In 2019, the GLTCRC reviewed a total of 27 cases involving the deaths of 28 elderly individuals (14 females and 14 males), including residents of long-term care and retirement homes. Of the 27 cases, six were mandatory reviews resulting from homicides that occurred in long-term care facilities. 

Of the cases reviewed in 2019, three of the deaths occurred in 2015, two in 2016, eight in 2017 and 15 in 2018.

[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 2019 is included in Appendix A.

Full, redacted reports and responses to recommendations may be obtained by contacting the OCC at occ.inquiries@ontario.ca.

Average age of decedent in cases reviewed in 2019: 

  • Female: 86 years
  • Male: 82.4 years
  • From the cases reviewed in 2019, the average age of all decedents was 84.2 years.

Graph Three: 2019 GLTCRC reviews based on manner of death and sex of decedent

Graph Three demonstrates the breakdown of cases reviewed by the GLTCRC based on manner of death and sex of the decedent.  Of the 28 cases reviewed, 11 were natural (five females and six males), nine were accidents (seven females and two males), six were homicides (two females and four males), two were undetermined (two males) and there were no suicide cases reviewed.  

In 2019, the GLTCRC generated a total of 64 recommendations aimed at preventing future deaths.  There were five 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 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 self-evaluate the implementation status of recommendations assigned to them.  

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

Graph Four: % of major issues based on theme(s) identified in GLTCRC recommendations made in 2019

Graph Four demonstrates the distribution of themes/issues for the recommendations made for the cases reviewed in 2019. The most commonly identified themes/issues were related to medical or nursing management (44%), the acute and long-term care industry (33%), communication and documentation (17%), use of drugs in the elderly (13%), “other” (including recommendations to other ministries, the police and Regional Supervising Coroners) (11%).  There were no recommendations made in 2019 pertaining to 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 2019: 

  • In 2019, there were 27 cases involving 28 deaths reviewed by the GCTCRC. There were 64 recommendations made.
    • Of the cases reviewed in 2019, three of the deaths occurred in 2015, two in 2016, eight in 2017 and 15 in 2018.
    • Medical/nursing management issues were identified in 44% of the recommendations made.
    • Communication and documentation issues were identified in 17% of the recommendations made.
    • MOHLTC and/or LTC industry issues were identified in 33% of the recommendations made.
    • ‘Other’ (including recommendations to police services and Regional Supervising Coroners, etc.) was identified in 11% of the recommendations made.
    • Use of drugs in the elderly was identified in 13% of the recommendations made.
    • None of the recommendations touched on the use of restraints in the elderly or determination of consent and capacity / DNR.
    • Some of the recommendations touched on more than one issue.
  • There were five cases that did not have any recommendations.
  • Of the 27 cases (involving 28 deaths) reviewed, 14 involved female deceased persons and 14 male deceased persons.
  • The average age of all decedents (i.e. male and female combined) in cases reviewed in 2019 was 84.2 years.
  • Of the cases reviewed in 2019, the manner of death for each of the 28 deceased persons was: natural (11), accident (9), homicide (6) and undetermined (2). There were no cases of suicide reviewed in 2019.