Probes on long-term care deaths cut back, inquiry told

Policy to review every 10th case reduced to save $900K a year, coroner tells Wettlaufer hearing

The Office of the Chief Coroner of Ontario cut back on investigations into deaths of residents in long-term care homes in order to save money, a public inquiry has learned.

In 2013, the coroner’s office ended the practice of automatically probing every 10th death in a long-term care home, Chief Coroner Dr. Dirk Huyer testified on Monday at a public hearing looking into how ex-nurse Elizabeth Wettlaufer went undetected as she killed eight residents.

The move, saving $900,000 a year, came in the midst of Wettlaufer’s killing spree at long-term care homes in southwestern Ontario.

There’s no indication such a review would have flagged Wettlaufer’s crimes, which occurred between 2007 and 2016.

Huyer said the practice of automatically investigating the “threshold deaths” had not provided good value for money.

“We weren’t finding trends or patterns or specific issues,” he said.

The change in policy came at around the same time as the Ontario health ministry increased its oversight of the long-term care sector. Because of this, there was “no incremental value of routine reviews” by coroners as well, according to documents from the coroner’s office, filed as exhibits.

“The proposed changes will decrease unnecessary coroner investigations and will result in savings of about ($900,000 annually) starting in 2013-14,” stated a business case from the coroner’s office.

The documents showed that there were 927 death investigations of long-term care residents in 2015, compared to 2,971 in 2011.

Between 8 and 9 per cent of death investigations in longterm care homes result in post mortems, Huyer said. That compares to 40 per cent of all deaths investigated.

Wettlaufer, 51, pleaded guilty to eight counts of first-degree murder, four counts of attempted murder and two counts of aggravated assault. She checked herself into a mental health hospital in 2016 and confessed to carrying out the crimes.

The inquiry earlier heard that a coroner had declined to investigate the death of one of Wettlaufer’s victims even though it had been flagged as suspicious. Maureen Pickering, a 79-year-old resident of the Caressant Care nursing home in Woodstock, Ont., died in 2014 after being given a lethal injection of insulin by Wettlaufer.

A doctor at the local hospital identified Pickering’s death as one the coroner should look into.

So too did a nurse from Caressant Care who suggested the local coroner do an autopsy.

But the local coroner, who will take the stand later at the inquiry, decided such measures were unnecessary.

The coroner’s office must probe all “sudden and unexpected” deaths, but has much discretion over the level of its response, the inquiry was told.

“There may be no substantial investigation beyond the first phone call,” Huyer explained.

The chief coroner outlined systems that have been put in place to track deaths at longterm care facilities and identify unusual patterns at individual homes. But those measures do not paint a complete picture, he said.

Although homes are mandated to file reports of resident deaths to his office electronically, Huyer said several still submit their forms by fax and are therefore not included in any analysis that’s carried out.

He also called for a change to the rules, which currently don’t track the deaths of long-term care residents who die in hospital rather than at the home.

“Deaths that occur in hospitals may well have been from incidents that initiated within the long-term care home,” Huyer told the inquiry. “Clearly that would be important for us to understand if we’re going to look at trends or patterns that may occur.”

He noted that what is considered a “sudden and unexpected” death to someone working in a long-term care home might be looked upon differently by a coroner.

He gave the example of a resident with heart and lung disease who participates in activities and is well enough to go to the dining room for meals.

If that resident passes away during the night, that may be viewed as a sudden and unexpected death to someone working in a long-term care home, but not necessarily to a coroner, Huyer said.

Huyer said it can be challenging for coroners to decide which deaths to investigate.

Some 26,000 deaths in Ontario are reported annually to the coroner’s office, the hearing was told. (This number includes residents of long-term care homes.)

Of those reported, 9,000 do not result in investigations after consideration by local coroners.

“If the death seems unusual and there are concerns about it, we should be investigating,” he said.

Huyer said there is no oversight of decisions by coroners not to investigate deaths.