In October 2015, the Geriatric and Long-Term Care Review Committee (the “Committee”) of the Office of the Chief Coroner for Ontario released their Annual Report for 2013 and 2014 (the “Report”). The purpose of the Report is to review circumstances surrounding deaths of elderly persons that have been investigated by the Office of the Chief Coroner and brought to the attention of the Committee, with a view towards recommending preventative measures.

Over the years, the Committee has identified themes that have been consistently present in the cases they review, including “communication/documentation” and “determination of capacity and consent for treatment”.

In 2013, the Committee reviewed 26 deaths, and in 2014, they reviewed 19 deaths. The four most common areas for improvement identified in the report were:

  • Medical and nursing management;
  • Communication between healthcare practitioners regarding the elderly;
  • Medical/Nursing documentation; and
  • Use of drugs in the elderly.

The Report and the recommendations generated in each case are made available to doctors, nurses, healthcare providers, social service agencies, and others, for the purposes of death prevention awareness. The organizations and agencies to whom the recommendations have been provided, are then asked to report to the Office of the Chief Coroner within one year of receipt, and provide an update on the status of their implementation. However, the organizations are not legally obligated to implement or respond to the recommendations.

It is also noted in the Report that “[t]rends or themes may exist due to a selection bias of cases that are referred to the [Committee] for discretionary review.” The Report also states that due to “resource issues”, the Reports for 2013 and 2014 have been summarized and combined. Therefore, there are potential deficiencies and areas in which there is room for improvement.

Reducing avoidable deaths of elderly persons is a moral imperative. Although the fact that this Report exists is a step in the right direction, we should continue to appreciate the seriousness of the issue and to examine how needless deaths of elderly persons can be prevented.

Thanks for reading.

Ian Hull