Ministry of the
Solicitor General

GLTCRC Report 2017

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Office of the Chief Coroner

Geriatric and Long Term Care Review Committee 2017 Annual Report

December 2017


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 Message from the Chair
Committee Membership
Executive Summary
Chapter One: Introduction
Chapter Two: Statistical Overview (2004-2017)
Chapter Three: Cases Reviewed in 2017
Chapter Four: Learning from GLTCRC Reviews
Appendix A: Summary of 2017 Cases and Recommendations


Message from the Chair

It is my pleasure to present to you the 2017 Annual Report of the Geriatric and Long term Care Review Committee (GLTCRC).  

The GLTCRC was e MBstablished in 1989 and consists of members who are respected practitioners in the fields of geriatrics, gerontology, family medicine, psychiatry, nursing, pharmacology, em MBergency medicine and services to seniors.

The Office of the Chief Coroner (OCC), through the GLTCRC, has made it a policy to review all homicides involving residents of long term care or retirement homes. The GLTCRC also reviews cases where systemic issues may be present or where significant concerns have been identified by the family, investigating coroner or Regional Supervising Coroner. 

Reviews conducted by the GLTCRC include a comprehensive and thorough review of the circumstances surrounding the death and if appropriate, the development of recommendations aimed towards the prevention of future similar deaths.  In 2017, the GLTCRC reviewed 18 cases, involving 18 deaths and generated 41 recommendations.

Reviews and recommendations prepared by the GLTCRC are widely distributed to service providers, long term care providers and other relevant agencies and organizations throughout the province. Our role is to provide information to relevant organizations that will subsequently lead to improvements in processes, policies and initiatives, with the goal of preventing future deaths in similar circumstances.

I would like to take this opportunity to thank Ms. Kathy Kerr (Executive Lead) for her assistance with the ongoing administration and management of GLTCRC activities and data.

It is an honour to participate in the work of the GLTCRC and I am grateful for the commitment of its members to the people of Ontario.

Readers who wish to obtain the redacted narrative reports can do so by contacting the OCC at occ.inquiries@ontario.ca.

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


Committee Membership (2017)

Dr. Roger Skinner
Regional Supervising Coroner, Committee Chair

Ms. Kathy Kerr
Executive Lead

Ms. Elaine Akers
Pharmacist

Ms. Julie Cavaliere
Registered Dietitian

Dr.  Barbara Clive
Geriatrician

Dr.  Margaret Found
Family Physician/Coroner

Dr.  Sid Feldman
Family Physician

Dr.  Heather Gilley
Geriatrician

Dr.  Barry Goldlist
Geriatrician

Dr. Rebekah Jacques
Pathologist

Dr. Mark Lachmann
Geriatric Psychiatrist/Coroner

Ms. Debbie Rydell
Retirement Home Regulatory Authority

Ms. Anne Stephens
Clinical Nurse Specialist

Dr. Ramesh Zacharias
Chronic Pain Management/Coroner


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 2017, the GLTCRC reviewed 18 cases involving 18 deaths and generated 41 recommendations directed toward the prevention of future deaths. Of the 18 cases reviewed, three resulted in no recommendations.
  • Of the 18 deaths that were reviewed in 2017, the breakdown for manners of death were:
    • Natural  - 9  (four males and five females)
    • Accident  - 5 (one male and four females)
    • Homicide* - 2 (one male and one female)
    • Suicide - 1 (one female)
    • Undetermined – 1 (one female)
  • In 2017, there was a comprehensive review involving five deaths that occurred at the same retirement home. While there was individual case reviews prepared for each death, there was also a collective analysis of common factors and suggested recommendations relating specifically to the home involved. 
  • Of the 18 deaths reviewed, six were male and 12 were female.
  • The average age of men whose deaths were reviewed was 77.8 years.
  • The average age of women whose deaths were reviewed was 85.7 years.
  • The average age of all deaths reviewed in 2017 was 83.1 years.
  • In 2017, the most common  areas for improvement identified by GLTCRC  through their case reviews consisted of:
    • Medical and nursing management
    • Communication and documentation
    • Use of drugs in the elderly
    • Acute care and long term care industry in Ontario, including the Ministry of Health and Long Term Care (MOHLTC)
    • Determination of capacity and consent for treatment/DNR

*Note: For the purposes of a coroner’s investigation, the finding of “homicide” does not imply a finding of legal responsibility or culpability.


Chapter One: Introduction

The annual GLTCRC report is intended to provoke thought and stimulate discussion about geriatric and long term care deaths in Ontario. It contains statistical information about cases reviewed and the resulting recommendations from those reviews.

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 others receiving services within long term care homes;
  2. To provide expert review of the circumstances of the care provided to individuals receiving geriatric and/or long term care in Ontario prior to their death;
  3. To produce an annual report that is available to doctors, nurses, healthcare providers, social service agencies, and others, for the purposes of death prevention awareness;
  4. To review cases forwarded to them and help identify whether there are any systemic issues, trends, risk factors, problems, gaps, or other shortcomings in the circumstances of each case, in order to facilitate the development of appropriate recommendations to prevent future similar deaths; and,
  5. To conduct and promote research where results and a comprehensive understanding may lead to recommendations that will prevent future similar deaths.

Note: The above described objectives and 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.

The OCC has made it a policy to submit all coroner’s investigations involving homicides in long term care or retirement homes in the province to the GLTCRC for further review.  Other cases involving the deaths of elderly individuals (regardless of whether they are in a long term care or retirement setting), may be referred to the GLTCRC for review if systemic issues or implications may be present.

Structure and Size

The GLTCRC consists of respected practitioners in the fields of geriatrics, gerontology,  pharmacology, family medicine, emergency medicine, psychiatry, nursing and services to seniors.  This Committee membership reflects practical geographical balance and representation from various levels of institutions providing geriatric and long term care.

The Chair of the GLTCRC can either be a Regional Supervising Coroner or Deputy Chief Coroner.   Committee support is provided by the Executive Lead, Committee Management, OCC.

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 officers, 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.

Methodology

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. 

A minimum of at least one member of the Committee reviews the information submitted by the Regional Supervising Coroner, and then presents the case to the other Committee members. Following Committee discussion, a final case report is produced that includes a summary of the events, the Committee’s collective findings and recommendations intended to prevent deaths in similar circumstances. The report is sent by the Chairperson to the referring Regional Supervising Coroner, who may conduct further death investigation if necessary.

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

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

Limitations

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 and 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 and subject to confidentiality and privacy limitations imposed by the Coroners Act and the Freedom of Information and Protection of Privacy Act. Accordingly, individual reports, review meetings, and any other documents or reports produced by the GLTCRC are confidential and may 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 publicly give opinions about cases they have reviewed.  In particular, Committee members  will not act as experts at civil trials for cases that the GLTCRC has reviewed. Additionally, 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.

It is recognized that the GLTCRC only reviews deaths that meet the criteria for mandatory referral (i.e. homicides in long term care or retirement homes), or discretionary referral (i.e. where systemic issues or implications may be present).  Discretionary referrals may be based on concerns or issues identified by the investigating coroner, Regional Supervising Coroner or family.

Statistics generated from GLTCRC reviews, particularly as they relate to themes and trends,  may be inherently biased due to the selection criteria for cases referred to the Committee.  It is also recognized that there is a certain level of subjectivity when themes are assigned during analysis.

Recommendations

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 Chairperson.

Organizations and agencies are asked to respond to the Executive Lead, Committee Management, OCC on the status of implementation of issued recommendations within six months of receiving them. Similar to recommendations generated through coroner’s inquests, GLTCRC recommendations are not legally binding and there is no legal obligation for agencies and organizations to implement or respond to them.  

Recommendations made to cases reviewed by the GLTCRC in 2017 are included in Appendix A.

Responses to recommendations are part of the public record and are available by contacting occ.inquiries@ontario.ca


Chapter Two: Statistical Overview: 2004-2017

Between 2004 and 2017, the GLTCRC reviewed a total of 300 cases and generated 680 recommendations aimed towards the prevention of future similar deaths. On average, the GLTCRC has reviewed 21.4 cases and generated 48.6 recommendations per year.

It is recognized that there is an inherent bias as to which cases undergo review (i.e. most cases are discretionary referrals sent to GLTCRC due to the presence of identified concerns and issues).  There is also the possibility of researcher bias in attributing certain themes to cases and recommendations.  It is also recognized however, that regardless of these potential biases, there are certain recurring themes that have emerged over the years.  These themes can be applied at a broader level to cases and more specifically to focused recommendations.   

The themes identified include:

  • Medical and nursing management
  • Communication and documentation
  • Use of drugs in the elderly
  • Use of restraints
  • Determination of capacity and consent for treatment/DNR
  • The acute care and long term care industry in Ontario, including the Ministry of Health and Long Term Care (MOHLTC)
  • Other: includes other Ontario ministries, justice and legal systems

The following statistical analysis on themes has been broken down into two distinct sections:

  • An analysis of themes based on individual cases reviewed
  • An analysis of themes based on individual recommendations made

By breaking the analysis down into cases vs. recommendations, it is possible to observe general trends relating to themes that emerge throughout cases that have been referred and reviewed by the GLTCRC, compared to themes that have emerged from specific recommendations. 

Trends based on themes in cases helps to identify what issues or themes are present in the cases that are being referred to the GLTCRC for review. These findings help to identify if there is a trend in the types of cases that are being referred and reviewed.

Trends based on themes in recommendations helps to identify what specific themes/issues have been identified and addressed in recommendations aimed toward the prevention of future similar deaths. A trend in themes of recommendations helps to identify specific areas where the need for change, action or attention has been suggested. 

Graph One: % of major issues based on theme identified in GLTCRC cases from 2004-2017

 

From 2004 until 2017, the GLTCRC has reviewed a total of 300 cases. 

Many cases had more than one theme/issue attributed to the recommendations.  A theme was attributed to a case if it applied to one or more of the recommendations made for that case.

Graph 1

**Note: ‘Other’ includes recommendations to other ministries or in the legal/justice sector.

Graph One demonstrates that in 48% of the cases reviewed by the GLTCRC from 2004-2017, issues relating to medical/nursing management were identified. This is followed by 37% of the cases where issues pertaining to the acute and long term care industry (including MOHLTC) were noted and 31% of the cases where issues of communication/documentation were present. Other key themes included use of drugs in the elderly (20%), use of restraints (5%), determination of consent and capacity/DNR (4%) and other (8%). 

Graph Two: Trend of major issues based on % of theme identified in GLTCRC cases (2004-2017)

Graph 2

**Note: 'Other' includes recommendations to other ministries or in the legal/justice sector

Graph Two demonstrates that consistently over the years, the themes of medical/nursing management, communication/documentation and acute care and long term care industry have been prominently identified in cases reviewed by the GLTCRC.  Communication/documentation issues were on a steady increase until 2014, declined in 2015 and 2016 and rose in 2017.  Use of drugs in the elderly has remained fairly constant.  Issues relating to the use of restraints were on the increase until 2012 and have declined since then.  The issue of determination of capacity and consent for treatment and/or DNR was a key issue addressed in five cases in 2016, but only one in 2017.

Graph Three: % of major issues based on theme(s) identified in GLTCRC recommendations (2004-2017)

From 2004 until 2017, the GLTCRC generated 680 recommendations aimed at the prevention of future similar deaths.

*Note: Some recommendations had more than one theme/issue attributed.

Graph 3

**Note: 'Other' includes recommendations to other ministries or in the legal/justice sector

Graph Three demonstrates the percentage of common themes/issues attributed to the individual recommendations made from the cases reviewed from 2004-2017. Some complex recommendations may have been recorded as having more than one theme or issue. It was found that 39% of all recommendations made were related to medical or nursing management while 23% of the recommendations touched on the acute and long term care industry, including the MOHLTC.  The other themes/issues that were present, but that were less frequently assigned to the recommendations, were related to communication/documentation (20%), use of drugs in the elderly (13%), determination of capacity and consent for treatment or DNR (3%), the use of restraints (4%) and other (4%).

 

Graph Four: Trend of major issues based on % theme identified in GLTCRC recommendations (2004-2017)

Graph 4

**Note: 'Other' includes recommendations to other ministries or in the legal/justice sector.

Graph Four demonstrates that consistently over the past 14 years, the majority of recommendations made by the GLTCRC addressed issues pertaining to medical and nursing management, communication and documentation and the acute and long term care industry, including MOHLTC.  The other themes/issues that were identified, but less frequently, were related to use of drugs in the elderly, determination of capacity and consent for treatment or DNR, the use of restraints and other.

This graph demonstrates that medical/nursing management issues appeared to be decreasing between 2010 and 2014, then rose, then declined. Issues surrounding the use of drugs in the elderly, the use of restraints and the determination of consent and capacity have fluctuated over the years.  In 2016, the determination of capacity and consent was an issue in five of the cases reviewed and in 2017, only one case identified this theme. Issues relating to communications/documentation were increasing until 2014, declined in 2015 and 2016, and then rose again in 2017.


Chapter Three: Cases Reviewed in 2017

In 2017, the GLTCRC reviewed a total of 18 cases involving the deaths of 18 elderly individuals (12 females and six males), including residents of long term care and retirement homes. Of the 18 cases, two were mandatory reviews resulting from homicides that occurred in long term care facilities. 

Of the 18 cases reviewed in 2017, one of the deaths occurred in 2014, five in 2015, 10 in 2016 and two in 2017.

In 2017, there was a comprehensive review involving five deaths that occurred at the same retirement home (see cases 2014A – 2014E).  While there was  an individual case review prepared for each death, there was also a collective analysis of common factors and suggested recommendations relating specifically to the home involved.  

[Note: The OCC has made it a policy to submit all coroner’s investigations involving homicides in long term care or retirement homes in the province to the GLTCRC for further review. Other cases involving the deaths of elderly individuals (regardless of whether they are in a long term care or retirement setting), may be referred to the GLTCRC for review if systemic issues or implications may be present, or if concerns were identified by the family, investigating coroner or Regional Supervising Coroner.]

A summary of cases reviewed and recommendations made in 2017 is included in Appendix A.

Full, redacted narrative reports may be obtained by contacting the OCC at occ.inquiries@ontario.ca.

From the cases reviewed in 2017, the average age of female decedents was 85.7 years and male decedents was 77.8 years; combined, the average age of all decedents reviewed in 2017 was 83.1 years.

Average age of decedent in cases reviewed in 2017:​

Average age graphic

Female - 85.7 years
Male - 77.8 years
Average - 83.1 years
 

  
 

Graph Five: 2017 GLTCRC reviews based on manner of death and sex of decedent

Graph 5

Graph Five demonstrates the breakdown of cases reviewed by the GLTCRC based on manner of death and sex of the decedent.  Of the 18 cases reviewed, nine were natural (five females and four males), five were accidents (four females and one male), two were homicides (one female and one male), one was undetermined (one female) and one was suicide (one female).

In 2017, the GLTCRC generated a total of 41 recommendations aimed at preventing future similar deaths.  There were three cases that did not result in any recommendations.  Although the GLTCRC may not have generated recommendations in these cases, the analysis of the circumstances and subsequent discussion contributed significantly to the larger coroner’s investigation of the deaths.

Recommendations made by the GLTCRC 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 OCC within six months. These organizations were encouraged to self-evaluate the implementation status of recommendations assigned to them.  

Recommendations were also shared with chief coroners and medical examiners in other Canadian jurisdictions and are available to others upon request.

 

Graph Six: % of major issues based on theme(s) identified in GLTCRC recommendations made in 2017

Graph 6

**Note: 'Other' includes recommendations to other ministries or in the legal/justice sector.

Graph Six demonstrates the distribution of themes/issues for the recommendations made for the cases reviewed in 2017. The most commonly identified themes/issues were related to medical or nursing management (41%), communication and documentation (32%), use of drugs in the elderly (22%), the acute and long term care industry (17%), “other” (including recommendations to the OCC and Regional Supervising Coroners) (7%) and determination of capacity and consent for treatment/DNR (2%). There were no recommendations in 2017 pertaining to the use of restraints.  

It is recognized that the issues identified and any resulting trends, are based on the cases that are referred for review.  Other than the reviews of homicides within LTCHs which are mandatory (based on the policy of the Office of the Chief Coroner), all other cases are referred for review based on a discretionary, and therefor subjective, decision to do so.  It is acknowledged that the discretionary nature of some referrals may result in trends based on issues or concerns that have been identified as areas requiring further attention and analysis.

Overall summary of cases reviewed and recommendations made by the GLTCRC in 2017: 

  • In 2017, there were 18 cases reviewed and 41 recommendations made.
    • Of the 18 cases reviewed in 2017, one of the deaths occurred in 2014, five in 2015, 10 in 2016 and two in 2017.
    • Medical/nursing management issues were identified in 41% of the recommendations made.
    • Communication and documentation issues were identified in 32% of the recommendations made.
    • MOHLTC and/or LTC industry issues were identified in 17% of the recommendations made.
    • ‘Other’ (including direction to the OCCO, Regional Supervising Coroner, etc.) was identified in 7% of the recommendations made.
    • Use of drugs in the elderly was identified in 22% of the recommendations made.
    • Determination of capacity and consent for treatment / DNR was identified in 2% of the recommendations made.
    • None of the recommendations touched on the use of restraints in the elderly.
    • Some of the recommendations touched on more than one issue.
  • There were three cases that did not have any recommendations.
  • Of the 18 cases reviewed, 12 involved female decedents and six male decedents.
  • The average age of female decedents in cases reviewed in 2017 was 85.7 years.
  • The average age of male decedents in cases reviewed in 2017 was 77.8 years.
  • The average age of all decedents (i.e. male and female combined) in cases reviewed in 2017 was 83.1 years.
  • Of the cases reviewed in 2017, the manner of death for each of the 18 cases was broken down into:  natural (9), accident (5), suicide (1), homicide (2) and undetermined (1).   
  • In 2017, there was a comprehensive review involving five deaths that occurred at the same retirement home. While there was individual case reviews prepared for each death, there was also a collective analysis of common factors and suggested recommendations relating specifically to the home involved.

Chapter Four: Learning from GLTCRC Reviews

Recurrent themes from the GLTCRC include violence in long term care (LTC), elder abuse, medical management including medication use, restraints, consent and capacity and the management of dementia and psychiatric illness.

Violence in LTC has received much attention within the sector and from the public. Strategies have been developed and resources deployed, yet the problem persists. The GLTCRC recognizes the need for government, regulators, industry and care providers to continue to collaborate on a comprehensive approach to address this issue. Management of aggressive behaviour should be a primary consideration as government pursues facility renewal and expansion.

Although physical abuse and neglect causing death is not often seen in the cases reviewed by the GLTCRC, elder abuse in its many forms is often a contributing factor. This is true not only in facilities, but also in the community, where the elderly cannot access resources or are in the care of those who cannot, or will not access the resources on their behalf. The community as a whole should accept responsibility for vulnerable seniors, much as we have for vulnerable children.

In regard to consent and capacity, it is clear that organizational practices often do not reflect the law as it applies to the use of advance directives, “do not resuscitate” (DNR) orders and powers of attorney for personal care. The committee has identified a need for broad industry education in order to ensure the rights of elderly individuals and residents of long term care facilities. Healthcare providers in particular must be aware of their responsibilities and authorities and of the resources available to them when questions and conflict relating to consent and capacity arise.

The GLTCRC 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.


 

Appendix A: Summary of 2017 Cases and Recommendations

Appendix A
GLTCRC File # # of Recs Summary of Case Recommendation(s) Theme
2017-01 0 This case involved the death of an 84-year-old woman who died after breaking her hip following an apparent fall during a lift transfer in the long term care home where she resided.  N/A
2017-02 1 This case was referred to the Geriatric and Long Term Care Review Committee (GLTCRC) as the death may have resulted from resident-on-resident aggression in a long term care home (LTCH). 1. Long-term Care Homes are reminded of the mandatory obligation under O. Reg. 79/10, s. 53 (1) to ensure that the needs of residents with responsive behaviours are met, and critically, to reassess and revise these measures when persistent physical aggression is seen. System resources, including psychogeriatric assessment, Behavioural Supports Ontario engagement and possible transfer to acute mental health inpatient units/behaviour support units should be considered for residents with persistent physical aggression. Medical/nursing management
2017-03 2 The Geriatric and Long Term Care Review Committee (GLTCRC) was asked to review the circumstances surrounding the death of this 90-year-old woman after concerns were raised about the provision of community-based healthcare support.
  1. Regulated Health Professionals employed in the Home and Community Care sectors of local LHINS are reminded of their professional obligation to obtain assistance, clarify goals of care and notify care coordinators when clinical deterioration is noted.
  2. Regulated Health Professionals and their respective organizations employed in the Home and Community Care sectors of local LHINS are reminded of the need to use trained interpreters when assessing patients who speak a different language than the provider.
Medical / nursing management Communication / documentation
2017-04 4 This case was referred to the Geriatric and Long Term Care Review Committee (GLTCRC) following the death of a 77-year-old man after chronic use of a narcotic type anti-diarrheal (i.e. Loperamide) in a Long Term Care Home (LTCH).  Concerns were raised that the drug may have led to a bowel pseudo-obstruction (Ogilvie’s syndrome) and subsequent complications resulting in death. 1. Interprofessional care conferences should include the clinical care providers most familiar with the resident’s health status. 2. Pharmacy medication reviews should include knowledge of the resident’s clinical status. Quarterly medication reviews by the physician and Medscheck reviews by the pharmacist should be done simultaneously and in person.  3. Referral to a specialist should include a full list of current medications and pertinent clinical information. 4. Physicians are reminded that diarrhea is a symptom and not a diagnosis. Anti-diarrheal agents should not be used in the absence of a diagnosis. Anti-diarrheal agents are for short term use and should not be used on a continuous basis especially in a vulnerable population at risk of Ogilvie syndrome such as those in Long Term Care Homes. Communication / documentation Medical / nursing management Medical / nursing management Medical / nursing management
2017-05 1 This case involved the death of a 75-year-old man following two years of declining health. He was normally fed through a jejunostomy tube (J-tube), and had known mild-to-moderate oropharyngeal dysphagia. The decedent’s family was concerned about his access to food and drink in his place of residence and about his medication management.  1. Frail elderly persons, especially in hospitals and Long Term Care Homes, frequently have changes in health status. As part of standard care, diagnosis and prognosis should be determined in the case of a change in health status. In addition, goals of care for an individual should be reviewed with the person and/or their substitute decision-maker, especially in the case of continual decline in health status over a period of time.

Medical / nursing management

2017-06 0 The Geriatric and Long Term Care Review Committee (GLTCRC) was asked to review the death of this 90-year old woman who was a resident of a regulated retirement home. The decedent died of an unwitnessed sudden cardiac arrest at the retirement home. The GLTCRC was asked to address the following issues: 1. Training of the staff in the retirement home in Basic Cardiac Life Support (CPR), and 2. The lack of availability of an Automated External Defibrillator (AED) in the retirement home. N/A
2017-07 3 This case involved the death of a 91-year-old woman who committed suicide while a resident in a long term care home (LTCH).  The woman died from mixed drug toxicity.  Concerns relating to suicide prevention, psychiatric care and medication management were identified.
  1. Long term care homes should develop an approach to suicide risk assessment that encourages assessment of residents expressing suicidal ideation and which includes developing care planning for the specific care needs of the resident. Such an assessment would include safety planning as well as identifying and treating modifiable risk factors such as untreated depression, physical pain, and social isolation
  2. Long term care clinicians are reminded that when patients are deemed to be capable, that consent for treatment is to be obtained from them, not their power of attorney or substitute decision maker.
  3. Long term care and retirement homes should be reminded of the privacy rights of residents. Guidelines should be developed to assist homes to balance those rights with the safety and security of the institution and other residents and staff.
Medical / nursing management Determination of capacity and consent for treatment / DNR Acute and long-term care industry, including MOHLTC
2017-08 5 This case involved the death of a 60-year-old woman who was schizophrenic and lived in a community group home.  The woman died from complications of constipation and fecal impaction.  Concerns relating to the management of constipation were identified. 1. Physicians treating patients on clozapine are reminded that clozapine is a potent inhibitor of gastrointestinal motility and can cause severe, and even life-threatening, constipation. There is an even higher risk of severe constipation in persons as they age, and in those who have other medical conditions that put them at higher risk of constipation (e.g. diabetes mellitus). This potential side-effect of clozapine needs to be closely monitored with regular assessment of bowel habit. Proactive management of this known adverse effect should be considered, with the first line of treatment being an osmotic agent (e.g. polyethylene glycol) and/or a stimulant laxative (e.g. senna). 2. The risk of adverse anti-cholinergic side effects of medications, particularly constipation, increases with age and the number of medications prescribed. Health professionals are reminded to watch for additive anti-cholinergic side-effects of medications, and to constantly monitor for opportunities to “deprescribe” as part of good practice. 3. When treating patients who are taking pro-constipatory medications, it is critical to anticipate, monitor and prescribe laxatives as a routine part of prescribing pro-constipatory medications (e.g. opioids, neuroleptics). Primary care providers are ideally placed to play this role, as it is often these providers who have the only overall view of all the medications a patient is taking. 4. Constipation is a life-threatening complication of clozapine. Bowel monitoring should be included as a routine aspect of the monitoring program for persons taking this drug. 5. The Regional Supervising Coroner should report this case to Health Canada as a death due to a side effect of clozapine. Use of drugs in the elderly Use of drugs in the elderly Use of drugs in the elderly Medical / nursing management Other**
2017-09 0 This was a mandatory referral to the Geriatric and Long Term Care Review Committee (GLTCRC) as the manner of death was determined to be homicide. The 92-year-old decedent died from complications of a hip fracture that she sustained after being pushed by another resident in the long term care home (LTCH) where they both resided. N/A
2017-10 3 This was a mandatory referral to the Geriatric and Long Term Care Review Committee (GLTCRC) as the manner of death was determined to be homicide. The 83-year-old decedent died after an altercation with another resident while in the long term care home (LTCH) where they both resided.  1. Staff and physicians working in long term care homes are reminded that: i) Non-pharmacologic management of responsive behaviours is essential, but early intervention with pharmacologic measures and psychiatric evaluation is necessary in those patients at high risk of harm to themselves and others; ii)  Mental illness in persons with co-morbid dementia needs to be treated with therapeutically effective doses of medication. 2. The Medical Director of the long term care home involved should review this case with the physicians and staff involved.  3. The Medical Director should explore opportunities for a sustained relationship with the psychiatric supports available in the community. Medical / nursing management Communication / documentation Communication / documentation
2017-11 1 This case was referred to the Geriatric and Long Term Care Review Committee (GLTCRC) as concerns were identified relating to the care the 71-year-old decedent received while a resident in a long term care home (LTCH).  Concerns related specifically to nutrition and hydration. 1. For patients with progressive diseases (especially those that are inevitably fatal), a management plan that focusses on patient centered management and outcomes should be favoured over detailed monitoring that cannot influence management.  This plan should reflect the patient’s wishes, and be carefully documented in the health care record. Medical / nursing management
2017-12 4 The decedent was an 85-year-old woman with an advanced dementia who lived in a long term care home (LTCH).  The woman died from bilateral pneumonia due to aspiration following an overdose of phenobarbital. Concerns were raised as to whether the medication error resulted in her death. 1. Medication software vendors should design medication administration records to meet the needs of end users (i.e. nurses) by ensuring that information is presented in a logical fashion to support nursing processes (e.g. the medication dose to be administered is clearly differentiated from the dosage strength/concentration supplied). 2. Pharmacies should ensure that where multiple dosage forms of a medication are available, that the dosage form dispensed is as close as possible to the ordered dose. 3. Pharmacies should ensure that instructions for medication administration can be followed with the equipment available. 4. ISMP should review this case and consider opportunities to share learning through an ISMP Canada Safety Bulletin. Other** Use of drugs in the elderly Use of drugs in the elderly Other**
2017-13 2 This case involved the death of an 84-year-old woman who died from complications of a hip fracture.  The Geriatric and Long Term Care Review Committee (GLTCRC) was asked to review the circumstances surrounding this death after concerns were raised regarding the decedent’s transfer from an acute care hospital back to a retirement home when her medical status was unstable.   1. Physicians are reminded that patients should only be discharged from the acute care hospital setting once they are clinically stable, and a plan and goals of care are in place that can be clearly met in the discharge setting. Patients who are clinically unstable, and receiving active medical and nursing care aimed at improvement, should remain in acute care until they are stable and/or improving. 2. The acute care hospital involved in this case should undertake a lessons learned case review of the circumstances surrounding this decedent’s death with particular focus on discharge planning and process, including decision-making.  Medical / nursing management Communication / documentation
2017-14 4 The Geriatric and Long Term Care Review Committee (GLTCRC) was asked to review a cluster of five deaths that occurred between January 2016 and July 2017 at Retirement Home A.  The reviews focused on concerns identified through the investigation into the circumstances of each individual death, together with a collective assessment of any patterns and/or systemic issues consistent throughout the cluster.
  1. The MOHLTC and the Ministry of Seniors Affairs should ensure that the care of frail elders with complex chronic health conditions (including dementia) is provided with similar standards, requirements, regulations and oversight regardless of where they reside.  The ministries should review the discrepancies between the Long-Term Care Homes Act, Retirement Homes Act and the Home and Community Care Services Act to ensure that the standards set meet the needs of frail seniors no matter what setting they live in.   This is increasingly important as the concept of “Aging in Place” becomes a cornerstone of our system of health and community care.
  2. The RHRA should consider a broader inspection of Retirement Home A to ensure that the residents living there are receiving proper care and support according to the regulations.
  3. Great care and caution should be used when transferring a resident of a long term care home to a retirement home. The care plan prepared at the long term care home must be shared with the retirement home and a comprehensive care plan for the newly transferred resident should be developed.  The resident’s family/substitute decision maker(s) should be fully apprised of the care plan and differences between a long term care home and retirement home. 
  4. The care of frail elders with complex health needs requires a full inter-professional team with excellent teamwork and processes of care in place. Retirement home operators who contemplate care of this population must have an inter-professional team in place, with excellent teamwork, processes of care and documentation in order to respond to the needs of this population.
Acute and long-term care industry, including MOHLTC Acute and long-term care industry, including MOHLTC Medical / nursing management Medical / nursing management
2017-14A 1 This case involved the death of a 92-year-old woman who was a resident at Retirement Home A. This case was referred to the GLTCRC after concerns were raised by the family and an inspection was conducted by the Retirement Home Regulatory Authority (RHRA).  This case was part of a cluster of five deaths referred to the GLTCRC involving Retirement Home A. 1. The Licensee of this home should carry out a thorough audit of charting procedures including medication administration records (MARs) and communication procedures between shifts, and implement changes to ensure accurate and complete documentation as well as compliance with provincial privacy legislation. The Licensee should also ensure adequate documentation and follow-up of falls is completed to ensure adequate care of residents and mitigation of future falls. Communication / documentation
2017-14B 3 The decedent was a 91-year-old woman who died in hospital from dehydration and hypernatremia shortly after transfer from Retirement Home A.  The decedent’s family had concerns about the quality of care provided in the retirement home.  This case was part of a cluster of five deaths referred to the Geriatric and Long Term Care Review Committee involving Retirement Home A. 1. The Licensee of Retirement Home A should ensure that all management staff is familiar with the provincial Retirement Homes Act, including incident reporting requirements. 2. The Licensee of Retirement Home A should ensure that charting, documentation and staff communication are sufficient to care for the needs of their complex clients. 3. Physicians are reminded that diphenhydramine can be very sedating in the elderly and may contribute to delirium.  Diphenhydramine should be used with caution and carefully monitored when prescribed to elderly patients. Acute and long-term care industry, including MOHLTC Communication / documentation Use of drugs in the elderly
2017-14C 1 This case involved the death of an 83-year-old man who died of dehydration while living in Retirement Home A. This case was part of a cluster of five deaths referred to the GLTCRC involving Retirement Home A. 1. Retirement Home A should review its approach to: • care planning based on the individual goals of the resident • documentation • inter-professional and team-family communication and team functioning. Acute and long-term care industry, including MOHLTC
2017-14D 4 The decedent was a 78-year-old woman with dementia who died from Staphylococcus Aureus bronchopneumonia in association with malnutrition, one week after being transferred from Retirement Home A to a long term care home (LTCH).   Concerns were raised about the quality of care received at Retirement Home A.  This case was part of a cluster of five deaths referred to the Committee involving Retirement Home A. 1. Health professionals visiting a client on behalf of a LHIN Home and Community Care Unit (formerly CCAC) should advise the Care Coordinator when concerns are identified where a living environment may not be meeting the needs of a client. 2. Frail elderly individuals with complex health needs who are waiting for admission to a Long Term Care Home should have regular reassessment by the LHIN team as to their care needs and health status. If they are living in a location where their care needs are not being met properly, expedited transfer to a LTCH should be offered. If necessary, “Crisis Placement” should be offered. 3. Where the needs of an elderly individual exceed what can be reasonably or safely provided in the congregate living situation (i.e., a retirement home), the LHIN Care Coordinator/Case Manager should escalate the situation to the LHIN Management Team to intervene and advocate for the appropriate level of care.   4. Retirement Home A should review its approach to: • care planning based on the individual goals of the resident • documentation • inter-professional and team-family communication and team functioning. Communication / documentation Medical / nursing management Medical / nursing management Acute and long-term care industry, including MOHLTC
2017-14E 2 This case was referred for review as the 79-year-old decedent died three days after being reported missing from the retirement home where he lived. This case was part of a cluster of five deaths referred to the GLTCRC involving Retirement Home A. 1. The Licensee of Retirement Home A should review the physical structure, policies and procedures for this home with respect to wandering residents and the use of the electronic tracking and security system in this setting to ensure that the safety and security needs of residents are met. 2. All staff in Retirement Home A should be trained in their language of choice (French or English) to ensure effective retention and exchange of information.  All staff within the home should understand the nature of the residents and their safety needs. Acute and long-term care industry, including MOHLTC Communication / documentation