In a nearly empty Ontario courtroom, with only a few relatives of the dead and a handful of fire chiefs in attendance, a little history was made on Friday - a nursing home and its administrator were convicted of violating the provincial fire code and fined.
The convictions also amounted to a shot across the bow of the Ontario government, which has been under increasing pressure to move on making sprinklers mandatory in all seniors' homes.
Sprinklers are already mandatory in new facilities, but those built before 1997, and all the elderly people who live in them, aren't covered.
Lawyers for the Muskoka Heights Retirement Home Inc., where a Jan. 19 blaze at the Orillia, Ont., facility last year killed four seniors and critically injured six others, and administrator Gail Wilson each pleaded guilty to two violations of the Fire Protection and Prevention Act and were respectively fined $50,000 and $15,000.
On top of the fines approved in Ontario Court by Justice of the Peace Malcolm Rogers is a 25-per-cent victim surcharge. The J.P. gave the company and Ms. Wilson a year to pay.
It was the first time in Ontario that a home administrator has been convicted under the fire code, and one of the few occasions - outside of the leading-edge city of Niagara Falls, where recently seniors' homes have been successfully prosecuted for similar code violations - that a home has been convicted.
Muskoka Heights and Ms. Wilson each pleaded guilty to two offences: failing to train supervisory staff in a fire safety plan and failing to hold fire safety drills.
Having such measures in place is particularly important, prosecutor Paul Dray said outside court, for older residences that don't have sprinklers.
The owners of such facilities have a duty to be "more diligent," Mr. Dray said, noting that more must be done with a fire safety plan "than sticking it in a damn drawer."
The early-morning fire on a frigid January day immediately killed Robert McLean, 90, and Hugh Fleming, 85.
But among the injured, many of whom were carried out in their nightclothes by firefighters, were two elderly residents who died later in hospital.
One of them was Vera Blair, a tough 91-year-old originally from Northern Ontario who had moved into Muskoka Heights about six months earlier.
She was in good health and still vigorous, her weeping daughter Gail Gibbons said outside court, and a "warm and giving person," according to her grandson Rob Gibbons.
"She was just a great person," Mr. Gibbons said. "The only reason she went in there was because she couldn't look after herself, by herself… She was still moving around and healthy too." He guessed "she'd still be alive now" but for the fire.
Instead, Ms. Blair lingered in hospital for seven weeks, while her family was in agony, hoping she'd recover, fearful that being in hospital on a respirator would be her life.
"She was there in name only," Ms. Gibbons said.
The deaths at Muskoka Heights brought to 44 the number of vulnerable seniors who have died in fires at "care occupancies," the general name for the array of seniors' residences, since 1980, when a blaze tore through the Extendicare Nursing Home in Mississauga and killed 25.
Afterwards, the first of three coroner's inquests recommended full retroactive installation of automatic sprinklers in all such facilities.
As Orillia Fire Chief Ralph Dominelli noted, there have been serious fires in three other seniors' residences in the past two years alone - one each in Huntsville, Owen Sound and Niagara Falls.
In fact, it was the May 14, 2008, fire at a retirement home - a close call, where 11 elderly residents had to be rescued by firefighters - that galvanized Niagara Deputy Chief Jim Jessop and city solicitor Ken Beaman to start vigorously enforcing fire code regulations at residences without sprinklers, and prosecuting offenders.
After watching vulnerable elderly residents being carried down ladders, knowing his department had the authority to act, "We would be breaching our duty of care if we did nothing," Deputy Chief Jessop once told a hearing.
His department issued orders to five retirement homes either to install sprinkler systems or significantly boost nighttime staffing levels.
But Niagara Falls and the Ontario Association of Fire Chiefs has had to fight the owners of these homes, in some instances the government and even firefighter associations every step of the way.
Still, after the Muskoka Heights fire, Orillia Chief Dominelli adopted the proactive Niagara approach and conducted mock evacuations in other facilities.
During the first of these, a resident was actually left behind.
"If it's too expensive to renovate and put in sprinklers," as Rob Gibbons said, "then maybe you shouldn't have a [seniors']home."
Sitting quietly in the back in court on Friday were Chief Dominelli, Ontario Association of Fire Chiefs president Tim Beckett, and Niagara's Deputy Chief Jessop, the man who started the ball rolling: If Queen's Park had listened to him, Mr. Gibbons might still have a grandmother.