year-old severely demented woman who was pushed by another resident and fractured her hip from the fall. She had peri-operative hypotension and elevated troponins and died two days post-operatively, on September 4, 2011.

The resident that pushed the decedent was subsequently seen by psychiatry on September 12, 2011 and admitted to a behavioural unit on September 19, 2011. She returned to the long-term care home on November 1, 2011.


To MOHLTC and the Ontario Association of Long-Term Care Physicians:

  1. Long-term care home residents who are assessed as a danger to other residents should be given priority to receive timely intervention, including admission to a behavioural unit as appropriate, to optimize the behaviour of the resident.
  2. Long-term care homes are reminded that if a resident is assaulted by another resident and sustains injuries that may constitute a criminal offence, the assault should be reported to the local police.
  3. Committee comments: Refer to the June 13, 2012 memo from the MOHLTC “Information Package: Licensee Reporting of Resident Abuse” found at:  This package includes “decision trees” to guide the LTC home licensee and staff when responding to the various types of abuse and neglect. 
  4. Long-term care homes are reminded of the MOHLTC’s High Intensity Needs Funding program, and the availability for supplemental staffing and preferred accommodation for residents with severe behavioural issues.   
  5. Long-term care homes are reminded to contact their Local Health Integration Network for assistance and information about behavioural support programs and training available in their community. Information on Behavioural Supports Ontario can be found at:

Case: 2012-11

OCC file: 2012-1105

Date of Death: January 29, 2012
97 years

Reason for Review

The decedent was a 97-year-old woman who died from injuries sustained after being pushed by another resident of the long-term care home where she resided.

Records Reviewed

  • Coroner’s Investigation Statement
  • Acute care hospital records
  • Police report
  • LTCH records


The decedent was a 97-year-old widow who was admitted to the long-term care home on June 13, 2011. She suffered from advanced dementia, hypothyroidism, diverticulosis, rheumatoid arthritis, diabetes mellitus, depression and a left leg ulcer.

On December 13, 2011, a physiotherapy assessment noted that the woman had no recent history of falls and that she had unsteady sitting balance and required assistance or support to stand. She was able to ambulate independently with a four-wheeled walker. She participated in gait, balance and strengthening exercises with the physiotherapist or physiotherapy assistant several times per week.

On January 14, 2012, the woman was entering the dining room with her walker. The doorway of the dining room was described as being six feet wide with ample room for two people to pass. A male resident approached the woman from behind and there was an exchange of words. The male resident then pushed the woman’s shoulders and she fell to the ground, hitting her head and left arm. Staff at the long-term care home arranged for the woman to be transported to hospital.

Medications at the time of transfer were: citalopram 40mg (by mouth once daily), furosemide 40mg (by mouth once daily) galantamine ER 24mg (by mouth once daily), Peg-Lyte 15mg (by mouth once daily), levothyroxine 0.125 mg (by mouth once daily), vitamin B12 500mcg (by mouth once daily), risperidone 0.5mg (by mouth twice daily on a scheduled basis), acetaminophen 325 mg (by mouth twice daily scheduled), Tylenol 3® one tablet (by mouth three times daily) and two tablets (by mouth at 1800 hours scheduled), Senokot® two tablets (by mouth every night at bedtime), cephalexin 500mg (by mouth four times daily for three weeks started January 10, 2012 for leg ulcer), hydrocortisone 10% urea to the legs (twice a day) and dressing change every three days to the left leg wound.

On arrival at the emergency department, the woman complained of pain in the left shoulder and left knee. Her vital signs were stable and she was treated with IV normal saline, morphine and Gravol®. X-rays revealed that her left shoulder had a subcapital, comminuted fracture-dislocation of the humerus and her left knee showed a minimally displaced, transverse fracture through the patella.

Later that evening, there was an attempt to reduce the shoulder dislocation under sedation with fentanyl 25 mcg and propofol 25mg IV. The reduction was unsuccessful. The decedent was seen in consultation by orthopedic surgery. Notes indicated that there were discussions with the woman’s family about her end-stage dementia and how she was unlikely to recover to her baseline. The surgeon explained to the family that closed reduction had been attempted and that even with the full reduction of the shoulder-dislocation, the woman would require three to four weeks in a sling and would not be able to ambulate for another four to six weeks due to the patellar fracture. The family requested that comfort measures be provided.

On January 16, 2012 while the woman was still in hospital, her family asked to meet with staff at the long-term care home to discuss the pushing incident and the care that the home would provide if she were to return there for palliative care. The family was reassured in the meeting that palliative care could be provided in the long-term care home and staff discussed a proposed plan to prevent future incidents. The home planned to implement a new “float” PSW in the evenings to provide additional support to the dementia wing. The role of this PSW was to engage the residents in activities in the lounge and to redirect those that had a tendency to interact poorly with others. They also proposed to have a manager on-call in the building every weekend and to have all managers rotate through day, evening and night shifts in order to provide support to staff. Most staff had been Gentle Persuasive Approach (GPA) trained in the spring and a refresher GPA training was planned as there had been turnover in staff.

The decedent returned to the long-term care home on the afternoon of January 18,, 2012. She was placed on a palliative care plan. A family conference was held on January 26, 2012 to outline plans for pain relief, scopolamine, oxygen and hypodermoclysis. Over the next several days, the woman developed chest congestion and a low grade fever.

The woman died on January 29, 2012.

Police were notified on February 17, 2012 when the Regional Supervising Coroner contacted them to investigate whether the pushing incident at the long-term care home contributed to the woman’s death.

The resident that pushed the woman was an 81-year-old male that was admitted to the specialized secure dementia wing of the long-term care home after being transferred from a regional psychiatric facility on June 4, 2011. Police interviews with LTCH staff indicated that the male was, “very challenging to deal with when he first arrived but has since improved with the help of medication.”

Post Mortem

Medical Cause of Death: Pneumonia

Due to/as a consequence of: Fractured humerus and fractured patella as a result of a fall

Contributing factors: Dementia

Manner of Death: Homicide


The 97-year-old decedent and the 81-year-old male who pushed her, were residents of a long-term care ward secure ward designed to meet the needs of residents with dementia. The unit was secured with an electronic pass-code to enter and exit.

The decedent was knocked to the ground when she attempted to enter the dining room through a doorway at the same time as the male resident. The decedent suffered injuries as a result of her fall that contributed to her death. Although records are limited on the male, it appears that he also suffered from advanced dementia and had previous behaviours that were under control with medications.

The GLTCRC is supportive of plans by the long-term care home to increase PSW support in the ‘responsive behavior unit’ particularly in the lounge area where the residents may interact; and to retrain staff and have managers available on all shifts to provide necessary support.


No recommendations.

Case: 2012-12

OCC file: 2011-10919

Date of Death: September 2, 2011
32 years

Documents for Review

  • Coroner’s Investigation Statement
  • Letter from Regional Supervising Coroner
  • Police sudden death report
  • Post mortem report
  • Laboratory and toxicology report
  • Hospital medical records
  • Community Living – Safety Audit Rights Procedures including bathing showering and swimming policy
  • Investigation Recommendations Summary Report
  • Lawyer’s letter to police from Community Living - May 31, 2012

Reason for Review

The committee was asked to independently review the circumstances surrounding the death of this 32-year-old man who was a resident of a group home for physically and mentally handicapped adults, who died after being left alone in the bathtub.


This is the case of a 32-year-old man who resided in a live-in group home with 24/7 supervision, with three other residents. He was completely dependent on others for his care and was confined to a wheel chair or bed. He had limited arm movement, was unable to support his upper body, and required two person transfer. He could not speak, but blinked his eyes in order to communicate with staff.

The man was active at the group home and participated in volunteer and other activities.

His medical history included:

  • Cerebral palsy
  • History of seizure disorder (last seizure more than 10 years ago)
  • Severe contracture deformities of all extremities
  • Gastric feeding tube (1994, 2009 and 2010) and jejunostomy tube (2009)
  • Low body weight (50 pounds at age 19 when he entered the residence)
  • Recurrent aspiration pneumonia
  • Severe gastroesophageal reflux
  • Laryngectomy (2009)
  • Tracheostomy (2009)
  • Appendectomy
  • Decubitus ulcers
  • Severe osteoporosis
  • Severe kyphoscoliosis
  • Ability to communicate with eyes only

The decedent was on the following medications: baclofen, domperidone, calcium carbonate, vitamin D3, Butylscopolamine, lansoprazole, celecoxib, diazepam, metoclopramide, Isosource® and lactulose. He also had bilateral hand splints.

The group home, often with input from the decedent, developed protocols regarding the care that was to be provided. These protocols included: feeding and medication schedules; hair, teeth and dressing preferences, bathing, positioning, sickness and illness, meals, sleeping, work and household chores, medication, financial arrangements, personal interests and hobbies, and tracheal stoma care. An ‘outcomes’ interview conducted by a worker (with a signed consent by the decedent) was entitled, “my self, my world, my dreams.”

The lifting/transferring protocol stated that if a mechanical lift was unavailable, then a two-person lift was necessary. When the man was in the hot tub, a staff member was to be in the water with him and he was to stay in his sling for support. In the bath, the man was to remain in the sling attached to the lift or be placed in a bath seating system for support at all times.

The sickness and illness protocol dealt with vomiting, signs of dehydration, bowels and fever. The decedent had many services including speech and language pathologists.

Summary of Events

On September 2, 2011 at 0900 hours, PSWs in the group home undressed the man and placed him in his tub sling. The water was turned on and he was lowered into the tub by an overhead lift. As he was placed in, the tub filled with water and the PSWs left the room.

When the worker returned, the man’s position had changed and water had entered the tracheal stoma. The man was without vital signs, so the worker drained the water and removed him from the tub. There were conflicting reports as to whether CPR was started. 9-1-1 was called.

Emergency Medical Services attended the home and transported the man to hospital. He was pronounced dead at 0947 hours on September 2, 2011.

There were no records provided from the workers at the home.

Post Mortem

The decedent weighed 48 kilograms and was 138 cm in height. A permanent tracheostomy site was present in the lower neck. A linear transverse scar was present just above the site. A gastric feeding tube was noted in the left upper quadrant of the abdomen. Multiple scars were noted on the lower abdomen as well as across the right hip and right proximal leg. There were extensive flexure contractures of all joints. Copious pulmonary fluid was noted at the tracheostomy site. The lungs were hyper inflated and touched in the midline. Prominent pulmonary edema was noted. The larynx had been previously resected. Toxicology was non contributory. The pathologist visited the scene and concluded that the water could reach the tracheostomy site if the decedent slipped down in the chair by as little as one - two inches. He stated that if the water level was at the top of the jet circle, it may have been high enough for water to enter the decedent’s stoma and cause a cough response which could cause the decedent to move from the original position.

The cause of death was drowning in a bathtub. The neurological impairment was contributory since the decedent had limited mobility and was not able to extricate himself from the environment.


The group home where this incident occurred retained an external investigator to review the circumstances surrounding the death and to provide recommendations, including policies and training. From this investigation, the group home has implemented programs to prevent future deaths.

The following tools/programs have been implemented:

  • Safety Audit Risk Assessment
  • Bathing protocols
  • Staff training on bathing protocols and sign offs
  • Assessed risk of new equipment
  • Review and assessment of new assistive device equipment
  • Staffing levels
  • Staff training
  • Standardized staff meeting agendas
  • Rights committee
  • Staff communication at shift change
  • Electrical appliances in the bathroom
  • Preventing staff complacency
  • Governance/accountability and board composition

Safety/Risk audit tools have been developed in areas such as: bathing, kitchen and living areas, community, transportation safety, health, financial, abuse and neglect, work and use of the Internet. Staff of the group home received a one-day training and orientation to the Safety/Risk Audit tool.


No new recommendations.

Case: 2012-13

OCC file: 2011-4775

Date of Death: March 23, 2011
85 years

Documents for Review

  • Coroner’s Investigation Statement
  • Acute care hospital notes
  • Long-term care home notes
  • CCAC assessment forms
  • Notes from retirement home


The decedent was an 85-year-old woman who had been living alone in her own home until she was admitted to a retirement home on May 17, 2010.  She had been seen by an experienced specialist in geriatric medicine at the Geriatric Day Hospital in June 2008. Her MMSE was 26/30, but she had functional deficits that led the specialist to make a diagnosis of Alzheimer’s disease.  Several interventions were recommended, but the team was concerned that they would not be followed. 

The next documentation on file was from a home visit done on April 10, 2010, where it was felt that the woman was not competent to live alone and would benefit from a psychogeriatric outreach team visit.  However, she was admitted to a retirement home on May 17, 2010 and the psychogeriatric team suggested that the consult was no longer necessary (as its purpose was to determine safety and competence while living at home), so the consult was cancelled.  Just before admission to the retirement home on May 13, 2010 the woman was re-evaluated at a cardiovascular centre for her hypertension.  Her blood pressure medications at that time were amlodipine 10 mg/day, hydrochlorothiazide 12.5 mg/day, and atenolol 25 mg/day.  It is unclear how compliant she was with this regimen.  She complained of dizziness during this appointment and the recommendation was to perform a CT scan of the head if dizziness persisted.

On admission to the retirement home on May 17, 2010 her diagnoses were Alzheimer’s disease, hypertension, and an aortic valve leak (unclear if this was hemodynamically significant).  Her admission medications were:

  • Amlodipine 10 mg/day
  • Hydrochlorothiazide 12.5 mg/day
  • Atenolol 25 mg/day
  • Possibly quetiapine (as there was an order to hold it two days later)

The woman was unhappy to be in the retirement home and was quite agitated. Lorazepam was ordered for her by phone on an as-needed basis.  She received some lorazepam the next day as she became agitated when her outreach worker came to visit.  Her family arranged for a private sitter.  The next few days, she was intermittently agitated, but easily re-directed and calmed. 

On May 22, 2010 the lorazepam was discontinued and loxapine 5 mg twice a day was prescribed on a regular basis.  This was changed on May 25, 2010 to 5 mg twice a day as needed and 5 mg at bedtime as she was felt to have been over-sedated.


The woman complained of abdominal pain and at the beginning of June, blood work suggested H. pylori infection, so appropriate treatment was initiated.  She seemed to be settling in and the family (who was attentive and involved, but living a significant distance away), started to cut back on the extra care they were providing.  In August, the woman developed peripheral edema, and her amlodipine was replaced with ramipril.  In mid-August, her family was visiting and felt their mother was over-sedated, so the loxapine dose was cut in half to 2.5 mg at 5:00 p.m., and 2.5 mg twice daily as needed. The woman started to wander frequently, and was markedly restless; often not able to sit down for more than a minute at a time.  The loxapine was increased to 2.5 mg twice daily on September 14, 2010 because of the restlessness. 

On September 19, she was very tired and complained of pain in her hip, but there was no witnessed fall that day. The next two days she was very weak and fell three times.  Her family organized extra help and rented a lift for transfers.  On September 22, she was very immobile, was sent to hospital and returned with a diagnosis of a sprained ankle.

On September 23, 2010 the woman was immobile and unable to sit securely.  She was a total assist for feeding. Her family visited and a decision was made not to send her to hospital, but rather to institute palliative treatment. As part of that decision, all of her regular medications were stopped.  By the next day, she started to improve and was considerably better on September 25, so most of her medications were re-started.  On September 26, her loxapine was also re-started.  By September 29, she had returned to the level of functioning she had before her medications were discontinued. 

On October 19, her loxapine was replaced with trazodone.  She continued to wander, but seemed less restless than before.  Over the next six weeks, she continued to wander and had numerous falls.  At the end of November, she deteriorated again and was sent to hospital, where pneumonia was diagnosed and treated.  She was initially given haloperidol which caused agitation and confusion and was then put on risperidone 0.25 mg three times a day, and 0.25 mg rapid dissolve tablets every four hours as needed. It was noted that her blood pressure was not well controlled, so her dose of ramipril was increased from 2.5 mg daily to 10 mg daily. 

On discharge her medications were ramipril 10 mg/day, atenolol 50 mg/day, ASA 81 mg/day, trazodone 50 mg/day, and risperidone 0.25 mg three times a day and 0.25 mg rapid dissolve every four hours as needed. She returned to the retirement home on December 14, 2010, very weak and requiring feeding.  However, by December 19, she was able to get up by herself and then continued to wander and fall on a regular basis for the next three months.  It was noted that her inability to sit still had returned.  She was given a short course of antibiotics for a respiratory infection in mid-January.  At some point, her ramipril dose was decreased to 5 mg daily.

Arrangements were being made for placement in a long-term care home in a city closer to her family. On March 17, 2011 however, she was temporarily sent to a different long-term care home in the city where she already resided. Her medications on admission to this home were ramipril 5 mg/day, atenolol 50 mg/day, ASA 81 mg/day, trazodone 50 mg/day, and risperidone 0.25 mg three times a day and 0.25 mg rapid dissolve every four hours as needed.

At 0730 hours on March 18, 2011, she was found on the floor wedged between the bed and the wall.  She was sent to the hospital where acute on chronic subdural hematomas were found, with midline shift.  After discussion with the woman’s Power of Attorney, a decision to institute palliative care was made.  The emergency department called the long-term care home to ensure that palliative care could be instituted there, and then sent her back.  She died that day.

Post Mortem

A post mortem examination was not conducted.

Cause of death was noted as acute on chronic subdural hematomas.


This case highlights the difficulty in prescribing medications in the elderly.  The episode in September 2010, when the woman dramatically improved after all her regular medications were stopped,  should have served as an indication that her medications were not beneficial and were probably harmful .  Falls in the elderly are an important cause of mortality and morbidity, and in order to manage them, trade offs with the management of other conditions are important. This woman’s dementia clearly was more likely to be a life-shortening diagnosis than her hypertension, and this should have been factored into the management of this complex case.

When the woman was hospitalized in November-December 2010, the attending teams noted her elevated blood pressure measurements and increased her medications, rather than review the case as a whole and manage accordingly.  This occurred in a hospital with a geriatric program, but there was no evidence that it was consulted. The woman’s restlessness (e.g. inability to sit still) started only after the introduction of antipsychotic medications for wandering, for which these drugs are not helpful or indicated.  This likely represented a well known side effect of such medications, namely akathisia. Rather than continuing (and increasing) antipsychotics, the appropriate management would have been to stop them. 

Finally, it seems as though the woman was receiving ASA as secondary prevention for events that were considered to be transient ischemic attacks (TIA’s).  These episodes were more likely to represent drug side effect. If this was the case, the aspirin increased the risks for intracranial bleeding without providing any benefit.

The family and investigating coroner were concerned about the delay in long-term care admission from application in September 2010 to admission in March 2011. This was not felt by the committee to be an unreasonable wait, particularly since the selected facilities were not local.  The care provided in the retirement home was generally at the same level that she would have received in a long-term care home because of the extra help the family had arranged. 

The key element to reducing the falls that this woman was experiencing was not dependent upon where she was residing (e.g retirement home vs. long-term care home).  Focus should have been placed on reducing the risk factors associated with the falls, including consideration of the risks and benefits of various drugs prescribed. 


To MOHLTC, Ontario Association of Long Term Care Physicians, Ontario Long-Term Care Association and the Retirement Homes Regulatory Authority :

  1. Health care providers are reminded that drug prescribing in the elderly requires balancing risks and benefits.  This requires assessing all the co-morbidities an elderly person presents with before aggressively managing a single disorder such as hypertension.
  2. Where specialized geriatric programs exist, health care providers should try to obtain their input into the management of complex older patients.
  3. Health care providers are reminded that falls are an important contributor to morbidity and mortality in the elderly and require a thorough assessment and search for modifiable risk factors1.
  4. Health care providers are encouraged to consider the risks and benefits of the use of neuroleptic medication for the treatment of the behavioural and psychological symptoms of dementia (BPSD).
  5. Pharmacists should be included in the interdisciplinary treatment team in hospitals, long-term care facilities and retirement homes.
  6. Long-term care homes and retirement homes should consider requiring continued professional development (CPD) in the area of geriatrics for physicians providing care in these facilities.

To The College of Physicians and Surgeons of Ontario:

  1. The College should ensure that Continuing Professional Development (CPD) is relevant to a physician’s area of practice.

To the Regional Supervising Coroner:

  1. The Regional Supervising Coroner should recommend that the hospital and the long-term care home complete a quality of care review for this case.

1. Tinetti, M & Kumar, C. (2010). The patient who falls – “It’s always a trade off.” JAMA, Vol. 303, No. 3.

2. Steinman, M. and Hanlon, J. (2010). Managing medications in clinically complex elders – “There’s got to be a happy medium.” JAMA, Vol 304, No. 14.

3. Poyurovsky, M. (2010). Acute antipsychotic-induced akathisia revisited. BJPsych 196, 89-91.

Case: 2012-14

OCC file: 2011-16583

Date of death: October 26, 2011
90 years

Reason for Review

This case was brought to the attention of the local coroner five months after the death. There were concerns raised that the death might have been related to, or caused by, an injury sustained in a fall by the decedent two weeks prior to her death resulting from the behaviour of another resident (Resident A) in the long-term care home. The GLTCRC was asked to comment on the approach taken regarding management of behavioural and psychological symptoms of dementia (BPSD) in this long-term care home as well as the system-wide approach to BPSD.

Records submitted for review

  • Coroner’s Investigation Statement
  • Institutional patient death record (decedent) - October 26, 2011
  • Long-term care home records for the decedent and Resident A
  • Critical Incident Report - October 13, 2011
  • High intensity needs funding submissions for this long-term care home
  • Notes on Resident A from the Behavioural Intervention Response Team (BIRT) from specialized mental health care centre
  • Consultation notes from consulting geriatrician - March 2009 - October 2011
  • Police General Occurrence Report - October 26, 2011



The decedent was a 90-year-old woman who had resided at the long-term care home for seven years. Her past medical history included advanced dementia, lower esophageal stricture with dilatations (most recently in January 2008), hiatus hernia, chronic anemia and osteoarthritis. She had prior fractures of her left wrist (2006) and left maxilla (2008), both after falls. A CT scan of her head in 2009 found generalized cerebral atrophy. She was totally dependent on others for the provision of care for all activities of daily living and was incontinent of bowel and bladder.

In June 2011, a multidisciplinary case conference noted that she only moved her limbs when she was guided through the motions. She also developed contractures of her knees and elbows. She had been drinking and eating well (a minced diet). She would occasionally smile and squeeze the hand of a caregiver.

In August 2011, she required a tilt wheelchair for positioning and to help prevent her from leaning too far forward. She had a Level 1 Advanced Directive indicating no CPR or transfer to hospital. She required a mechanical lift for transfers. Medication at the time of her death included lansoprazole twice daily and acetaminophen as needed.

In the six months prior to her death, she was noted on occasion to have emesis associated with illness (e.g. fever, runny nose, change in stool pattern). She was noted to have vomiting on September 29 and October 3, 2011. She also had loose stools and low-grade fever on September 29, 2011.

(Resident A)

Resident A was an 86-year-old male who lived in the same long-term care home as the decedent. He had lived in the home since 2007 and had a past history of Alzheimer’s Disease (diagnosed at age 75), depression, prostate cancer-in-situ and vitamin B12 deficiency. Behavioural and psychological symptoms of dementia (BPSD) had been present for at least four years prior to the incident involving the decedent. He was widowed in 2010 and was a retired security guard.

Resident A had been seen by a geriatrician at the acute care general hospital in March 2009 and January 2010. At the January 2010 appointment, he appeared to have increasing disinhibition secondary to “progressive frontal lobe damage” and was started on conjugated estrogen 0.625 mg daily and cimetidine 600 mg daily. The cimetidine was discontinued, although it could not be ascertained from the notes provided when this occurred.

In September 2010, the geriatrician found that Resident A continued to decline. In addition to galantamine 24 mg daily, he was started on memantine 20 mg at bedtime. In January 2011, he was found to be increasingly ataxic and the memantine was “not of benefit” so it was discontinued. The geriatrician discharged Resident A from care, noting that environmental modification was the preferred method of treatment.

Resident A’s past behaviour included wandering into other residents’ rooms, inappropriate defecating and urinating, physical aggression and sexually inappropriate behaviour. This included an incident on May 2, 2010 when he was found in his room, naked on top of a female resident. A “red area” was noted on the female resident’s genital region.

Resident A’s behavioural symptoms increased in frequency towards the end of August 2011. This included the following behaviours that were recorded in the long-term care home’s progress notes:



Aug 28, 2011

Grabbed another resident’s ultimate walker and tried to tip her out.

Sept 4, 2011

Tried to tip over another resident’s dresser.

Sept 7, 2011

Punched personal support worker (PSW) during peri-care while being cleaned after fecal soiling.

Sept 8, 2011

Found on top of a female resident, in her bed, hitting her face and yelling “I want my money.” A urinary tract infection was suspected and the resident was treated with oral antibiotics (the urine culture did not demonstrate significant bacteriuria).

Sept 11, 2011

Hiding items under his shirt, moving furniture around on the unit.

Sept 21, 2011

Barricaded a resident into another resident’s room. Grabbing cutlery in dining room. Wouldn’t sit and was hard to redirect. Slapped and shook other residents.

Sept 21-23, 2011

Found in a resident’s room trying to pull her out of bed.

Tried to pull a female resident out of her chair. Wandered into another resident’s room and when asked to leave, he hit the resident with a shoe.

Application was made to the Ministry of Health and Long-Term Care (MOHLTC) for high intensity funding to support 1:1 care. The application was approved.

Sept 25, 27 and 28, 2011

Acts of physical aggression towards staff.

Oct 1, 2011

Wandering in/out of co-residents’ rooms.

Oct 8, 2011

Found naked in a co-resident’s room, sitting on her bed.

The care team responded to this escalating behaviour with a number of assessment and intervention strategies. These included:


Intervention strategy

Sept 23, 2011

Behavioural Intervention Response Team (BIRT) was consulted for “aggressive behaviour/risk of harm.”

Sept 28, 2011

Initial assessment by BIRT.

Sept 29 – Nov 16, 2011.

Several BIRT visits.

Numerous behavioural intervention strategies were suggested and appeared to have been modestly effective (e.g. continued aggressive behaviour and wandering, with decreasing frequency however).

Key behavioural targets were identified (e.g. grabbing, physical aggression during personal care). Appropriate use of monitoring tools was encouraged (e.g. DOS charting, ABC charting of events).

Specific strategies implemented included: timing of personal care (e.g. full care after breakfast and only change incontinent brief before breakfast), consistent approach strategies by all staff (e.g. use a low voice volume, pleasant tone, large smile, remain calm, make eye contact), distraction (e.g. have him look at himself in a mirror during care, have him hold a towel to prevent hitting), stop and re-approach techniques, use of a “rummage box, etc.

Specific education to staff around redirection, validation, reassurance was provided. Mention was made of gentle persuasion, PIECES and Montessori strategies.

Additional interventions included pet therapy and a change to the smaller dining room to decrease stimulation and an alarm being placed on Resident A’s door in order to alert staff when he was in the hallway.

Sept 29 and October 26, 2011

Nurse practitioner visits from acute general hospital.

The attending physician was involved in trying to use pharmacotherapeutic interventions. The progress notes from this institution however, did not include physician notes and no separate physician records could be found in the materials reviewed. There were numerous comments in the progress notes indicating that the attending physician was actively involved in the care of Resident A, was responsive when asked to see the patient, and was actively involved in communication with the power of attorney (POA) for personal care.

Based on notes received for this review, on September 29, 2011, Resident A’s medications included: citalopram 20 mg daily, lansoprazole 30 mg twice daily, B12 IM monthly, calcium 500 mg daily, vitamin D 1000 IU daily, olanzapine 5 mg in the morning and 5 mg twice daily as needed, divalproex 125 mg twice daily. The ‘as needed’ dose of olanzapine was used at least once, and sometimes twice daily, on a number of days during this time period.

Events leading to the Death

On October 12, 2011, there was a ’Fall Note‘ from a registered nurse documenting that a personal support worker had found the decedent on the floor beside her bed at 1920 hours. The note detailed the following:

  • Resident was on her left side with head pressed against the lowered bed rail. Left forehead was open with swelling approximately 4 cm x 2 cm in duration.
  • No other physical injuries were noted.
  • Resident opened eyes to name and assisted back to bed with three assists.
  • Wound cleansed with normal saline and pressure dressing applied. Ice compresses being done at 15 minute intervals. Vital signs were stable.
  • Family notified and advised that they did not want the woman sent to hospital and requested that a nurse practitioner see her. The family was advised that a nurse practitioner was not available at that time. The family indicated that one of their members was a physician and that he would come in and assess the wound.
  • Family arrived at approximately 2020 hours. The family member physician used local freezing prior to suturing the woman’s forehead.
  • The attending physician spoke with the family and advised them that that there was another resident (Resident A) whom he suspected may have been responsible for the woman’s injury.

It was suspected that Resident A may have been responsible for the woman’s injuries because his shoes were found in her room and blood was found on his pajamas. Earlier that evening, Resident A had been seen “coming and going” into rooms.

The family member physician reported to the investigating coroner that the laceration on the woman was deep to the bone, requiring internal and external sutures. Telephone orders were received from the attending physician at 2245 hours for both side rails up at all times and that yellow magnetic barrier tape be placed across the room door at all times. Plain acetaminophen was administered and vital signs were monitored.

A critical incident report was sent to the MOHLTC on October 13, 2011. The report identified that the following immediate actions were taken to prevent recurrence:

  • Investigation of movements of co-residents on the unit and the possibility of co-resident wandering into resident’s room and pulling down side rail
  • resident transferred to another unit in the facility

The investigating coroner raised concerns that the critical incident report did not highlight that Resident A (the suspected perpetrator of the pushing incident), had numerous prior behavioural incidents.

In response to the coroner’s investigation, the status on the critical incident report was amended to “assessed as per current process. Inspection required. Intake [number redacted] completed.”

Clinical Path (decedent)

October 13, 2011, was clinically uneventful for the decedent.

On October 14, some yellow emesis was found on the decedent’s bed by the attending PSW. The resident was able to open her eyes to command. The dressing was found to be “soaked with blood.” The dietician noted increased difficulty with swallowing and some drooling.

On October 20, 2011, a nurse practitioner (part of an outreach team from the local acute general hospital), assessed the woman’s sutures for removal.

On October 25, 2011, it was noted that the woman was not eating or drinking well and she could not be awoken. She had a runny nose and nasal congestion and was afebrile. Other residents in the LTCH had similar symptoms and an outbreak was declared on October 25, 2011. The putative agent was later identified as Rhinovirus. All other residents were reported to have recovered fairly quickly.

On October 26, 2011 at 1305 hours, the woman was found in bed with vital signs absent.

An Institutional Patient Death Record (version 3) was completed and submitted to the MOHLTC. The attending coroner raised concern that in response to the question as to whether this was an accidental death, the long-term care home answered “no.”

Clinical path (Resident A)

The Behavioral Intervention Response Team (BIRT) continued to work with the care team in developing and implementing a behavioural plan. Applications for high intensity funding were submitted to the MOHLTC to support 1:1 care. A submission dated October 13, 2011 commented on the decedent’s fall, that Resident A’s shoes were found in her room and that blood was on his pajamas. The application specifically stated that the long-term care home believed that Resident A, “may have wandered into this female co-resident’s room and pulled her out of bed.”

The investigating coroner has expressed concerns regarding the discrepancy between this submission and critical incident report dated October 13, 2011 which did not indicate any involvement of Resident A in this event.

One-to-one care was provided for Resident A on September 11, 12, 23, 26 and October 13 and 24, 2011.

On October 14, 2011, (two days post ‘fall’ of the decedent), Resident A was transferred to another unit within the facility.

On October 17, 2011, Resident A was transferred to the acute general hospital geriatric unit for further assessment, and an attempt at adjusting his medications. This admission lasted for approximately three – four hours as the acute general hospital was unable to cope with the man’s behaviours, despite the presence of two security guards at his door. Resident A was transferred back to the LTCH with a change in medication from olanzapine to quetiapine at an initial dose of 75 mg twice daily.

The combination of behavioural interventions as recommended by the BIRT and the adjustment in medication, appears to have substantially decreased Resident A’s physical aggression. While incidents were still reported, they decreased in intensity and frequency.

On October 26, 2011, Resident A’s dose of lactulose was decreased from 30 to 15 mL daily and this appears to have helped. As he was incontinent of stool less frequently, staff found it easier to provide personal care when he was less likely to be soiled.

On October 27, 2011, his dose of quetiapine was decreased to 50 mg in the morning and 75 mg at bedtime.

Early in November 2011, his status changed and Resident A became more ataxic and unsteady on his feet. His level of arousal was lower and his appetite decreased. Notes referred to him being “unusually drowsy.”

On November 8, 2011, Resident A punched a staff member in the throat while she was attempting to redirect him. He received 2 mg haloperidol IM.

On November 10, 2011, Resident A fell while walking. His quetiapine was decreased to 25 mg in the morning and 50 mg at bedtime.

On November 11, 2011, Resident A vomited. Staff continued to comment on his decreased responsiveness.

On November 13, 2011, the physician spoke with the Resident A’s POA for personal care regarding his decline in overall status. A decision was made to approach his care in a comfort-directed manner, rather than pursue further investigation and treatment of specific underlying pathology.

For the remaining days of his life, Resident A was given morphine, Gravol, and scopolamine on an as-needed basis, and gradually declined. He was noted to have Cheyne-Stokes breathing on November 20, 2011 and died on November 21, 2011. A post mortem was not performed.

Post Mortem

Post mortem examinations were not conducted on either decedent.


This case highlights some of the challenges of dealing with residents with aggressive behavioural and psychological symptoms of dementia (BPSD) in long-term care and in particular, in developing comprehensive, seamless, responsive systems of care to aid in the care of individuals with BPSD.

The GLTCRC could not determine from this review whether Resident A’s behaviour and the circumstances of the death constituted evidence of a ‘non-accidental action of a person that led to the death of another person’ required for the manner of death to be deemed homicide. It is believed however, that Resident A’s actions might have been a factor in the death. The committee agreed with the coroner determination that the cause and manner of death were undetermined.

Effective BPSD management is multi-faceted 1, 2, 3, 4 and usually, if behaviour is severe, requires non-pharmacological and pharmacologic strategies. In this case, the care team was supported by a knowledgeable behavioural intervention response team and implemented over 20 behavioural responses to deal with Resident A’s persistent and dangerous behavioural symptoms. With the support of the BIRT, the home implemented proper goal-setting, behavioural observation using validated tools, and incorporated comprehensive behavioural strategies including gentle persuasive approach (GPA), PIECES and Montessori approaches.

The facility appropriately asked for help in the form of additional 1:1 care through the High-Intensity Funding mechanism.

Upon review of the circumstances surrounding this death, it was surprising to learn that the psychogeriatric resource consultant (PRC) available to the long-term care home was not involved in supporting the team in managing Resident A. While the role of the PRC is educational, this education can centre on the specific needs of a care team to cope with active behavioural problems.

The level of physical aggression exhibited by Resident A certainly deserved the attention of specialist consultation. The attending physician contacted the geriatrician on October 14, 2011 (two days post ‘fall’ of the decedent) and this prompted a three-hour hospital admission and a change in medication to quetiapine at a high starting dose of 150 mg daily. It is not known why there was no referral to a geriatric psychiatrist. There was also no documentation of follow-up by the geriatric medicine consultant (perhaps due to the decision to change to a palliative approach to care).There may have been ongoing communication between the attending physician and the consulting geriatrician in the weeks between the brief hospital admission and Resident A’s subsequent death, but this was not evident in the materials available for review.

Debate exists in medical literature regarding the efficacy of pharmacotherapeutic interventions for BPSD. Alleviating pain might have some benefit. 3 4 In this case, increased analgesia was not trialed. The anticholinergic properties of olanzapine at higher doses (Resident A received 10-15 mg of olanzapine on some days), may have exacerbated his behavioural problems and contributed to akathisia (including increasing wandering behaviour) and anti-cholinergic delirium. Alternate pharmacotherapeutic strategies may or may not have helped in this difficult situation. It is interesting that Resident A’s behaviour improved significantly when olanzapine was discontinued and quetiapine was initiated. Divalproate may require higher doses to be effective for BPSD, though this comes with increasing potential for adverse reactions as well. All pharmacotherapy for dementia has significant risks and it is noteworthy that Resident A declined in terms of arousal and ultimately died within weeks of the change in his neuroleptic medication, even though his physically aggressive behavioural symptoms improved considerably.

The GLTCRC was concerned that documentation from the long-term care home to the MOHLTC was inconsistent. As identified by the investigating coroner, a critical incident form related to the decedent’s fall did not contain information about Resident A’s possible involvement, but the request for high-intensity funding did. The Institutional Patient Death Record did not identify the decedent’s death as potentially accidental even though the long-term care home, in other documentation, accepted that Resident A’s behaviour could certainly have been a factor in the death.

This case also highlights the importance of a system-wide approach to the management of long-term care residents with BPSD. It is hoped that the Behaviour Support Ontario Strategy (BSO), 5 now in place in all local health integration networks (LHINs), will help provide the seamless integrated system-wide care that is required for these challenging individuals who place themselves and others at significant risk of harm. It is important that each LHIN have a structured mechanism in place to deal with the emergent needs of physically aggressive residents in LTC. The three-hour acute hospital admission and the long waiting time (i.e. months) identified for placement in an inpatient psychiatric bed within this region underscores that simply relying on existing mechanisms is not sufficient.

With the creation of an internal behaviour team, it is expected that the long-term care facility involved in this incident will not need to wait for an external team to provide the same level of response to similar residents.

The long-term care home, through their quality management committee, has identified the facility’s response to BPSD. Behavioural challenges are reviewed at the resident safety committee (although the frequency of such meetings was not noted). Education in gentle persuasive approach (GPA) and PIECES had been provided to staff. As a result of work to date, the frequency of worsened behavioural symptoms had decreased from 18.1 % (Q1 2010) to 9.7% (Q1 2011). Improved behavioural symptoms in the same time period increased from 8.5% to 13.2 %. A psychogeriatric resource consultant is also available to the facility.

Future planned interventions included additional staff training and education, ongoing review of quality statistics and the development of an internal behaviour response team.


To Local Health Integration Networks:

  1. All LHINs should ensure that the Behaviour Support Ontario (BSO) plan for the LHIN includes specific measures to accommodate the urgent/emergent needs of physically aggressive long-term care residents with behavioural and psychological symptoms of dementia (BPSD) in a timely and effective manner.

To MOHLTC, CPSO, CNO, Ontario Long-Term Care Physicians, Ontario Nurses’ Association and all long-term care homes:

  1. All long-term care homes should ensure that documentation is consistent in describing the details of situations involving physical aggression within long-term care homes (e.g. critical incident reporting and requests for high-intensity needs funding should be consistent).
  2. All long-term care homes should ensure that Institutional Patient Death Records are accurate and reflect the situation surrounding the death of individuals within their facilities.
  3. All long-term care homes should continue to provide education to staff in methods of assessing, documenting and managing behavioural and psychological symptoms of dementia (BPSD) including such strategies as gentle persuasive approach (GPA), PIECES and Montessori Methods of Dementia. Physicians who work in long-term care homes should avail themselves of educational opportunities to learn more about the non-pharmacologic and pharmacologic management of BPSD (such as those programs offered through the Ontario Long-Term Care Association, Ontario Long-Term Care Physicians, Ontario College of Family Physicians, College of Family Physicians Canada, etc.)


  1. The MOHLTC should consider linking information received in critical incident reports and high-intensity needs funding requests. This documentation should be reviewed at the time of home compliance assessments.


  1. Conn DK, Gibson MC, Feldman S, Hirst S, Leung S, MacCourt P, McGilton K, Mihic L, Malach FM, Mokry J. National Guidelines for Seniors' Mental Health: The assessment and treatment of mental health issues in long-term care homes (Focus on mood and behaviour symptoms). Canadian Journal of Geriatrics. 9(S2): S59-S64, 2006
  2. Hermann N, Gauthier S. Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease. CMAJ 2008;179(12):1279-1287
  3. Seitz DP, Gill SS, Herrmann N, Brisbin S, Rapoport MJ, et al. Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. International Psychogeriatrics, Available on CJO doi:10.1017/S1041610212001627
  4. Seitz DP, Brisbin S, Herrmann N, Rapoport MJ, Wilson K, et al. Efficacy and feasibility of nonpharmacological interventions for neuropsychiatric symptoms of dementia in long term care: a systematic review. J Am Med Dir Assoc. 2012 Jul;13(6):503-506.e2.
  5. Behavioural Supports Ontario.

Case: 2012-15

OCC file: 2011-15213

Date of Death: December 10, 2011
67 years

Documents for Review

  • Coroner’s Investigation Statement
  • Post mortem report
  • Health record of decedent from acute care general hospital admission November 27- December 10, 2011
  • Letter from Regional Supervising Coroner to GLTCRC

Reason for Referral

The decedent was a 67-year-old man who died two weeks after admission to an acute care hospital. Family of the deceased expressed their concerns to the investigating coroner regarding the care provided at the acute care general hospital.


The decedent was a 67-year-old retired male with four children.

The decedent was admitted to the local acute care general hospital on November 27, 2011 via the emergency department due to confusion, anxiety, insomnia and low back pain. The triage nursing note documented, “c/o anxious feeling + lower back pain x past 3 weeks. Unable to sleep. Family states patient has been more disoriented + has ↑ memory loss over past 2 months + has been progressively worsening. Pt seems to have difficulty answering Qs. Hx. HTN.”

The decedent’s health history at the time of admission included:

  • Alcoholism: Voluntarily attended a residential addiction treatment facility 12 years prior, but had resumed drinking. There was no history of severe withdrawal or cirrhosis.
  • Cannabis usage: Family reported to a mental health nurse that they thought the decedent had run out of cannabis and that perhaps this was the reason for his complaints of insomnia at the time of admission.
  • Major depression and generalized anxiety disorder: Under the active care of a community psychiatrist (x monthly).
  • Obstructive sleep apnea: Utilized Continuous Positive Air Pressure (CPAP) at night during sleep.
  • Hypertension: Seen by family physician in the prior two-three weeks and started on new anti-hypertensive medication (it was not clear from the records which one was new).
  • Hyperlipidemia.
  • Peripheral vascular disease with abdominal aortic aneurysm.
  • Smoker with mild chronic obstructive pulmonary disease (COPD).Treated with puffers.
  • Migraine headaches

Family indicated that the decedent’s psychiatrist was aware that he had been experiencing memory loss in the six months prior to admission to hospital. Also during that time, the man’s family noted deterioration in his self-care and hygiene. The man’s short-term memory was declining and he was forgetting to take his medications and lock his door, and was losing his telephone and keys. He was disoriented as to time and day and was missing appointments and meetings. He forgot the names of members of his extended family and became increasingly dependent on friends and family to remind him of things.

A computed tomography (CT) scan of the decedent’s brain completed in September 2011 (three months prior to death) demonstrated, “minute periventricular white matter hypoattenuation. Small hypodensity in the left superior cerebellar hemisphere representing an old infarct or possibly CVA. FINDINGS: No change [committee note: from a prior scan in 2006], no specific correlate to the given history.”

At the time of admission to hospital, the man was on the following medications: aripiprazole 5 mg daily; venlafaxine XR 112.5 mg daily; lithium carbonate 600 mg daily; zopiclone 7.5 mg nightly; fluticasone inhaler 250 mcg puff twice daily; salbutamol inhaler 200 mcg as needed; indapamide 2.5 mg daily; irbesartan 300 mg daily; nifedipine XL 60 mg daily and propranolol 80 mg twice daily.

Upon admission to the emergency department on November 27, 2011, blood work showed an ethanol level of 22.5 mmol/l and the presence of cannabanoids. Lithium level was therapeutic at 0.6 mmol/L, potassium was 2.5 mmol/L, BUN elevated at 8.4 mmol/L, creatinine 97 umol/L and liver enzymes were normal. The man’s level of consciousness and attentiveness was fluctuating, from alert and anxious to somnolent and unable to respond well verbally. He was noted by the emergency department physician to be “agitated but cooperative.” During his emergency department stay, the man was restless at times and made several attempts to climb over the side rails of his stretcher. He was placed in a “Geri-chair” and was successful in breaking out of wrist restraints, climbing out of the chair and falling on the floor. He sustained no injuries from the fall.

The ED physician interpreted the chest x-ray as showing a right lower lobe infiltrate, and the subsequent radiologist report of the study documented, “slight crowding of markings at right lung base likely from poor inspiratory effort although early pneumonia is not totally excluded.” A CT scan of the brain showed “stable mild cortical atrophy and mild chronic small vessel ischemic change, stable left superior cerebellar hemisphere hypodensity.” Treatment for alcohol withdrawal was initiated using the “Clinical Institute Withdrawal Assessment - Adult Revised (CIWA-Ar)” to guide medication use. Intravenous fluids were started and treatment for pneumonia was initiated using moxifloxacin. He was admitted under the care of his usual family physician and initially, his regular medications were held.

Over the first several days, his condition gradually improved. The biggest clinical management challenge was his ongoing confusion, fluctuating level of consciousness and intermittent restlessness and agitation. He was given thiamine and he received a total of 110 mg of diazepam for his alcohol withdrawal symptoms during his first two days in hospital. His agitation was managed with a combination of neuroleptics, beginning after discontinuation of the diazepam, as follows:





Nov 29, 2011

Dec 1, 2011

Dec 2, 2011

Dec 3, 2011

Dec 4, 2011

2.5 mg daily

2.5 mg daily

5 mg daily

2.5 mg daily

2.5 mg daily


Nov 29 through

Dec 7, 2011

25 mg every evening at bedtime


Nov 30, 2011

Dec 1, 2011

Dec 2, 2011

Dec 3, 2011

Dec 4, 2011

.5 mg three times a day, as needed (TID PRN)

.5 mg TID PRN

1.5 mg TID PRN

2 mg TID PRN

1 mg TID PRN


Nov 30 through

Dec 8, 2011

5 mg every morning

The decedent’s anti-hypertensives were gradually re-introduced. On November 29, 2011, irbesartan was restarted (Creatinine 84), along with a nicotine patch to manage smoking withdrawal symptoms. On November 30, the decedent complained of low back pain (a pre-existing chronic problem); back x-rays that day were normal. Acetaminophen with 30 mg codeine was ordered. The decedent’s psychotropic medications (i.e. aripiprazole and lithium), were restarted on November 30, 2011 as were his other anti-hypertensives.

On December 2, 2011 (5 days after admission) a repeat chest x-ray was clear. He remained on moxifloxacin and used only two tablets of acetaminophen with codeine each evening on November 30, December 1, and 2. On December 3, he required two doses of this analgesic. He had not had (and was not ordered) any medications to prevent or treat constipation.

By December 3, 2011, according to a physician note, the family felt that the decedent was almost back to his baseline and discharge was being discussed. There were some concerns raised by the family about the decedent’s ability to manage while at home. According to nursing notes, the decedent was still confused with frequent periods of agitation and he still required medication for management of agitation and restlessness. He was advised by the family physician to stop drinking alcohol.

On December 4, 2011, blood work revealed rising creatinine (170 umol/L), but a normal white blood cell (WBC) count (11.4). An order was written to “↑ hydration po” [increase hydration by mouth/orally]. In addition to his regular medications (which included aripiprazole and lithium), the decedent required haloperidol 2.5 mg, lorazepam 2 x 0.5 mg, and quetiapine 25 mg (at night) as well as four doses of acetaminophen with codeine to manage his agitation and pain that day.

On December 5, 2011 an order to “push po fluids” [push fluids by mouth/orally] was written, and the decedent was started on rabeprazole 20 mg daily due to “c/o heartburn” (this was switched to pantoprazole the next day based on an automatic substitution policy at the hospital pharmacy). A consulting nephrologist recommended discontinuation of moxifloxacin and irbesartan due to concerns about renal artery stenosis given temporal relation of initiation of irbesartan to rise in creatinine.

The decedent became more obtunded, confused and intermittently agitated. He received haloperidol 2.5 mg x two doses, lorazepam 0.5 mg once, his regular lithium and aripiprazole, quetiapine 25 mg (at bedtime) and one dose (two tablets) of acteminophen with codeine.

On December 6, 2011, the decedent became febrile (with a temperature of 39.8° C) and his WBC increased to 19.96 (up from 11.4 on December 4, 2011) and creatinine up to 224 umol/L. Intravenous (IV) fluids were initiated and the attending physician started IV levofloxacin. He was seen by a second consulting nephrologist, who recommended discontinuation of the levofloxacin and initiation of ceftriaxone IV. For agitation and pain that day, he received three doses (of two tablets) of acetaminophen with codeine, 0.5 mg of lorazepam, 25 mg quetiapine at bedtime and his usual aripiprazole and lithium.

On December 7, 2011, the decedent was afebrile, but his WBC rose further to 21.7. His lithium level was therapeutic that morning at 1.1 mmol/L. His lithium and venlafaxine were discontinued by the consulting psychiatrist. Creatinine had fallen to 154 umol/L.

On December 8, 2011, the decedent continued to be confused, intermittently agitated, and had to be cared for in the hallway as he was restless and trying to get out of bed. Haloperidol and quetiapine had been discontinued. Lorazepam 0.5 mg (x two doses), two doses of acetaminophen with codeine and aripiprazole 5 mg were given. He was taking fluids poorly by mouth. A CT scan of the brain was completed, and reported as follows:

Findings: There is no evidence of hemispheric infarct, mass, mass effect or hemorrhage. Tiny lacunar infarcts involving bilateral lentiform nuclei are unchanged. A few patchy areas of periventricular hypodensity likely reflect small vessel ischemic change. A linear hypodensity involving the superior aspect of the left cerebellum is unchanged likely reflecting a focal area of encephalomalacia related to remote ischemia.

The decedent was recognized as being unwell and confused and sepsis was still suspected. However, he was afebrile, and his creatinine (142 umol/L) and WBC (11.4) were falling. The attending physician wondered about possible discitis (because of the back pain). No source of sepsis had been identified and a lumbar puncture was considered, but not done as the internist did not feel that there were any symptoms to justify the procedure. An MRI of the spine was attempted, but could not be completed because of the decedent’s agitation and restlessness. Urine cultures were reported as no growth, blood culture results were pending, and he was constipated.

With respect to the constipation, the normal bowel pattern for the decedent was not assessed or charted at the time of admission in the nursing notes. From November 28, 2011 through to December 7, 2011, the man had two documented bowel movements; one on December 2 and another on December 4. On December 8, 2011, he was given docusate sodium 100 mg three times daily (he received three doses), lactulose 30 ml two times daily (he received two doses), and one bisacodyl suppository 10 mg per rectum. That evening, he began to have worsening and copious diarrhea. He became hypotensive (52/34), requiring aggressive fluid resuscitation.

On December 9, 2011 at 0500 hours, the decedent was transferred to the intensive care unit (ICU). Pressor agents were required to maintain his blood pressure. He was somnolent and unrousable, and unable to protect his airway so he was intubated. The lab reported that his stool was positive for Clostridium difficile (C. difficile) antigen. Metronidazole IV and vancomycin by nasogastric tube (NG) were started and the ceftriaxone was discontinued. An infectious disease consultant saw the decedent and concurred with the treatment plan at that time. It was also recommended that further use of proton-pump inhibitor medications and antibiotics be avoided if possible. Later that day, a CT scan of the abdomen was reported as showing:

There is fusiform ectasia of the distal abdominal aorta measuring up to 2.8 cm in diameter. No evidence of rupture or dissection. Mild calcific plaque in the abdominal aorta end iliac arteries, 50% narrowing at the celiac artery origin, mild narrowing at the SMA origin. The IMA is patent. The early bifurcation of the right renal artery, no significant renal artery stenosis.

Moderate amount of free fluid in the upper abdomen, and in the pelvis.

Diffuse wall thickening throughout the colon. Appendix is normal. No free air. No abscess.

Impression: there is some ectasia of the aorta but no significant aneurysm. Diffuse colonic wall thickening suggestive of colitis, which could be infectious or inflammatory.

The decedent’s condition continued to deteriorate, with very little urine output and the development of a coagulopathy. It was difficult to maintain a mean arterial pressure greater than 60 mm Hg despite use of high doses of three pressor agents.

On December 10, 2011, he was taken to the operating room for total colectomy and formation of an ileostomy in an attempt to save his life. A dialysis catheter was placed in the peritoneal cavity at the same time (presumably in case of the need for long term dialysis).

The pathology report on the resected colon showed: pseudomembraneous colitis; associated ischemic changes proximally including the terminal ileum; transmural inflammation and necrosis with full thickness necrosis in areas distally; three necrotic polyps; unremarkable appendix; small lymphoid aggregate or small lymph node.

Despite the surgical intervention and full supportive ICU care, he continued to deteriorate and suffered a cardiac arrest later on December 10, 2011. He could not be resuscitated, and was pronounced dead.

Post Mortem

At autopsy, major gross findings were:

  • Small pericardial and bilateral pleural effusions
  • two litres of blood in the abdomen. The etiology of this was not clear, as it did not seem to be from the surgical sites. Ultimately felt to be possibly due to oozing from the coagulopathy
  • No lung consolidation
  • Concentric left ventricular hypertrophy (LVH)
  • Unremarkable and viable small bowel, colonic stump dusky in color
  • No hepatic cirrhosis
  • Pale kidneys

Histopathology demonstrated:

  • No pneumonia
  • Acute renal cortical and renal tubular necrosis, and vascular changes consistent with chronic systemic hypertension
  • Large patches of fibroadipose tissue in the lateral and inferior myocardial walls consistent with old infarcts. No evidence of recent or acute infarction
  • Extensive vascular congestion and engorgement of the hepatic sinusoids

The examining pathologist referred to the ante-mortem resected colonic pathology for a description of the large bowel. Small bowel was unremarkable and viable.

Cause of death: Pseudomembraneous colitis. Other significant conditions contributing to the death, but not causally related to the immediate cause included hypertensive cardiomyopathy.


Issues raised by the decedent’s family and the investigating coroner included:

  1. Bowel management (particularly prior to December 8);
  2. Appropriateness of antibiotic prescribing, and
  3. Management of delirium.

Bowel management

The concern expressed by the family was regarding bowel management prior to December 8. The decedent was sedentary, not eating and drinking his usual amounts, and on a number of constipating medications (codeine and anti-psychotics). With all of these factors combined, he was at high risk of constipation, and indeed had only two bowel movements during his first 11 days in hospital. Constipation might have contributed to some of his agitation and restlessness.

While the committee agrees that a pro-active bowel management plan ought to have been in place from the time the constipating medications were prescribed, the committee also felt that the constipation did not play a role in this man’s death.

Appropriateness of antibiotic prescribing

The investigating coroner was concerned about the appropriateness of antibiotic prescribing in this case. The decedent was placed on antibiotics at admission for a suspected pneumonia, and remained on various antibiotics for the duration of his hospital stay with the exception of one 24 hour period (December 5-6, 2011). As he died from complications of C. difficile colitis, a review of the antibiotic prescribing in this case was suggested by the local and regional coroners.

The decedent received his first course of antibiotics for possible community acquired pneumonia (CAP) that both the ED physician and radiologist noted on chest x-ray. Moxifloxacin is a respiratory flouroquinolone, and is appropriate first-line therapy for CAP in an older patient with comorbidities that included alcoholism and chronic lung disease (COPD) 1.

The decedent was treated for eight days with oral moxifloxacin, and then it was discontinued. Five days into therapy (on December 2, 2011), a repeat chest x-ray did not show any evidence of pneumonia. However, the patient had clinically improved, and the day following the chest x-ray had responded so well that discharge was being discussed. The committee is aware that, while chest x-ray improvement usually lags behind clinical improvement, in approximately 25% of cases, the chest x-ray findings will resolve at the same time as the clinical findings2. Recommended length of therapy for CAP in hospital is five – seven days. In summary, the committee had no concerns about the management of the decedent’s CAP, including the antibiotic prescribing.

Unfortunately, the decedent began to deteriorate clinically on December 5, the day the antibiotics were stopped. He was more confused, with a rising creatinine and was continuing to require pharmacologic management of his delirium symptoms. The following day, he developed a fever, worsening confusion, and his WBC count rose to almost 20. An infectious process was thought to be the most likely etiology of this constellation of signs and symptoms by both the attending physician and a consulting internal medicine specialist. A full set of investigations was pursued, and a broad-spectrum third generation cephalosporin was initiated. The committee felt that, looking at this clinical scenario prospectively, the empiric prescribing of antibiotics while awaiting the results of the investigations was justified.

It is unlikely that avoidance of antibiotics at this point would have avoided the C. difficile infection. The median incubation period for C. difficile infection is 2-3 days 3. Given the decedent’s other risk factors for C. difficile infection (i.e. age >65, use of a proton-pump inhibitor medication, length of hospitalization, and recently completed antibiotic therapy for pneumonia), it is likely that his C. difficile infection was already well established. Certainly, his rapid clinical decline on December 8-9, 2011 would suggest a well-established infection by that point.

It is worth noting that, as of January 2013, all acute care hospitals are required to have an Antimicrobial Stewardship Program (ASP) in place that meets all the requirements for Accreditation Canada’s ASP Required Organizational Practice. Hospitals are being supported in developing their ASPs by the Ontario Hospital Association and Public Health Ontario. An ASP is defined as, “Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting selection of the optimal antimicrobial drug regimen, including dosing, duration of therapy and route of administration.” One of the goals of the programs is to reduce the risks associated with antibiotic prescribing in hospitals, including C. difficile infections.

Recognition, Investigation and Management of Delirium

The committee was concerned with the management of this man’s delirium. Although it was not directly related to the cause of death in this case, it is a critical quality of care issue that must be addressed in acute care hospitals.

The committee concerns with respect to delirium were:

  1. Recognition that the decedent was suffering from the syndrome of delirium. While there may have been a background of mild dementia, the presentation to hospital on November 27, 2011, was one of acute delirium.
  2. Investigation of the possible causes of the delirium. There appeared to be no systematic approach to trying to determine the underlying cause of the delirium.
  3. Management of the delirium, most notably agitation and restlessness. The committee was also concerned that some of the treatments prescribed likely made the delirium worse.

The investigation and management of the decedent’s delirium was complex. The background history of psychiatric illness with multiple medications, substance abuse, and possible dementia, all in the setting of unstable physical health status, made this situation difficult. However, even though this was a challenging clinical scenario, the basic issues in delirium recognition and management were not appropriately addressed.

The decedent was not recognized as having an acute delirium. The diagnosis did not appear in the notes and reports of the multiple physicians (i.e. hospitalist, nephrologist, psychiatrist, infectious diseases specialist) caring for him. Delirium is a clinical syndrome that occurs commonly in hospitalized patients, particularly those who are older. It carries with it significant morbidity and mortality, and usually prolongs hospitalization. Recognition of the syndrome of delirium in a patient is critical. The diagnosis of acute delirium triggers appropriate nursing care and care plans, physician investigations and medical care for not only the underlying cause of the delirium, but also the complications of delirium itself (i.e. agitation, restlessness). In this case, the delirium was not recognized or diagnosed. As a result, there was no systematic approach to the underlying causes and management, and some of the management in hospital likely worsened the delirium.

Non-pharmacologic measures (e.g. frequent reorientation, regular day/night routines, normalization of routines for toileting and meals, presence of familiar objects and people) for managing the delirium do not appear to have been implemented until December 6, 2011, when the decedent was seen by the geriatric psychiatry nurse consultant. It is well documented that these measures are critical to recovery from delirium.

One of the factors that made this case complex was the management of the man’s various psychoactive medications. Sudden withdrawal, then reintroduction at full doses of his pre-admission medications, would have resulted in large swings in drug levels and, therefore, symptoms of withdrawal and toxicity that were not recognized.

Specific to the delirium symptoms, the pharmacologic management of agitation and restlessness in delirium must be carefully orchestrated by the health professional team working together. Use of a single, low-dose neuroleptic medication such as haloperidol, risperidone or quetiapine, on a scheduled basis, with as needed (PRN) doses, is the initial mainstay of treatment. The recommended initial dose of haloperidol for management of delirium is 0.5-1.0 mg per dose in published studies.

The use of benzodiazepines has no place in the management of behaviours and agitation in delirium. Studies have shown that they increase confusion and sedation, can prolong delirium, and are less effective than neuroleptic medications.

The committee is aware that the Ontario LHINs have committed to developing ’Senior Friendly Hospitals’ across the province. In their September 2011 report, “Senior Friendly Hospital Care Across Ontario: Summary Report and Recommendations,” all 14 LHINs in Ontario committed to the cross-LHIN quality improvement strategy of improving hospital care for seniors. There were three priorities for action suggested for hospitals: (1) Functional decline; (2) Delirium – Implement inter-professional delirium screening, prevention, and management protocols across hospital departments to optimize cognitive function; (3) Transitions in care.


To the LHINs of Ontario and the MOHLTC:

  1. The committee is encouraged by the identification of delirium as a priority for implementation in the Senior Friendly Hospitals framework. We urge the LHINs to continue to steward the implementation of this framework and its priorities to ensure excellent care for seniors in all Ontario Hospitals.

To the College of Physicians and Surgeons of Ontario, the College of Nurses of Ontario, the Ontario Hospital Association and MOHLTC:

  1. Health care providers should be reminded that acute delirium is a common clinical syndrome in hospitalized adults, particularly older adults. All health professionals working in a hospital setting should be knowledgeable in the prevention and recognition of the clinical syndrome of acute delirium.

To the College of Physicians and Surgeons of Ontario, the College of Nurses of Ontario, the Ontario Hospital Association and MOHLTC:

  1. Health providers should be reminded that the investigation and management of delirium in hospitalized patients requires a coordinated, interprofessional team approach. Health care teams in acute care hospitals should have interprofessional clinical protocols for delirium, which include non-pharmacologic and pharmacologic management strategies.

To the College of Physicians and Surgeons of Ontario, and MOHLTC:

  1. Physicians who are prescribing treatment for hospitalized elders with delirium should ensure that they are familiar with commonly cited literature regarding pharmacologic management of delirium (for example, Campbell N, Boustani MA, Ayub A, et. al. Pharmacological management of delirium in hospitalized adults--a systematic evidence review. J Gen Intern Med. 2009;24(7):848). Physicians should also routinely access the expertise of colleagues for this purpose, including pharmacists, and specialists in geriatric medicine and psychiatry.


. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.

2. Bruns AH, Oosterheert JJ, Prokop M, Lammers JW, Hak E, Hoepelman AI. Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia. Clin Infect Dis. 2007;45(8):983

3. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol 2010;31:431–55

4. Campbell N, Boustani MA, Ayub A, et. al. Pharmacological management of delirium in hospitalized adults--a systematic evidence review. J Gen Intern Med. 2009;24(7):848.

5. ibid

Case: 2012-16

OCC file: 2001-6780

Date of death: March 30, 2011
75 years

Reason for Review

The Regional Supervising Coroner requested a review of this case as there were concerns regarding the quality of care provided at the long-term care home where the decedent resided.

Records Submitted for Review

  • Coroner’s Investigation Statement
  • Letters of concern from the next of kin dated February 25, 2011 and March 18, 2012
  • Recommendations from the MOHLTC
  • Plan of corrective action from the long-term care facility
  • Risk management review
  • Medical records from the long-term care home
  • Medical records from the acute care hospital


The decedent was a 75-year-old woman who had been admitted to the long-term care home in August 2008. She had been cared for at home by her daughter for approximately ten years. She had suffered two previous strokes; one in 2007 and one in 2008, leading to left hemiparesis, expressive aphasia and significant dysarthria. The decedent was legally blind due to diabetic retinopathy and glaucoma. Her medical history included two previous myocardial infarctions, Graves disease, type 2 diabetes mellitus, hypertension, obesity, osteoarthritis, chronic knee pain, hysterectomy, cholecystectomy, fractured wrist (2006) and recurrent urinary tract infections with an episode of bacteremia in 2008.

The decedent required a sit-to-stand lift and two-person assistance for transfers, and extensive two-person assistance for dressing and bathing. She used a front closing restraint belt when in her wheelchair and she was encouraged to propel herself in her wheelchair. She was on a modified consistency diet for dysphagia.

The decedent’s medications on January 5, 2011 (prior to the recognition of a tibial fracture) included: amlodipine 5 mg daily, acetylsalicylic acid 81 mg daily, levothyroxine 0.125 mg daily, furosemide 40 mg daily, lansoprazsole 30 mg daily, meloxicam 15 mg daily, oxycodone – acetaminophen 5/325 mg at bedtime, Senokot® 8.6 mg at bedtime, vitamin daily, quinapril 20 mg twice daily, atenolol 25 mg twice daily, docusate sodium 100 mg twice daily, Nitro-Dur® 0.6 mg daily, potassium chloride 8 meq daily, Tylenol Extra Strength® 2 tabs in the morning and at noon, Tylenol® 500 mg 1 to 2 tabs as needed twice daily (mostly receiving once a day), Humalog® 10 units SC three times daily, escitalopram 20 mg daily and temazepam 30 mg at bedtime.

The decedent had a noted history of joint and arthritic pain. A pain assessment carried out on September 16, 2010 indicated that she had “restlessness, repetitive verbalization or movements, verbal expressions of distress or crying, sad/pained/worried facial expressions” as a result of pain. The report indicated that she could communicate the location and characteristics of the pain, and that the pain occurred less than daily (but more than weekly), and that it was predominantly in her hips and joints. The pain increased with morning care and improved with Tylenol Extra Strength® tablets. The likely cause was felt to be arthritis.

The decedent received acetaminophen as well as oxycodone – acetaminophen (Oxycocet) for pain. At times, she was unable to participate in activities due to pain. On October 29, 2010 during a swallowing assessment by the speech language pathologist, it was documented that she was “crying due to leg pain.” An MOHLTC compliance review indicated that the decedent received only one dose of “as needed” Tylenol® between December 1 and December 19, 2010. Over the next month however, she required 23 doses of Tylenol® “as needed” to assist with pain control. No pain assessments were documented between November 23, 2010 and January 29, 2011 in the electronic records management tool (Point Click Care documentation tool).

On the evening of December 19, 2010 the decedent’s daughter visited the long-term care home and found her mother to be crying and complaining of left knee pain. The daughter brought this to the attention of the personal support worker who was not aware of any recent injury. Nursing assessments the following day showed no evidence of swelling, redness or warmth of the knee. There was apparently slight discolouration bilaterally with a small scabbed area on the right knee that was felt to be related to the sit-to-stand lift. The decedent had a known history of osteoarthritis.

A physiotherapist assessed the decedent on December 21, 2010 and noted some pain on range of motion, but stated that the decedent was able to weight bear and complete a physiotherapy program with no discomfort or complaints. The treatment plan continued with Tylenol® and physiotherapy which was felt to be effective for control of the pain.

By December 30, 2010, the daughter was becoming increasingly concerned about her mother’s persistent crying and pain complaints in the left knee. The daughter requested that an x-ray be done immediately. She was informed that the decedent’s doctor was away and would not be returning until January 10, 2011. The notation that the physician was away for three weeks was made in a doctors’ communication book that was only available at one nursing station and not known throughout the facility. The daughter requested that the on-call physician assess her mother and order an x-ray. This was not done.

On January 5, 2011 the decedent was assessed by the Geriatric Mental Health Outreach Program. They were asked to see her because she was “crying most days and staff had difficulty settling her.” The daughter was present and reported that she felt her mother had a marked decline since her last fall.

The psychiatric note indicated that the decedent had suffered three falls in the spring of 2010 and that she had hit her head in one of the falls. The decedent had also been assessed (including CT scan) in the Emergency Department in December 2009 with a fall and head injury. The decedent had another fall in June 2010 when she fell and the wheelchair landed on top of her as she was belted into it.

The Mental Health Outreach worker noted concerns about the decedent’s possible depression as she was “howling” at night when the daughter was not there and had increased crying episodes when the daughter was away in November 2010. The daughter usually visited each night to give her mother the evening meal.

It was also documented that there was an ongoing issue of left knee pain and it was advised that Tylenol® be given more regularly and oxycodone – acetaminophen be given at bedtime. The note indicated that following the daughter’s return, and the increase of Cipralex® and more regular pain medications, the crying had improved.

The decedent reported feeling sad and frustrated and had hallucinations. Quantitative Mini-Mental State Examination (MMSE) was not possible due to blindness and speech difficulty, but the woman did know the month, year, season, province, name of the facility and had some insight into her current situation. The daughter felt that rather than further psychiatric intervention, the decedent required additional speech therapy and more physiotherapy to decrease her frustration with her inability to communicate and mobilize.

On January 7, 2011, the daughter took the decedent to an appointment. The decedent’s foot got stuck, causing bruising of the great toe and left shin; the bruising later spread across the foot and ankle. On January 8, 2011 a nurse told the daughter that another physician was in the facility, but the doctor had decided to leave assessment of the decedent to her own physician two days later.

On January 10, 2011, the decedent’s usual physician assessed her and ordered an x-ray of the left knee. The x-ray was done on January 11, 2011 using a mobile imaging service. The x-ray showed minor osteoarthritis of the knee. There was minimal deformity of the upper tibia with a faint lucency extending from the lateral tibial plateau to the intercondylar region of the proximal tibia and the appearance was also suggestive of minor irregularity of the medial tibial plateau. This appearance was suggestive of an undisplaced fracture. It was recommended that a further clinical assessment and oblique x-rays be carried out. The decedent was placed on bed rest on January 11, 2011.

On January 13, 2011, the decedent was transported to hospital by ambulance for further assessment and x-rays. The emergency department treatment record indicated a left knee injury secondary to a tibial plateau fracture. The decedent was placed in a Zimmer splint and an orthopaedic surgery referral was made. There was no documentation in the health record of the orthopaedic opinion.

Following confirmation of the fracture in the Emergency Department, the decedent was returned to the long-term care home with a splint for immobilization and analgesics. Oxycodone – acetaminophen was increased to twice daily on January 18, 2011 and on January 25, 2011, the oxycodone – acetaminophen was replaced with morphine syrup 1 mg by mouth, twice daily, on a scheduled basis.

On January 13, 2011, the MOHLTC was notified by the long-term care home about the critical incident involving the missed fracture diagnosis. A letter was also submitted to the MOHLTC by the daughter on February 25, 2011 outlining her concerns about the care provided to her mother in the long-term care home.

On March 9, 2011, prior to the decedent’s death, an inspection was carried out in response to the complaint of the critical incident.

Notes for the month of March 2011 indicated the following:



March 1, 2011.

Daughter of decedent left for holiday.

Consent was given for switching the diet from a minced diet to a pureed diet if necessary as the decedent was having some swallowing difficulty.

“In and out” catheterization was done.

March 3, 2011.

Chest x-ray showed “no active process.”

Urinary tract infection was identified and doctor prescribed nitrofurantoin for seven days.

March 6, 2011.

Decedent was having problems with hyperextension of her neck and this created difficulty with positioning.

March 9, 2011.

Decedent was up in a wheelchair and ate all of the two meals served to her that day.

March 10, 2011.

Received the last dose of nitrofurantoin and later that day was noted to have a fever of 38.7C.

Physician was notified and a urine test for culture and sensitivity was ordered.

Trimethoprim and sulfamethoxazole twice daily for seven days was started.

The decedent continued to decline and was sent to hospital at 1705 hours.

March 11, 2011.

Returned from hospital at 0415 hours with a diagnosis of urinary tract infection. Treated with cephalexin.

The ED doctor recommended more frequent monitoring of blood sugar. Nurse called the doctor’s office regarding the recommendation to monitor sugars more frequently, but the doctor was away until March 15, 2011, so the office nurse advised to increase the glucose monitoring and call again if the resident deteriorated.

Decedent had difficulty swallowing and consumed only half of her lunch.

March 12, 2011.

Complaining of pain in her left knee and the doctor on call was notified who advised to only give the “as needed” medications.

March 13, 2011.

Decedent was “content and watching television,” but was complaining of some left shoulder pain.

March 14, 2011.

Physiotherapy assessed the decedent to adjust the wheelchair to keep her head and neck in neutral position “otherwise she tends to extend her neck which makes swallowing more difficult.”

March 16, 2011.

Dietician assessment was done and a puree diet with honey thick liquids was ordered until the daughter returned March 28.

In the morning, the decedent was up in the wheelchair, but by the afternoon she was noted to be making grunting sounds, so she was returned to bed.

By 1700 hours, she had a temperature of 38C.

Treated with Tylenol and encouraged to take fluids through the night.

March 17, 2011 – March 30, 2011.

A.M. - temperature had climbed to 39C and she was refusing all oral medications.

Physician was contacted for further direction in view of the ongoing fever and breathing difficulty.

Decedent was transferred to the hospital.

No notes were available from the acute care hospitalization, but the LTCH kept in touch with the hospital.

Decedent was admitted to the Intensive Care Unit (ICU) on a ventilator. She improved slightly and was extubated.

She subsequently developed pneumonia and died on March 30, 2011.

Post Mortem

A post mortem examination was not conducted. The coroner determined that the cause of death was sepsis, due to medical complications of a tibial plateau fracture - left leg. Contributing factors were stroke and diabetes mellitus. The manner of death was accident.


The decedent was a 75-year-old woman who was confined to a wheelchair as a result of a hemiparesis from two previous strokes and osteoarthritis. She was legally blind due to diabetic retinopathy and glaucoma. She required a mechanical lift for transfers. She had previous complaints of knee pain. On or around December 19, 2010, she probably sustained a tibial plateau fracture that was not confirmed by x-ray until January 13, 2011. She was treated conservatively with splinting and analgesia.

On March 10, 2011, she had fever and was treated for a urinary tract infection. The decedent was again transferred to hospital a week later because of a febrile illness and respiratory difficulties. She was found to be in respiratory failure and required intubation and ventilation. She was subsequently extubated but was diagnosed with pneumonia. She died in hospital on March 30, 2011.

She had demonstrated a progression of dysphagia. Early in March it was recognized that there were increased problems with swallowing and the diet texture was changed. There were problems with positioning of the neck. Hyperextension was thought to be interfering with swallowing. The committee suspects that she developed aspiration pneumonia as a result of her dysphagia. It is difficult to definitively link her death from pneumonia to a minimally traumatic fracture that possibly occurred three months earlier.

The MOHLTC carried out an inspection as a result of this critical incident. Orders and written notices were directed to the facility. A risk management review was carried out and a corrective action plan was put in place.

In the Risk Management Review conducted by the long-term care home, staff was extensively interviewed. They did not appear to recognize a significant change in the decedent’s behaviour or status as she had a long-standing complaint of knee pain. In addition, the electronic medication record for “as needed” medications did not display a long enough time line for staff administering medications to notice that there was an increase in the “as needed” medication use in the latter part of December. Staff also indicated that they did not suspect a significant injury as there was no recognized traumatic event. According to the coroner, it was the opinion of the orthopaedic surgeon that it would not have taken significant force to cause a fracture in this elderly woman who was an immobile diabetic with severe osteoporosis and that the injury could have occurred during a transfer. The surgeon felt that if an x-ray had been done when first requested by the family, it would have resulted in a diagnosis and more timely care of the deceased with analgesics and other measures to reduce her pain level, such as splinting the left leg and non-weight bearing during transfers.

The Risk Management Review conducted by the long-term care home also examined communication issues between the physicians and nursing staff, particularly over the holiday season.

There was some question as to why the long-term care home did not transport the decedent to the emergency department at the hospital for an evaluation, particularly when faced with the difficulties of having a physician assessment at the home. There was an indication that some long-term care homes have felt criticized in the past for sending too many residents to the emergency department. While the decedent did not necessarily require transfer to an emergency department, she did require an adequate on-site assessment and ordering of mobile x-rays.

The Regional Supervising Coroner requested a review of this case because there was a missed tibial fracture which likely occurred December 19, 2010 and was found on x-ray January 11, 2011. The investigating coroner identified communication between nursing staff and family as well as the attending physicians, as a root cause of the problem. An investigation was carried out by the MOHLTC in which there were two orders and six written notices directed to the long-term care home

The Regional Supervising Coroner subsequently had all deaths in the long-term care home investigated over a six month period. There were no further quality of care issues identified.


To: MOHLTC, Ontario Association of Long-Term Care Physicians, Ontario Association of Long-Term Care Homes, Ontario College of Nurses, College of Physicians and Surgeons:

  1. Health care providers should have a high index of suspicion of fracture or significant injury in frail, immobile seniors even in the absence of known trauma and the absence of definitive clinical signs of trauma.
  2. Long-term care homes should ensure the availability of clinicians (i.e. physicians or Registered Nurses – Extended Class) to assess residents on site in the event of a change in resident status.

Committee comments: The long-term care home involved with this case might benefit from the knowledge and assessment skills or an Advanced Practice Nurse who could evaluate residents on site and organize investigations as necessary.

  1. Long-term care documentation tools should allow staff to identify trends in pain, behaviour or medical care that might imply a significant change in health status.

To the Regional Supervising Coroner and the MOHLTC:

  1. The Regional Supervising Coroner should follow up with the long-term care home involved to ensure changes have been made in staff-physician communication and that adequate physician/nursing coverage is available to assess residents with a change in status in a timely manner.

Case: 2012-17

OCC file: 2012-4170

Date of Death: April 7, 2012
88 years

Documents for Review

  • Letter from Regional Supervising Coroner
  • Coroner’s Investigation Statement
  • Police Report- general occurrence
  • Police Report – Investigative Conclusion Summary
  • MOHLTC – report on assailant
  • Personal Health Profile- on Resident B
  • Personal Health Profile – on decedent
  • CCAC Behavioural Assessment Tool – on Resident B
  • CCAC Behavioural Assessment Tool – on decedent
  • LTC records – on decedent

Reason for Review

The committee was asked to independently review the circumstances surrounding the death of this 88-year-old woman who died as the result of injuries received following an assault by another resident (Resident B) in the licensed long-term care home where they both resided. As the manner of death was classified as homicide, the policy of the Office of the Chief Coroner is to conduct a mandatory review by the Geriatric and Long-Term Care Review Committee.

Synopsis of Incident

On October 7, 2011, the decedent was pushed onto the floor by another resident of the long-term care home. There were no injuries noted.

On November 1, 2011, the decedent pulled a chair away from another resident and the other resident tried to kick and hit the decedent, but no contact was made.

On November 4, 2011, the decedent was in an altercation with yet another resident and sustained scratch marks to her face.

On November 6, 2011 the decedent had an unwitnessed fall and required sutures to a scalp laceration.

On November 13, 2011, the decedent hit another resident multiple times.

On November 16, 18 and 19, 2011, the decedent was aggressive towards another resident without provocation.

On November 30, 2011, the decedent started treatment for a urinary tract infection. Her aggressive behaviors settled until December 7, 2011. Her aggression was intermittent with calm days and days on which she would verbally abuse and attempt to physically abuse staff and other residents.

On January 19, 2012, the decedent was slapped by another resident after a verbal disagreement.

On January 30, 2012, the decedent lost her balance and hit her head. She was sent to the hospital where she refused a CT scan.

On February 15, 2012 the decedent was feverish and remained in bed. She was started on ciprofloxacin for a suspected urinary tract infection. Following this infection, the records showed that the decedent was less aggressive and she only had one record of minimally resisting care.

On March 1, 2012, Resident B approached the decedent who was standing near the elevator and shoved her into the elevator door. The decedent fell and fractured her hip. Emergency Medical Services notified police of the incident.

From police interviews with the staff who witnessed the altercation on March 1, 2012, the decedent was “yapping in the face” of Resident B who was sitting down by the elevator. Resident B got out of the chair and pushed the decedent into the elevator. The staff was aware that each of the residents were known to be aggressive to other residents, but had never been in an altercation with each other. Resident B was known to hug people or get angry and push people. Both residents were independently mobile. The decedent was vocal and Resident B “babbled in her own language.”

On March 2, 2012, surgical correction of the decedent’s hip took place.

The decedent returned to the long-term care home on March 23, 2012 and subsequently died on April 7, 2012.

There were no notes submitted from her March 23, 2012 return to the facility until her death on April 7, 2012. The coroner noted that she had been diagnosed with delirium postoperatively and that her intake was poor upon return to the long-term care home where she continued to decline. The coroner attributed the death to complications of the fractured hip. Charges were not laid as it was determined that Resident B was unaware of the consequences of her actions.

Post mortem

A post mortem examination was not conducted.

Manner of death: Homicide

History of Decedent

The decedent was living at home with her spouse until May 2011 when she was admitted to the hospital with rapid atrial fibrillation. Due to her dementia, she was unable to return home and was admitted to the long-term care home in September 2011.

Her weight on admission to the long-term care facility was 40 kg and height 143 cm. Within two days of admission, the woman was physically and verbally abusive towards the staff and showed signs of paranoia. There were several entries in the record indicating the decedent would strike out at staff and it would take several staff members to redirect her.

Her medical history upon admission included:

  • Dementia – MMSE 3/30 – diagnosed March 2010
  • Osteoporosis
  • Coronary Artery Disease
  • Atrial Fibrillation
  • Decreased hearing
  • Polycythemia rubra vera
  • Congestive heart failure
  • Cellulitis of great toe with ingrown nail- treatment difficult due to resistance to care.
  • Urinary tract infections

Her medications included:

  • Quetiapine – 12.5 mg twice daily
  • Bisoprolol 10 mg daily
  • Furosemide 40 mg daily
  • Losartan – 50 mg daily
  • Nitroglycerin patch – 0.4 mg daily
  • Warfarin – 1.25 mg daily
  • Digoxin – 0.125 mg daily
  • Diltiazem – 30 mg twice daily

The decedent was known to be paranoid, wandered into rooms and elevators and hoarded her own and others’ belongings.

She was frequently physically and more often, verbally aggressive to staff and other residents. The staff used a variety of strategies to calm her, including 1:1 time with a staff member, offering her a snack or a meal if appropriate, redirecting her to another activity,  taking her to a quiet area and sometimes giving her 12.5 mg of quetiapine. If one of theses strategies did not work, they would try another. The majority of the time, one of the strategies would be successful within thirty minutes.

History of Resident B

Resident B, who assaulted the decedent on March 1, 2012, had been admitted to the long-term care home in May 2011. She was 74 years old, weighed 69 kg and was 154 cm in height. Her medical history included:

  • Dementia
  • Depression
  • Osteoporosis

Medications included:

  • Citalopram -40 mg daily
  • Galantamine 24 mg nightly
  • Lorazepam – 1 mg nightly
  • Didrocal – 400 mg daily
  • ASA- 81 mg daily
  • Quetiapine – 50 mg three times daily
  • Memantine – 20 mg daily
  • Ventolin – 1-2 puffs qid
  • Lactulose 30 mls daily
  • Senekot – 8.6 mg nightly

The MOHLTC – MDS (Minimum Data Set) report indicated that Resident B was unable, or rarely able, to express herself and did not comprehend. She had verbally and physically abusive behavioural symptoms and was resistant to care. Resident B could be at ease interacting with others, but also openly expressed conflict or anger with family and friends. She would often embrace people or push them if angry.


This is the case of an 88-year-old woman who died from complications of a hip fracture that occurred after being pushed by another resident of the long-term care home where they both resided. Both the decedent and Resident B suffered from dementia and had a history of aggressive behaviour towards others.

An autopsy was not performed in this case. It is important to understand how the injury occurred and whether it was causative in the death in order to make a fully informed determination of manner of death. Post mortem examination can provide necessary information in this regard.


No new recommendations.

Case 2012-18

OCC file: 2012-4974

Date of Death: April 24, 2012
90 years

Documents for Review

  • Letter from Regional Supervising Coroner to GLTCRC
  • Coroner’s Investigation Statement
  • Post mortem report
  • Police Report
  • Acute Care Hospital “Fall Prevention Strategy” Policy (March 2008)
  • Acute Care Hospital “Least Restraint Policy” (February 2011)
  • Acute care hospital records (March-April 2012)


The decedent was a 90-year-old man who lived in a retirement home, but was admitted to hospital for functional decline, delirium and Clostridium difficile (C.difficile) diarrhea. He died April 24, 2012 while attempting to get out of a bed that had the split side rails in the ‘up’ position. He was also wearing a jacket-type restraint device at the time.

The decedent’s health history included:

  1. Mixed dementia (treated with donepezil)
  2. Atrial fibrillation (treated with clopidogrel for stroke prophylaxis)
  3. Sick sinus syndrome requiring permanent pacemaker (2005)
  4. Hyperlipidemia (treated with simvastatin)
  5. Hearing loss (he disliked wearing his hearing aids).

At the retirement home, the decedent was independently ambulatory, calm, pleasant and required only once daily assistance for activities of daily living . Around March 20, 2012, there was an acute change in his behaviour. He stopped attending meals, was eating less, and started to sleep with his clothes and shoes on. A urinalysis was completed and this indicated a possible urinary tract infection. He was started on oral antibiotics, but was having difficulty swallowing, was falling, and had become somnolent. On March 25, 2012, he was transferred and admitted to the local acute care general hospital.

Admission investigations showed hypernatremia (Na 161 mmol/L), creatinine 212 umol/L (baseline was 80-90), and elevated white blood cell (WBC) count at 19.9 (predominantly neutrophils). A chest x-ray was clear and a CT scan of his brain showed “age-related atrophy and microangiopathic change.” He was started on IV antibiotics (ceftriaxone for four days, followed by oral ciprofloxacin), and IV fluid replacement. He was totally dependent in his activities of daily living, had a urinary catheter and was incontinent of stool.

During the first few days of the admission, he was physically agitated. On March 27, 2012, the registered nurse noted that he was, “restless in bed, disrobing, putting legs over side rails, taking oxygen off and pulling on catheter.” He was treated with lorazepam 1mg IV.

From March 28 – 31, 2012, he was placed in a jacket restraint. The restraint was applied after a nurse found the man on the floor after he had climbed out of a bed with all four side rails in the ‘up’ position and with an alarm in place. It was documented that the reason for the restraint was, “risk of self-harm – restless – danger to self.”

The first night he was restrained, the man attempted to remove the jacket restraint over his head.

Consent for restraint was obtained from the man’s power of attorney the next day via telephone. The following is taken from the documentation of the consent conversation:

Bilateral wrist restraints were added for a few hours on March 29, 2012 until the urinary catheter was removed. The jacket restraint continued to be used despite a note on March 30, 2012 stating, “re-settles easily, chats about wartime.”

power of attorney

By March 30, 2012, his electrolytes and renal function gradually normalized and his WBC fell to the normal range. His activities of daily living, including walking, continued to improve and he was discharged back to the retirement home on April 4, 2012. He required limited assistance with personal hygiene, bathing and eating, and was independent in transfers, toileting and ambulation.

On April 7, 2012, he was sent back to the acute care general hospital by ambulance due to “refusing medications and food, not getting out of bed, having constant diarrhea (since discharge from hospital 3 days earlier), not drinking water.” The Emergency Medical Services (EMS) reported that the man was “uncooperative and aggressive” and that he threatened to punch a paramedic in the face. EMS reported prolonged scene time due to the aggressive nature of the man.

Upon arrival at the hospital emergency department, the man was initially confused and combative, but after a few hours, he settled down. He continued to have diarrhea, described as “yellowish with streaks of blood, foul odour.” Upon admission to the regular ward, he was placed on contact precautions. He was noted to be agitated and threatened to punch the nurse. He subsequently settled down after the nurse talked with him about the limits of appropriate behaviour.

On April 9, 2012, stool cultures were positive for C. difficile toxin. The man was moved to a private room, contact precautions were continued, and he was started on treatment with oral metronidazole and saccharomyces (Florastor®) for ten days. By April 13, 2012, he had gone 48 hours without diarrhea, and precautions were discontinued (as per the Ontario Provincial Infectious Diseases Advisory Committee Best Practice Guidelines) and he was moved out of the private room.

During the 10 days of treatment for C. difficile, the man continued to have clinical features of an acute delirium, likely caused by the C. difficile infection. His behaviour was characterized by intermittent refusal of meals, medications and personal care.

He slowly began to improve functionally, and he was walking independently with a walker. The health care team and family decided that the man would need to be discharged to a long-term care home as his care needs were too great to be managed at the retirement home.

On April 16, 2012, the ‘Alternate Level of Care’ designation was made. The man’s condition was stable (even with his resolving delirium) and he could be discharged to a long-term care home when a bed became available. He completed his course of treatment for the C. difficile on April 19, 2012.

On April 22, 2012, his condition changed and he experienced four bowel movements, followed by diarrhea the next day. He became more agitated, indicating a worsening of his delirium, from which he had not yet fully recovered. His medications at that time included: donepezil 10 mg daily, clopidogrel 75 mg daily, dalteparin 5000 U sc daily (for deep vein thrombosis prophylaxis), olanzapine 2.5 mg each evening, acetaminophen 325-650 mg every six hours as needed (never given), zopiclone 5 mg at bedtime as needed (never given), quetiapine 25 mg by mouth as needed (never given), haloperidol 2.5 mg every four – six hours as needed (never given), and dimenhydrinate, sennosides and lactulose as needed (never given).

He was placed back on contact precautions and moved to a private room. A bed alarm was utilized to monitor his risk for falls.

In the late evening of April 23, 2012, the bed alarm was activated and staff found the man attempting to climb out of bed with his legs through the side rails. He appeared to be confused about time and place. Staff reviewed his history and noted a previous fall on April 14, 2012, so a Posey vest was applied. Restraint documentation was initiated and the man was observed approximately nine times over the following eight hours. The last recorded observation was at 0920 hours on April 24, 2012.

At 0950 hours, a nurse entered the man’s room and found him wedged on the right side, between the upper and lower bed rails. He was found face down with his arms over his head and his torso caught between the side rails, at chest level. His chin was tucked downwards and his buttocks were hanging over the side of the bed. His feet were on the floor, but were non-weight bearing. The restraint jacket was noted to be pulled up around his back, sitting level to the bottom of his rib cage. The left restraint jacket tie was pulled tight across the bed and the restraint jacket was on his neck at approximately the hairline level. It was noted to be taut, but with no skin indentation or redness. His skin was pale, his eyes were fixed, he had no response to loud verbal stimuli and was pulseless.

It was noted that all four side rails of the bed were raised and that the man was wearing a hospital gown and a size “small” Posey vest restraint, both of which were twisted around his torso. Additional documentation indicated that the jacket restraint was up under the man’s arms, tight in axilla and that the bottom of the restraint jacket was at xiphoid level. The jacket restraint ties remained secured to bed.

As there was a ‘Do Not Resuscitate’ order in place, the nurse summoned assistance to lift the man back into bed and removed the restraint jacket.

Post mortem

External examination confirmed recent injury, including abrasions to the left knee and elbow, and patchy erythema of left lateral chest.

On internal examination, significant findings included:

  • No petechial hemorrhages of scleral or visceral surfaces
  • Atheromatous disease in the coronary arteries, leading to a 90% stenosis of the LAD, 80% stenosis of proximal circumflex artery, 60% stenosis distal RCA
  • Patchy myocardial fibrosis lateral free wall subendocardial over an area 2.0 x 1.0 cm in greatest size
  • Aortic atheromas with multiple ulcerations
  • Emphysematous cystic change in upper lobes of both lungs
  • No evidence pseudomembraneous colitis
  • Mild cerebral atrophy.

Further histological examination findings included:

  • Patchy myocardial interstitial fibrosis, no acute myofiber necrosis or inflammation
  • Numerous sclerotic renal glomeruli and thick walled blood vessels with some patchy interstitial inflammation
  • High grade intimal atheromatous narrowing of coronary arteries.

In the discussion of findings, the examining pathologist stated, “death is attributed to ischemic heart disease and emphysema. What role possible chest compression associated with restraint/contorted position played is undetermined. However the temporal relationship of the decedent’s contorted body position with his chest between the side rails of the bed and his death suggests that these factors played at least a contributory role in his death.”

The investigating coroner indicated that a combination of positional and traumatic asphyxia likely occurred. “Positional asphyxia” occurs when “either the body is positioned in such a way that respiration is compromised or enough external pressure is placed on the chest, neck and other areas of the body to make respiration difficult or impossible.” “Traumatic asphyxia” is believed to have occurred with entrapment between the rails, in addition to twisting of the decedent within the jacket which caused it to be tight, and constriction of the thoraco-abdominal area and decreased ventilation. The investigating coroner postulated that in the struggle to free himself from restraints, the man might have experienced a surge of catecholamines, leading to metabolic and cardiovascular changes and sudden death (which may explain the lack of findings on autopsy). The coroner determined that the cause of death was mechanical asphyxia in association with cardiopulmonary disease, due to jacket restraint and spaced upper and lower bed side rails. Contributing factors were dementia and Clostridium difficile infection.


The deceased was a 90-year-old retired military officer and former prisoner of war, who died while trying to free himself from two sets of physical restraints – a jacket and bed side rails. The restraints had been applied after a single episode of trying to get out of bed while in an isolation room due to C. difficile.

It was not clear that the man’s health care team recognized that he was suffering from an acute delirium. Acute delirium in a frail elder person requires an interprofessional approach to supportive care and behaviour management. For example, non-pharmacologic measures such as frequent re-orientation, normalization of routines, the presence of familiar objects (e.g. photos) and people (e.g. family members), have all been clearly demonstrated to help in management of acute delirium. There is also strong evidence to support the short-term use of regular (not just “as needed”) doses of neuroleptic medications to assist with behaviour management. The use of these medications should be carefully monitored and titrated, with close teamwork and communication between the prescribing physician and the health professionals providing daily care.

Although neuroleptic medications were ordered on an “as needed” basis for the deceased, they were never administered. There was no clear overall plan in place for the healthcare team to manage this man’s delirium and physically agitated behaviours.

The acute care hospital where the decedent died, operated according to a ‘Least Restraint’ policy. The policy however, did include the option for jacket restraint to be used. The use of jacket restraints in acute care hospitals, while permissible, is contradictory to the current legislative direction prohibiting their use within all long-term care homes within the province. Many acute care hospitals have successfully discontinued using jacket restraints without any noticeable increase in adverse events, such as falls. Jacket restraints are dangerous and have been responsible for deaths in similar circumstances, some of which have been reviewed by this committee.

In this case, implementation of the ‘Least Restraint’ policy was problematic in a number of areas:

  1. Alternatives to use of restraints in the context of management of delirium with agitated behaviour: It was not clear that there was an attempt to understand the nature/cause of the man’s behaviour. (e.g. pain, hunger, loneliness, boredom, fear, etc.)

Putting in place a comprehensive ‘delirium plan of care’ might have prevented the need for use of restraints. Such a plan would include non-pharmacologic measures and judicious use of regular doses of neuroleptic medication.

It was evident that the bed alarm (an alternative to restraint) was being used and was successful to some extent in that it had alerted a nurse when the man had tried to exit the bed. It was not clear why it was felt that the alarm was not adequate on its own and that further physical restraints were necessary.

  1. Documentation of alternatives to restraint: There was no documentation of consideration given to other alternatives besides restraint and bed alarm. It was unclear if other options, such as a ‘Hi Lo’ bed and floor cushion, were considered. It was not clear if consideration was given to lowering the bed rails and allowing the man to mobilize freely after a discussion of risks and benefits with his substitute decision maker.
  2. Consent: During the first admission to hospital, partial consent was obtained (by telephone), the day after the initiation of restraints. In the second admission, no consent was obtained. There was no documentation describing the details of the discussion with the substitute decision maker. It was not clear that the significant risks of restraint use were discussed with the substitute decision maker.

This case demonstrates that there continues to be inconsistent implementation of Least Restraint policies in institutions across Ontario. The spirit of the legislation (PRMA 2001) is to eliminate or minimize the use of restraints rather than to add more administrative steps to the existing practices in order to justify their use. It appears that some health professionals practice as though the latter is true and go through the required steps in order to achieve the ultimate goal of restraint application. A shift in thinking and practice regarding the care of agitated, confused elders needs to be reinforced if the goals of restraint elimination (or minimization) are to be achieved.


To providers of healthcare services to the elderly:

  1. Healthcare providers are reminded that acute delirium is a complex condition, and requires a comprehensive, interprofessional management plan that includes both non-pharmacologic and pharmacologic interventions. In particular, assessment and management of agitation caused by delirium requires close collaboration between the treating physician, the other treating health professionals, and the family/substitute decision maker. Only in this way can use of physical restraints be minimized or eliminated.
  2. Healthcare providers are reminded that restraints to prevent injuries should only be used after all other injury prevention strategies have been tried and deemed to be ineffective. The risk of physical restraints most often outweighs the benefit. The use of restraints should be reserved for treatment of life threatening issues and for short periods of time only.
  3. Healthcare providers are reminded of the importance of documenting the trials of alternative strategies prior to the initiation of restraints.
  4. Healthcare providers are reminded that bed rails pose a significant safety risk to patients/residents, especially split side rails. The benefit of bed rails is almost always outweighed by the potential for harm and therefore, alternatives to the use of bed rails should always be sought (and documented). The use of side rails may constitute a restraint and therefore all the usual standard policies for restraints, including physician’s orders, must be followed.
  5. Healthcare providers are reminded that agitated behaviour usually worsens with the application of physical restraints, placing the individual at higher risk of restraint complications. When caring for an individual with altered cognition (i.e. acute delirium, or chronic dementia) and agitation, healthcare providers should search diligently for the root cause of the behaviour. Often such factors as hunger, pain or fear will drive behaviour, and behaviours can improve with treatment of the underlying cause(s).

Case 2012-19

OCC files: 2012-1072 and 2011-3448

Decedent #1

Date of Death: January 28, 2012

Age: 94 years

Decedent #2

Date of Death: May 3, 2011

Age: 69 years

Reason for Review

The GLTCRC was asked to review the circumstances surrounding the deaths of two individuals who resided in the same long-term care home. The families of the decedents identified numerous concerns that focused on a perceived systemic pattern of care related issues and non-compliance with the Long-Term Care Homes Act, 2007 (LTCHA).

Documents Reviewed

The following documents were reviewed for each of the decedents:

Coroner’s Investigation Statements; Medical hospital records; Physician Orders; Physician notes; Consultation Reports Diagnostic Reports; Medication and Treatment Administration Records; Assessments; Plans of Care including care routines and toileting protocols; Progress Notes; MOHLTC Inspection Reports; correspondence between the Regional Supervising Coroner and the families; Medical Certificates of Death.

Decedent #1


The decedent was a 94-year-old female with advanced dementia who was admitted to the long-term care home on January 8, 2009. It is unknown where the decedent came from, although there is mention that she was in a “nursing home” in 2008.

The woman had a medical history that included: C. Difficile with relapsing C. Difficile colitis and possible diverticulitis; constipation; pneumonia; dysphagia; gastroesophageal reflux (GERD); hypertension; hypothyroidism; Alzheimer’s type dementia with visual hallucinations; conductive hearing loss; depression; anemia; osteoarthrosis; aphasia; retinitis pigmentosa with legal blindness; frontal lobe head injury; urinary tract infections (UTIs); transient ischemic attacks (TIA); blepharitis; and possible exposure to tuberculosis as a child.


  • Acetaminophen 650 mg PO or PR QID
  • Dilaudid 1 mg Q4H s/c per butterfly
  • Dilaudid 0.5mg Q2H s/c per butterfly (breakthrough)
  • EC ASA 81 mg PO daily
  • Eltroxin 0.1 mg PO daily
  • Euro-Fer 300 mg cap PO daily
  • Haloperidol 0.5 mg. Q12H PRN
  • Lansoprazole 15 mg cap. PO daily
  • Micro-K-Extencaps 16 mEq PO daily
  • Mirtazapine 15 mg PO hs
  • Ultracran Max Strength 500 mg cap TID
  • Cerumol ear drops 2 drops each ear 2 x/week PRN
  • Bowel management medication PRN (Fleet enema; glycerine suppository, Milk of Magnesia, Senekot®)


Quinolones (Note: tolerated ciprofloxacin with no complications), imidazole, macrolides, ketolides, alpha blockers, sulfa; beta blockers; Lactulose; Elastoplast; sensitivity to large doses of ASA

(Additional potential allergies identified by family but not verified in record reviews: Remeron, Tylenol, iron supplements; all broad spectrum antibiotics including Flagyl; laxatives, enemas, soaps/lotions containing sulfa or perfume)

Post mortem

No post mortem examination was conducted.


During the last month of the decedent’s life, she was dependant in many activities of daily living. She was incontinent of both bowel and bladder; able to weight bear and required a two-person assist with a transfer belt for all transfers. She used a tilt wheelchair when out of bed, and two half-bedrails to assist with repositioning when in bed. She had several of her own teeth and required hydrogen peroxide treatment for her upper and lower gums. She was on a texture modified diet including nectar-thickened fluids (including cranberry juice) and minced meat. She required a nutritional supplement for weight loss and poor appetite, although she frequently refused to eat or drink and would occasionally spit out food/medication/fluids. She experienced back pain secondary to immobility and pain in the left shoulder from a former fracture.

The decedent’s skin integrity was at risk of being compromised. She had a special surface on the bed and was on two hour re-positioning at the time of death. She experienced intermittent well-formed visual hallucinations, such as seeing people in her room with whom she appeared to interact. Staff reported that she had to be removed from the group at times when becoming too loud or distressing to others while talking to herself. She tended to pick at her clothing, but was easily distracted with a tactile blanket or a stuffed toy. She frequently used an MP3 player with music when not attending a program. Her 2009 MMSE indicated a score of 0/30, which although she was blind, had decreased from 8/25 in 2006.

The decedent’s daughter was very supportive to her mother. She was actively involved in her mother’s care. The decedent also had a private caregiver.

The daughter identified multiple concerns to the staff and management of the home on various occasions. Although documentation indicated that management had discussion about the concerns on multiple occasions, the daughter was not satisfied that the issues were resolved and reported concerns to the MOHLTC prior to her mother’s death.

The significant events leading up to the decedent’s death began on January 12, 2012, when the daughter identified, among other things, that her mother had an acute medical issue related to not eating and drinking that morning. Upon assessment by the registered nurse, the decedent indicated that she would eat when she wanted, and although she was tired, she had no pain. The resident was afebrile. The daughter explained that on the previous evening, her mother complained of “burning” and “stone.” Upon request of the daughter, the physician was informed. The physician inquired whether the daughter wanted her mother transferred to the hospital for investigation and hydration. The daughter declined the transfer, upon which the physician directed the registered nurse to monitor the resident and notify him of any signs and symptoms of a urinary tract infection at which time he would order an antibiotic along with Flagyl to prevent a C. Difficile relapse. The daughter agreed with the plan. The registered nurse’s offer of intravenous or hypodermoclysis was further declined by the daughter. The daughter identified multiple concerns to nursing staff and the registered nurse reviewed concerns and interventions with the daughter on January 12, 2012 and noted the daughter’s indecision and final agreement to the administration of Tylenol® for the decedent. The resident continued to take adequate food and fluids and remained afebrile until January 21, 2012.

A clean urine sample was obtained on January 16, 2012 showing strong odour, a normal pH (7), leukocytes 2+, nitrites and protein 2+. The physician was notified and ordered urine for culture and sensitivity, which showed no significant growth.

On January 18, 2012 the registered practical nurse made a referral to the registered dietician inquiring if a risk [release] form needed to be signed by the daughter because the daughter insisted on giving the resident a regular [textured] diet.

On the morning of Saturday, January 21, 2012, the decedent had a temperature of 38.2 C, was shivering, delirious and agitated, making a physical assessment difficult. The daughter was notified and after a lengthy discussion and some confusion about the daughter not being aware that her mother was on Tylenol®, the daughter agreed that the on-call physician could be called. The daughter declined the registered nurse’s invitation to transfer the resident to the hospital for an investigation. The daughter agreed to an antibiotic and Flagyl. After the order was received by the on-call physician and the medication obtained through the emergency pharmacy, the daughter indicated that she would only consent to the antibiotic therapy if the urine was positive for infection. A call to the lab indicated the urine was negative for infection and thus no consent was obtained to administer the antibiotic.

On Sunday, January 22, 2012, a different on-call physician was notified and ordered a chest x-ray and stat complete blood count (CBC) and communicated the plan to monitor, push fluids, administer Tylenol® supplements for fever and malaise, keep family informed, follow-up on results of CBC and chest x-ray and inform primary physician Monday morning and request a visit.

On Monday, January 23, 2012 the registered dietician indicated that the resident was on a regular textured diet, including fluids, because the family signed the negotiated risk form. The stat CBC showed an elevated white blood count (WBC) of 26.2; the chest x-ray and previous urine were negative. The regular physician ordered Cipro and Flagyl for possible diverticulitis, which the daughter agreed to after discussion with the physician, although later the daughter refused the antibiotic when the nursing staff attempted to administer it. The same evening, the physician wrote additional “as needed” (PRN) orders for Haldol and Dilaudid injectable as well as Tylenol® supplement regularly. He noted that the woman appeared comfortable, but not alert and unable to take anything orally.

Palliative care was provided to the decedent. On January 24, 2012 she was found resting comfortably, although unable to rouse verbally. Her pulse was rapid (100-110) and irregular, and skin was pale, warm, dry, with flushed cheeks. In the early morning, the daughter indicated that she changed her mind and insisted that her mother have the oral antibiotics, and would wake her mother enough to take her medications. The Director of Nursing and Personal Care intervened and spoke with the daughter and reviewed the decedent’s chart, outlining the sequence of events, which were different from what the daughter was expressing. The Director of Nursing and Personal Care and the registered practical nurse provided support to the daughter and the decedent, although the daughter was inconsolable and threatened to notify the MOHLTC with her concerns.

At 1300 hours, the son-in-law contacted the physician and requested that the woman be transferred to the hospital where she would be treated with IV antibiotics. The physician indicated his disagreement. The physician visited in the evening and increased the Dilaudid, including an order for breakthrough pain as needed.

On January 25, 2012, the daughter was offered use of the palliative family suite, which she refused in order to stay at her mother’s bed side. Changes in staff providing care for the decedent were made upon the daughter’s request on January 26 and 28, 2012.

The woman died on January 28, 2012. The Medical Certificate of Death indicated sepsis as the primary cause of death and dementia, anemia and failure to thrive as the significant conditions contributing to her death.

Post mortem

No post mortem examination was conducted.

Decedent #2


The decedent was 69-year-old female with dementia who was admitted to a long-term care home on December 19, 2008, after a two-month stay in the hospital. Prior to that time, she lived in the community where she fell several times per week and was unable to get up on her own; she was incontinent, uncooperative and unable to manage the household work and her finances. In 2008, her MoCA scale was 19/30 and her immediate and recent memory were poor, with possible organic mood disorder related to alcohol abuse. She was unable to make decisions on her own and deemed incapable of making the admission decision. She had worked until 54 years of age, when she retired due to depression.

The decedent had a medical history that included: cirrhosis of the liver secondary to alcoholism; ascites; bilateral edema of the lower ankles/legs and the use of compression stockings; chronic anemia; gastrointestinal (GI) bleeds; multiple transfusions, splenomegaly; anxiety disorder; hepatic encephalopathy; bilateral asterixis; limb weakness; significant osteoarthritis; total knee arthroplasty; history of a fractured right ankle with deformity; neurodermatitis, congestive heart failure (CHF); coronary artery disease (CAD) with angina; chronic obstructive pulmonary disease (COPD); hypothyroidism; frequent urinary tract infections (UTIs); lithotripsy left kidney; hypertension, depression; hyperlipidemia; abdominal hernia; history of hyperglycemia; hiatus hernia and reflux; difficultly chewing and swallowing; hemorrhoids; and degenerative changes in lower lumbar facet joints. She had a left laser retinopexy; cholecystectomy; and removal of six teeth in 2010.


  • Allernix 50 mg, PO BID; and Allernix 50 mg PO QID, PRN
  • Amoxicillin 500 mg – 4 caps 1 hour prior to dental appointment PRN
  • Anusol cream BID
  • Anuzinc Supp 10 mg 1-2 PR, PRN
  • Cipro 500 mg PO BID x 10 days
  • Detrol LA Tolterodine ER 4 mg SR cap, PO OD;
  • Dilaudid 2 mg Q1H via s.c. butterfly
  • Dimenhydrinate 50mg PO or IM Q6H PRN
  • Ferrous Gluconate 300 mg PO TID
  • Furosemide 20 mg PO OD, PRN, if edema in lower legs; (given daily)
  • Lactulose 30 ml. PO OD
  • Lansoprazole 30 mg, 1 cap. PO BID
  • Lorazepam 0.5 mg, 1-2 tabs (0.5 – 1 mg) PO TID PRN
  • Midazolam 1 mg s.c. QH PRN (Apr. 24/11 – palliative care)
  • Nitro SL Spray PRN for chest pain max X 3; If x3, transfer to hospital
  • Potassium Chloride 8 mEq, 2 tabs PO OD with food
  • Scopolamine 0.8 mg Q1H via s.c. butterfly (May 3/11)
  • (Apr. 30/11 Scopolamine 0.4 mg Q1-2 H PRN via butterfly)
  • (Apr. 24/11- Scopolamine 0.4 mg s.c. Q2H PRN)
  • Semetil 10 mg PO/IM TID PRN (Apr. 23/11) – (Not transcribed onto May MARs, but never given)
  • Senokot 8 mg. 1-2 tabs PO hs PRN
  • Sertraline 50 mg, 3 caps (150 mg) PO, OD;
  • Spironolactone 100 mg PO OD
  • Synthroid 0.025 mg. PO OD
  • Thiamine 100 mg PO OD
  • Trazodone 25 mg PO QHS
  • Tylenol 500 mg, 2 tabs, PO QID, PRN
  • Tylenol supp 650 mg PR Q4H PRN
  • Vitamin D 1000 IU, 1 PO OD


  • Right knee – cleanse with normal saline, apply non-adherent dressing, wrap with Kling to secure, change dressing Q 2 days
  • Westcort 0.2% cream to affected areas, BID
  • Bactigras (10 cm x 10 cm) 0.5% P/P dressing, apply to left arm skin tears OD PRN; cover with non-adherent dressing and wrap with Kling
  • In & Out catheter PRN or indwelling catheter PRN


Acetylsalicylic Acid (ASA),


In August 2009 (nine months after the decedent was admitted to the long-term care home), the decedent’s sister (Power of Attorney for personal care) indicated that although there was a slow physical decline related to hand dexterity, skin condition, balance, and speech, she agreed that the decedent was mostly continent, more social, her mobility increased with physiotherapy and she required less frequent blood transfusions.

The decedent’s sister was a nurse and actively involved in the decedent’s care. She took her out on appointments, brought her to activities and during the later months, assisted with feeding every day.

During the last year of her life (2010-2011), the decedent declined both physically and cognitively, with a significant decline occurring in the last few weeks of life, when she required extensive, to total, assistance with many activities of daily living. Her continence level changed from occasional urinary and bowel incontinence to complete incontinence; transfers declined from a two-person transfer (sit/stand lift) and a wheelchair when up, to being completely bedbound with the use of a Hoyer lift; bed mobility declined from the two half-bedrails to assist with repositioning, to the need for total assistance; physiotherapy was decreased from assistance with walking to conducting range of motion; skin integrity on extremities was compromised related to itchiness, scratching and picking.

The decedent remained disoriented to person, time and place, unable to fully comprehend, and her speech was low and disorganized. Her MMSE score was 21/30 in March 2011; 26/30 in March 2010; and 27/30 in January 2009. She was on a regular diet, regular texture with regular fluids, accepting the associated risk after refusing to accept the speech language pathologist’s recommendation in February 2011 that the fluids be nectar thickened due to swallowing and chewing problems. Although previously able to eat on her own with limited assistance, she later required total assistance with feeding; lunch and supper feeding was provided by her sister. Her mood was depressed and angry with frequent repetitive non-health related complaints and occasional verbal abuse. She had both verbal and non-verbal complaints of pain.

The sister changed the decedent’s attending physician on February 14, 2011. In February 2011, nursing staff noted concerns about the sister’s ability to cope with the decedent’s declining condition. On February 16, 2011, in a letter to the new physician, the decedent’s sister identified her need for reassurance, explained her behaviour which she understood was frustrating for staff to deal with, and stated that the long-term care home was providing the best care possible.

On March 8, 2011 the sister became frustrated that nothing was being done, although the new physician had ordered additional tests and a gastroenterology (GI) referral. The abdominal ultrasound of February 18, 2011 confirmed a moderate volume of ascites was present and on March 29, 2011, the decedent received three units of albumin and had a therapeutic paracentesis, with the removal of a total of 8 litres of fluid. Her hemoglobin was 79 requiring a blood transfusion on March 30, 2011. Additional bloodwork results were: creatinine 106, albumin 22; and a minimally elevated bilirubin at 26. Overall, the decedent’s condition was deemed quite poor and she was given less than three months to live.

On March 31, 2011, the sister reportedly showed signs of caregiver burnout and staff identified interference with their ability to care for the decedent as outlined in her plan of care. The sister wished to remain in control of decisions affecting the care of the decedent.

The full plan of care and a pharmacological audit was conducted in early April 2011, with no recommendations.

On April 19, 2011, the decedent was less responsive with abnormal blood results, including a hemoglobin of 74.

The Advanced Directives were at full code until April 24, 2011 when, after a discussion with the physician, they were changed to Level 2 (i.e. remaining at home, with additional treatment for comfort, e.g. transfusions, paracentesis). At the same time, the physician offered intravenous or to arrange a paracentesis later in the week, although questioned the futility of such, but the sister agreed to keep the decedent at the home and to keep her comfortable. The sister indicated to nursing staff that she would live at the home from now on and give direction to staff about what medication to use. Staff indicated that the sister was indecisive and insecure about end-of-life decisions. However, the sister wished to remain in control of the end-of-life decisions, including medication and treatments, particularly during the decedent’s last few days, sometimes refusing medications and dressing changes and making requests to the physician to change medication.

Documentation of the last few weeks confirmed frequent assessments, interventions and monitoring of the decedent, including making referrals as deemed necessary, e.g. dietitian and gastroenterologist. The decedent was offered and/or provided end-of-life comfort measures, including pain management, food and fluids as tolerated, skin care, oral care, repositioning and suctioning as requested and needed. The sister was upset with the decline of the decedent and expressed difficulty in making the requested decisions at one point. The sister received significant emotional support, reassurance and explanations from staff during this very difficult time. The sister’s commitment was remarkable as she continued to provide needed care and emotional comfort to the decedent.

During the last few hours of the decedent’s life, she was reported to be mainly comfortable and when pain was expressed non-verbally, pharmacological intervention was provided. The woman died prior to midnight on May 3, 2011 with the immediate cause of death being reported as cirrhosis of the liver due to alcohol abuse, with other significant conditions – CAD, CHF, COPD, anemia and GI bleeds.

Post mortem

No post mortem examination was conducted.

Summary of Findings

The committee did not find evidence of systemic care related issues in the review of these two deaths.


To the MOHLTC:

  1. The MOHLTC should ensure that residents and their families are aware of the Long Term Care ACTION Line.

Case 2012-20

OCC file: 2011-16002

Date of Death: December 30, 2011.

Age: 60 years

Documents for Review

  • Letter from Regional Supervising Coroner
  • Coroner’s Investigation Statement
  • Post mortem report
  • Ministry of Community and Social Services reports
  • Acute care hospital neurology report
  • Acute care hospital Emergency Room consult
  • Letter from executive director of group home
  • Notes from Group Home
  • Notes from Acute care hospital


The decedent was a 60-year-old man who was severely impaired secondary to cerebral palsy and anoxic brain damage. He was able to recognize and interact with friends and family. He had been cared for at home by his elderly parents until about six years prior when his mother was admitted to a long-term care facility because of Alzheimer’s dementia and his father could not care for him alone. The man moved into a group living home that provided residence and services for six clients.

By all accounts, the decedent was happy and well cared for in the group home where he lived. The notes made by group home staff in the two years prior to the man’s death revealed excellent knowledge of his limitations and preferences.

The decedent’s past medical history included seizures and hypothyroidism for which he was prescribed phenobarbital and thyroxin. His vision was impaired by cataracts, but surgery was felt to be too risky as he continually rubbed his eyes.

The decedent was non-verbal and spent most of his day in his wheelchair equipped with a lap restraint. The wheelchair was tilted backwards slightly to prevent slipping down in the chair. He had full use of his hands and had the manual ability to undue the lap belt. He did not however have the cognitive ability to complete the task.

In November 2010, the decedent slipped down in the wheelchair. Staff in the group home wondered if the sling from the man’s lift (which was always left on the chair) might have been a factor. A formal lift assessment and recommendations from the health and safety/ergonomics person recommended leaving the sling on the chair. The decedent’s wheelchair was obtained from an accredited assistive devices program (ADP) provider and was custom fitted to match his needs.

On the evening of December 27, 2011 at approximately 1915 hours, one of the staff in the group home was helping another resident in an adjacent room when he heard what he interpreted as ”happy sounds” coming from the decedent’s room. The staff member checked on the man and found him watching television and in good spirits.

The staff member was walking by the decedent’s room at approximately 1945 hours – just 30 minutes later - and noticed that the man was not in his wheelchair. Upon entering the room, the staff member found that decedent had slipped down in the wheelchair with the lap belt around his neck and was turning blue in colour.

The staff member undid the belt, called 911 and started cardiopulmonary resuscitation (CPR). Emergency Medical Services arrived at approximately 2005 hours and found the decedent in asystole. With epinephrine and intubation, his pulse returned at 2040 hours and he was transported to the acute care hospital.

Despite all efforts at the acute care hospital, it was apparent that the prognosis was extremely grim, even though formal brain death could not be diagnosed (as per neurology consult). The intensive care unit team maintained close contact with the family. It was decided that palliative care would be given and the decedent subsequently died on December 30, 2011.

Post mortem

Autopsy revealed that strangulation was the cause of death, and there was no other traumatic injury apparent. There was evidence of significant underlying cardiac pathology, so an arrhythmia resulting in unconsciousness and loss of bodily control could not be excluded.

Seizure as the predisposing factor could also not be excluded even though the decedent had not had a seizure in several years.

Toxicology testing indicated that the phenobarbital level was sub therapeutic.


No concerns were identified with the care that the decedent received in the group living home setting for the six years preceding his death.

It is unclear whether the terminal events could have been prevented.

Ensuring correct and safe seating in a wheelchair requires a complex and expert assessment 1. The decedent required a lift for transferring and a formal lift assessment was performed to guide the staff. His wheelchair was individualized for his needs by an accredited provider and there was no doubt that his quality of life was enhanced by using the lap belt, even though it functioned as a restraint. It could not be determined from the records reviewed whether the lap belt was fitted in the optimal manner.2 Recommendations on how to use a lap belt in these circumstances are supported by low levels of evidence (mostly expert opinion).

The committee agreed that the use of a restraint in this case allowed the decedent to experience a quality of life that he would not have enjoyed otherwise.


To health care providers, the Ontario Association of Long-Term Care Physicians, The Ontario Association of Long-Term Care Homes, Ministry of Community and Social Services:

  1. This case should be used to help educate health care providers about the potential dangers of using wheelchair lap belt restraints. All methods of restraints, even when used appropriately as in this case, are associated with risk and a policy of least restraint should always be employed.


  1. Mary Isaacson EdDOTR/LATP (2011): Best Practices by Occupational and Physical Therapists Performing Seating and Mobility Evaluations, Assistive Technology: The Official Journal of RESNA, 23:1, 13-21.
  2. Chaves, E. et al (2007): Review of the Use of Physical Restraints and Lap Belts with Wheelchair Users. Asst Technol 2007;19:94-107.

Chapter Five

Learning from GLTCRC Reviews

A primary and recurrent theme of the GLTCRC reports is that, when it comes to medical care, the elderly are a special group. The interplay of multiple medical and social issues requires the effort of a team of professionals to ensure the provision of competent and compassionate care. The recognition by policy makers of the special needs of the elderly is of critical and urgent importance as the population of Ontario ages.

No issue exemplifies the complexity of geriatric care as well as the management of the behavioural and psychological symptoms of dementia (BPSD). This is a pervasive factor in the safety of the elderly as it relates to falls, the use of restraints and to assaults. More than half of the long-term care home residents in Ontario have a diagnosis of dementia and almost half exhibit aggressive behaviours. The education of care providers in the effective management of BPSD and the appropriate allocation of resources have been identified as priorities by the GLTCRC.

The GLTCRC recognizes the increased complexity and acuity of long-term care residents. Elderly people in need of care, who, in the past, would have been patients in hospitals, are now residents in long-term care homes or retirement homes. Long-term care homes and retirement facilities are now home to adults of all ages with a variety of chronic illnesses and to people with mental illness whose residential options are limited. Long-term care homes are challenged to provide living environments that meet the needs of such a broad spectrum of individuals.

The GLTCRC also recognizes and appreciates the many Ontarians involved in the provision of care to the elderly. These individuals have taken on the responsibility for this valuable and at times vulnerable segment of our population, and they do so with considerable skill and dedication. It is hoped that the work of this committee will be of assistance to them and to the families of those whose deaths have been reviewed.

Questions and comments regarding this report may be directed to:

Geriatric and Long-Term Care Review Committee
Office of the Chief Coroner
25 Morton Shulman Avenue
Toronto, ON
M3M 1J8