"Communicating With Care" – Ombudsman Reports On Investigation At Extendicare Sunset
Today, Ombudsman Mary McFadyen released a report titled Communicating With Care: An investigation into the care, incident review and concern-handling practices of the Regina Qu’Appelle Regional Health Authority and Extendicare (Canada) Inc. at Extendicare Sunset. The report examines the administrative actions of these organizations leading up to and after the death of Mrs. Jessie Sellwood, a former resident of Extendicare Sunset.
Mrs. Sellwood fell at Extendicare Sunset on December 23, 2013 and was transported to the Pasqua Hospital emergency room, then back to Extendicare Sunset, transported to the emergency room a second time and back again, and died on December 27, 2013. Her family had questions about her care and were frustrated with the responses they received. They eventually took their concerns to then Minister of Health, Dustin Duncan, who referred them to the Ombudsman.
McFadyen said, “Communication is vital to long-term care residents and their families – whether it is the information shared when a resident is transported to or from hospital, or the information collected for an internal investigation, or information provided to families who have questions after the death of a resident.”
The investigation found several issues including:
- gaps related to fall prevention at Extendicare Sunset, and a lack of awareness about some of the gaps.
- questions about whether communications between Sunset, the ambulance and the emergency room were as detailed and complete as they could have been.
- delays in reporting the death to the Coroner, including a lack of awareness about when to report a death to the Coroner.
- review processes were conducted in isolation, with none that looked at all aspects of care provided at all three sites (Extendicare Sunset, the ambulance and the emergency room).
- a lack of clear understanding about what information could be provided to her immediate family after her death.
- a lack of meaningful and timely answers to the family’s questions.
McFadyen made recommendations to Extendicare (Canada) Inc. (Extendicare) and the Regina Qu’Appelle Regional Health Authority (RQHA): that Extendicare ensures its procedures meet the Ministry of Health’s and RQHA’s standards of care; that the RQHA implement a process to ensure all unexplained and unexpected deaths in long-term care facilities are investigated in a coordinated manner; that Extendicare implement this process; that the RQHA ensure that
staff and physicians working in long-term care comply with The Coroner’s Act, 1999 about when to report a death; that the RQHA ensure complete and accurate information is shared when residents are transferred to acute care facilities such as emergency rooms; that Extendicare ensure managers in its Saskatchewan facilities understand the information that can be shared with families; and that RQHA and Extendicare apologize to Mrs. Sellwood’s family and explain improvements they are making as a result of this case.
McFadyen thanked Mrs. Sellwood’s family for bringing the case forward. She also acknowledged that the RQHA and Extendicare (Canada) Inc. have accepted the recommendations and are in the process of implementing them, along with other initiatives of their own and some related to her previous report, Taking Care: An Ombudsman investigation into the care provided to Margaret Warholm while a resident at the Santa Maria Senior Citizens Home.
Communicating With Care is available at https://www.ombudsman.sk.ca/documents_and_files/systemic-reviews. The Ombudsman is an independent officer of the Legislative Assembly who operates under The Ombudsman Act, 2012. Her Office promotes and protects fairness and integrity in the design and delivery of government services.
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Director of Communications
Communicating With Care Executive Summary Conclusion (application/pdf, 111.04 Kb)