Chapter 3: Cases reviewed in 2023
In 2023, the Geriatric and Long-Term Care Review Committee (GLTCRC) reviewed a total of 17 cases involving the deaths of 17 older individuals (eight males and nine females), including residents of long-term care and retirement homes. Of the 17 cases, two were mandatory reviews as these were homicides that occurred in long-term care facilities.
Of the cases reviewed in 2023, one of the deaths occurred in 2019, two in 2020, six in 2021, and eight in 2022.
A summary of cases reviewed, and recommendations made in 2023 is included in the Appendix.
Full, redacted reports and responses to recommendations may be obtained by contacting the OCC at occ.inquiries@ontario.ca.
Average Age of Deceased Person in Cases Reviewed In 2023
- Male: 83.9 years
- Female: 87.2 years
From the cases reviewed in 2023, the average age of all deceased persons was 85.6 years.
Graph Three: 2023 GLTCRC reviews based on manner of death and sex of deceased person (n=17)
Graph Three demonstrates the breakdown of cases reviewed by the GLTCRC based on manner of death and the biological sex assigned at birth of the deceased person. Of the 17 deaths reviewed, seven were natural (three female and four male), seven were accidents (four female and three male), two homicides (two female), and one undetermined (one male); there were no suicide deaths reviewed.
In 2023, the GLTCRC generated a total of 76 recommendations aimed at preventing further deaths. One case resulted in no recommendations. However, despite the absence of specific recommendations, the analysis and subsequent discussions were valuable, offering important insights that contributed to the coroner’s broader investigation and addressing the concerns that prompted the referral to the committee.
Recommendations made by the GLTCRC are 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 are asked to respond to the OCC within six months. These organizations are encouraged to report on the implementation status of recommendations assigned to them. Recommendations and response to these are available upon request.
Graph Four: Percent of major issues based on theme(s) identified in GLTCRC recommendations made in 2023 (n=76)
Note: Some recommendations had more than one theme/issue attributed.
Note: 'Other' includes recommendations that do not fall into any of the other listed themes.
Graph Four demonstrates the distribution of themes/issues for the recommendations made from the deaths reviewed in 2023. The most commonly identified themes/issues were related to the acute and long-term care industry (37%), communication and documentation (26%), medical or nursing management (24%), training and education (20%), “other” (12%), use of drugs in the elderly (12%), and determination of consent and capacity (1%). Although the use of restraints was recognized as a recurring recommendation theme, there were no specific recommendations that fit into the category.
It is recognized that the issues identified and any resulting trends, are based on the deaths that are referred for review. Other than the reviews of homicides within LTCHs which are mandatory (based on the policy of the OCC), all other deaths 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.