Ombudsman Annual Report Highlights Long-term Care Investigations

Ombudsman and Public Interest Disclosure Commissioner, Mary McFadyen’s 2021 annual reports were tabled in the Saskatchewan Legislature today – the last ones before she retires on May 6, 2022. McFadyen said long-term care was an important theme this year, as it was throughout her time as Ombudsman. She said, “Residents’ families want to know that their loved ones are safe and well-cared for, their concerns will be dealt with appropriately, and if something goes wrong and a resident is injured or dies, it will be promptly reported and investigated to prevent it from happening to someone else.” Also, in her role as Public Interest Disclosure Commissioner, she is asking for a review of The Public Interest Disclosure Act so it better protects public sector employees who want to speak out about wrongdoings at work.

McFadyen said that throughout her time as Ombudsman, her Office’s long-term care investigations found issues with concern-handling, adverse health events (critical incidents), and ensuring facilities meet provincial standards. A resident’s story (“Sophia”) in the 2021 Ombudsman Annual Report touches on all three of these issues. Upon her admission into long-term care, Sophia was identified as a high fall risk, so care plans were made to prevent her from falling. Tragically, she fell, and died three days later. Her family had many questions about how this could have happened. They were concerned that her death was not properly investigated. McFadyen made several findings including that the Saskatchewan Health Authority failed to provide Sophia with the minimum standard of care required by the Ministry of Health’s Program Guidelines for Special-care Homes. Despite the detailed planning that took place, Sophia still fell. The fall was eventually reported as a critical incident, but not within the timelines required under legislation, so vital details were no longer available by the time it was investigated. The SHA’s process for selecting an investigator did not take into account the person’s home position and whether they were adequately trained for the task. McFadyen said, “Critical incident investigations are meant to get at root causes and to prevent mistakes from happening again. They need to be done on time by skilled, impartial investigators.”

The report also provides an update on the Ombudsman’s investigation into the COVID-19 outbreak at Extendicare Parkside. All but four of the facility’s 198 residents contracted COVID-19 during the outbreak and 39 died of it. The Saskatchewan Health Authority accepted all four of her recommendations. It stopped allowing four residents to a room in long-term care facilities, and the other three recommendations are progressing. This includes a detailed annual review process to ensure facilities are following the Ministry of Health’s Guidelines, and to make the results of this process public for each facility. Extendicare (Canada) Inc. has not responded to or accepted the recommendations made to it. These include providing families with a written apology, completing a comprehensive critical incident review, and ensuring it complies with the province’s standards, including effective infection prevention and control management on site.

As Public Interest Disclosure Commissioner, McFadyen said in the more than 10 years since The Public Interest Disclosure Act has been in force, only 139 public sector employees have contacted her Office, and the Public Service Commission has reported only 10 disclosures internally at public sector workplaces. “The Act was meant to provide an effective way to facilitate disclosures of wrongdoing by protecting public sector employees who report them. This is a good time to reflect on whether the Act, in its present form, is accomplishing its purpose.” She proposes a legislative review of the Act to ensure public sector employees are better able to come forward and feel safe to do so. She would also like to see these protections properly extended to health and municipal sector employees.

Both annual reports are available at The Ombudsman and Public Interest Disclosure Commissioner is an officer of the Legislative Assembly who operates under The Ombudsman Act, 2012 and The Public Interest Disclosure Act. Her Office promotes and protects fairness and integrity in the design and delivery of government services.

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