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Twenty-nine people died during Ontario’s first major COVID-19 outbreak at a long-term care facility. Who were they? How did their chaotic final weeks unfold? The Globe and Mail investigates

When David Adams walked into his mother’s room on March 29, tears began to silently fall down her cheeks. Nine other residents of the Pinecrest Nursing Home in Bobcaygeon, Ont., had already died of COVID-19, and visitors had been banned. Many of the home’s workers were sick, and those who were still showing up for their shifts were frantically trying to care for Pinecrest’s remaining residents.

Mr. Adams’s mom, Marguerite Adams Miller, had spent 30 years as a nurse at Pinecrest. Now 98 and living with dementia, she’d moved in nearly a year earlier. As a lifelong local in a facility filled with the same, she knew pretty much everyone.

When Ms. Adams Miller began showing signs of COVID-19, a Pinecrest nurse called her son, who insisted he be allowed to sit with her. When the worker on the other end of the phone hesitated – no family or friends were allowed inside – Mr. Adams told her that as a child, he’d missed many meals with his mother because she’d stayed late to sit with dying patients. “There’s no way she’s going to die alone,” he told the staffer.

Inside his mom’s private room, Mr. Adams found her conscious, but struggling to breathe and unable to speak. For the next 24 hours, he kept a vigil at her bedside, holding her hand and swabbing her mouth with water.

During his time inside the site of Ontario’s first major outbreak, Mr. Adams says he saw a facility in chaos, with the few remaining workers running from patient to patient, struggling to keep up with their care. During one sick resident’s intense coughing fit, a worker called for help – a plea that to Mr. Adams went unanswered for a painfully long time. There were delays getting his mother’s doses of morphine because the nurses were so busy. One personal support worker told him she was pulling a double shift because her replacement hadn’t arrived.

“In all this, they worked admirably,” Mr. Adams says. “They had nothing but love and concern for the people who were there. They were desperate to do all the right things.”

Nonetheless, his mother died on the evening of March 30, the victim of an outbreak that served as an ominous prelude to dozens of other catastrophic flare-ups inside seniors’ homes, which are now the source of more than three-quarters of COVID-19 deaths across the country. In just two and a half weeks, 29 of Pinecrest’s 65 residents died, and all but two of the survivors tested positive for the virus. Some 32 of the home’s 68 employees were also infected.

The harrowing outbreak in the heart of cottage country exposed troubling gaps in provincial policies that govern nursing homes, and laid bare shortcomings at the local public health unit and at Pinecrest itself that put already fragile residents at risk.

Initially, provincial policy limited testing to just three residents, leaving Pinecrest’s nurses and personal support workers – not to mention patients and their families – blind to exactly who was infected and who wasn’t. Public health failed to inform the broader Bobcaygeon community about the sheer scope of the outbreak and the dangers it posed. Inside the home, a lack of space thwarted the staff’s early infection-control measures, and an ill-fated plan to separate the sick from the supposedly healthy may have helped spread the virus.

When it was all over, nearly half of Pinecrest’s residents were dead.

Family and community are words the people of Bobcaygeon use frequently when they talk about Pinecrest. Most of the residents had forged connections through years of living in and around the small town 150 kilometres northeast of Toronto.

Steve Oldridge, one of the two family doctors who treated residents there, says that as his local patients grew older, many chose Pinecrest over the fancier nursing home on the waterfront. “They had friends and neighbours at Pinecrest,” he says. “It just felt like more of a homey, community place.”

Ms. Adams Miller bought life insurance from Ted Pollock, who lived down the hall. She’d shopped for clothes at Thompson’s Ready to Wear, owned by Ruth Thompson, a trailblazing businesswoman and widow of a former town reeve, and attended community luncheons with Ruth Sheppard, who lived at Pinecrest with her daughter, Tami.

The elder Ms. Sheppard, a past president of the Ladies Auxiliary at the Bobcaygeon Legion, knew Joe Arsenault’s daughter, who tended bar at the Legion. Mr. Arsenault grew up in Prince Edward Island not far from Elmer DesRoches, who shared a room with Don Danilko and Ronald Patrick. All died in the outbreak, along with fellow residents Heather Budway-Townsend, Barbara Simon, Shirley Wiltshire, Marguerite Vandinther, Shirley Kitching and many others.

They lived out their final days in a building that was decades old and rife with problems.

Many of Ontario’s nursing homes are part of much larger chains. Pinecrest is a rare independent facility owned by Paul Burch, who took over the home from his parents, according to staff. (Mr. Burch did not respond to questions sent to his personal e-mail address and to the home’s administrator, Mary Carr.)

When the outbreak began, most of Pinecrest’s residents were elderly, many with dementia, but a few were much younger, with health conditions requiring round-the-clock attention. Many of them had roommates; half the rooms in the single-storey building are wards, shared by four residents. There’s a small dining room for the few who are able to walk to meals and feed themselves, and a larger one for everyone else.

During the provincial government’s last in-depth inspection of Pinecrest in 2018, inspectors found black debris in bathrooms, and corrosion on lifts, transfer devices and bath chairs. The tubs were chipped and gouged from wear and tear, and some of the original wood-frame windows – which, the inspectors’ report noted, had been flagged as deficient in a previous inspection – neither opened nor closed properly. Some were perennially stuck open by an inch or two, and could only be closed if someone went outside to push them shut. The inspection also criticized Pinecrest’s infection-control practices – particularly its failure to label denture cups, urinals, razors and other personal items in shared bathrooms. In some cases, inspectors found soiled towels on the floor and urinals full of fluid.

Ms. Carr said in a written response to questions that the deficiencies flagged in the 2018 inspection “were dealt with immediately.” A follow-up inspection in the spring of 2019 found the home had fixed the problems.

During past outbreaks – of influenza or other routine infectious diseases – Pinecrest staff would isolate residents in their rooms, close the privacy curtains in shared accommodations, and don gowns, gloves and surgical masks to feed and bathe the sick. In keeping with provincial guidelines, Pinecrest would test a handful of ill residents to identify the viral or bacterial culprit, then treat anyone who was symptomatic as though they were infected.

When COVID-19 first hit, Ontario’s Chief Medical Officer of Health David Williams stood by that protocol, repeatedly insisting that once the root cause of a wave of illness in a long-term care home was identified, there was no need to test further, especially with testing materials in short supply. That approach proved to be no match for COVID-19.

Nobody knows for certain how the new coronavirus found its way into Pinecrest, but the outbreak began in mid-March, when a handful of residents began showing symptoms including nasal congestion, coughing, fever and lethargy.

Even before anyone at Pinecrest tested positive for COVID-19, management ordered staff to wear protective gear – but only when dealing with residents who were obviously ill. By the time the outbreak was confirmed on March 20, 23 residents were already sick, says Dr. Michelle Snarr, the facility’s medical director.

Personal support worker Penny McLean remembers the news spreading through the home with little explanation from management. There was no handover meeting at the start of her 2 p.m. shift on March 20. Instead, an e-mail landed at 2:14 p.m. “Public Health has informed us that one of the swabs taken for our Outbreak has tested positive for COVID-19. Basically our plan remains the same,” wrote Ms. Carr and Shelly Griffin, the home’s director of care. The e-mail explained that all residents were to be isolated in their rooms, with staff donning procedure masks “at [the] very least” at all times. Anyone who had recently worked at other homes – a common practice for low-paid health care aides – were to inform the local public health unit immediately and stop working elsewhere.

At the time, all of Pinecrest’s 65 beds were full and residents with roommates were separated only by curtains drawn between the beds. “Isolating residents in a shared room is often the only option available to us when our home is at capacity,” Ms. Carr said in the e-mail to The Globe.

The same day, the Haliburton, Kawartha, Pine Ridge District Health Unit issued a news release saying COVID-19 had been lab-confirmed in three Pinecrest residents. The statement did not say, however, that many more residents and staff were exhibiting symptoms, too.

Jeremy Jones, a cardiologist in nearby Lindsay, hinted at the extent of the outbreak in a social-media post the next day. “What they haven’t revealed,” Dr. Jones wrote of the local health unit, “is that there are 20 other residents and eight staff at the nursing home that have symptoms, but have not been tested. This additional 28 people undoubtedly are further cases of COVID-19.”

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Pinecrest staff wave to passing cars.Fred Thornhill/The Canadian Press/The Canadian Press

Kawartha Lakes councillor Kathleen Seymour-Fagan says the public health unit and Pinecrest should have done more in the early days to alert the community to the seriousness of the situation. It was nearly a full week before even she – an elected official whose ward includes the nursing home – grasped the severity of the outbreak.

“How many people were put in jeopardy at that point because nobody knew?” she says. “People were out and about, and the community did not know.”

Chandra Tremblay, a spokeswoman for the local public health unit, said in a written response to questions that, along with the initial March 20 news release, the organization issued a second statement on March 26 to say two residents had died, 14 staff members had tested positive and an additional 35 residents were showing symptoms. “The information provided was current as of that date,” she wrote.

Inside Pinecrest, communicating with the public took a backseat to caring for residents as staff called in sick and families clamoured for information.

“The phones at Pinecrest are ringing off the hook,” Ms. Carr and Ms. Griffin wrote in an e-mail to staff on March 21. They pleaded for help from healthy employees, temporarily boosting pay to time-and-a-half.

Ms. McLean, who normally earns about $19 an hour, says that during her afternoon shifts on March 21 and March 22, she worked with just two other PSWs instead of the usual seven. When she arrived for work on March 22, the skeleton day crew was struggling to finish feeding the residents lunch in their rooms. Staff temporarily ran out of disposable gowns and began using cloth alternatives.

By the end of what would be her last shift, Ms. McLean was sick; at one point, she had to crack open a window in a resident’s room because she couldn’t breathe. “I could feel this gurgling and something stuck in my chest when I was breathing," she says. "And then I started coughing. It scared me.”

She later tested positive for COVID-19.

A few days later, Ms. Carr hinted at the gravity of the situation in an e-mail to residents’ families asking for help finding people to handle laundry, cleaning and to work as PSWs. “The challenges we are facing right now are at a level that is unprecedented,” she wrote.

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Edna Bowers, left, was one of the first Pinecrest residents to die.Family photo/Handout

In the midst of the scramble for staff, the home recorded its first two coronavirus deaths, on March 24 and March 25. One of them was 87-year-old Don Danilko, a former log truck driver. Neither he nor the other victim had been tested, but were presumed to have died from COVID-19.

On March 28, four residents died in a single day: Leo Riel, 75; Thomas Ormerod, 89; Edna Bowers, 83; and Michael St. Thomas, 71, whose 95-year-old mother, Jean, would die at the home one week later.

Ms. Bowers, who had dementia, was an artist who taught children to figure skate and helped her late husband process hides as part of the fur trade. Her granddaughter Tanya Bartley is still upset about a letter Dr. Snarr wrote to families on March 21, asking them to think carefully about whether they wanted their loved ones put on a ventilator – an intervention that hasn’t worked well for elderly COVID-19 patients elsewhere.

“How is her life any different than anybody else’s, whether it’s a child, a 20-year-old, 40-year-old?” Ms. Bartley said. “Why aren’t they being treated like everybody else?”

Dr. Snarr says residents or their next of kin had the final say on whether they went to hospital, but in the end, all 29 died at Pinecrest, with oxygen and morphine to make them comfortable.

While some residents had a nurse or PSW hold their hand as they died, many were alone when they took their last breaths.

Tami Sheppard had lived with her parents all her life. She was 56 and had Down Syndrome, and she loved listening to the Monkees, watching Starsky and Hutch and tossing off signature one-liners. Her niece, Sydney Sheppard, says that if Tami walked into a room and found a few people there, she would inevitably exclaim: “What is this, a party?”

A few months before the outbreak, Tami and her widowed mother, Ruth Sheppard, moved into Pinecrest, where they shared a room. When residents began dying, Gary Sheppard considered taking them out. But Ruth, 93, reassured her family by phone that she was fine.

Then she got sick.

“The last thing I said to my mother,” recalls Mr. Sheppard, “was that I love her, and she said she loves all of us, too.” She deteriorated quickly, and on April 1, she died.

Around the same time, Pinecrest and the local health unit, whose nurses held daily phone meetings with staff to discuss residents’ symptoms and provide direction on infection-control measures, made the decision to separate sick residents from those believed to have escaped the virus. With 16 residents dead over 10 days, the home now had enough space to create distinct wings.

At the time, they didn’t know that even people with no symptoms could still pass on the virus. So, Ms. Carr says that Pinecrest, with guidance from a private long-term-care staffing company, decided who would move where based on who exhibited symptoms.

“The medical community now understands that asymptomatic carriers can be highly contagious for an incubation period that is much longer than that of other common viruses,” Ms. Carr says.

The Ontario Ministry of Health, acknowledging that fact, finally ordered coronavirus testing for all nursing-home residents on April 22, something Premier Doug Ford had been publicly calling on health officials to do for weeks. By then, 447 residents of long-term care homes, as well as one staffer, had died of COVID-19 – almost 70 per cent of the coronavirus deaths in the province, according to official figures.

Two days after her mother passed away, the staff moved Tami to the north wing, earmarked for healthy residents. Though Tami hadn’t been feeling well, the workers put it down to a painful abscessed tooth, says Mr. Sheppard. He doesn’t know if his younger sister understood why she was changing rooms or whether she grasped what had happened to their mom.

Tami died before he could find out, at 3:10 a.m. on April 7, while a Pinecrest worker gently stroked her hand in the new, four-person room she shared with other residents also thought to be uninfected.

The next day, Tami’s test came back positive for COVID-19.

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Ruth and Tami Sheppard were 93 and 56 years old, respectively, when they died at Pinecrest.Family photo/Handout

Another resident who was moved to the healthy section of the home was Miriam Newhook, whose roommate had passed away early on in the outbreak. Ms. Newhook, who went by Marian, was once an avid gardener and baker whose dinner rolls were a staple at local Anglican church suppers.

Now, however, the 91-year-old had dementia and could no longer speak in full sentences. Ms. Newhook had what staff thought was a bad cold, says her daughter, Barbara Coulter. But when she developed a cough, the nurses realized she’d contracted COVID-19 and transferred her to the home’s sick wing.

Meanwhile, Ms. Coulter herself had started coughing and having trouble breathing, and ended up being hospitalized with COVID-19 in late-March. The retired hairdresser believes she contracted it at Pinecrest during daily visits with her mom.

Shortly after Ms. Coulter was released from hospital, she stood at her mother’s window to say goodbye. Ms. Newhook died on the evening of April 5, with only her doll – which she called “my baby” – beside her. Ms. Coulter ensured they were buried together. “I wanted to make sure she was not alone.”

Ms. Coulter believes Pinecrest staff did their best, but she’s haunted by the loneliness of her mother’s final moments.

“That’s really killing me,” she says through tears. “I know a lot of the residents in there who passed. It’s just terrible. … It’s like we’re one big family.”

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Miriam Newhook was buried with a doll that she called 'my baby.'Family handout

That big Pinecrest family – now nearly half the size it once was – is cautiously optimistic that the outbreak is finally over.

Nobody has died since April 9. Testing is underway to determine how many of the survivors are free of the coronavirus, and the official COVID-19 death toll has actually fallen, from 29 to 28 – it turns out one resident who died with COVID-19 symptoms tested negative.

The local health unit has even given Pinecrest permission to take some of its residents outside. While the fresh air is bound to lift the spirits of seniors who’ve been confined to their rooms for more than a month, nothing can erase what they’ve lived through.

“It just feels like all the life has been drained out of the building,” says Sarah Gardiner, a nurse at Pinecrest.

Ms. Gardiner was one of the first staff members to speak up about the devastation at Pinecrest, and she’s not sure what the future holds for the half-empty home. For now, the home’s administrator says Pinecrest has been touched by the outpouring of support from the local community. “This support means the world to us, and we will come together at the end of this outbreak to honour our residents who have passed away,” Ms. Carr says.

In the meantime, Hayley Chazan, a spokeswoman for Ontario Health Minister Christine Elliott, says the provincial government is doing all it can to fight a virus that is ravaging long-term care facilities. It’s dispatching hospital SWAT teams to help out, and the military has been called in to five of the hardest-hit homes. “What occurred at Pinecrest, and other long-term care homes across the province, is tragic,” Ms. Chazan says.

Mr. Adams, the son of former Pinecrest nurse Marguerite Adams Miller, wants more than words. He believes the government should call a public inquiry into how the coronavirus was allowed to wreak such havoc inside the province’s nursing homes.

“Something’s broken here,” he says. “So, if something’s broken, you’ve got to sit back and decide how you’re going to fix it.”

With a report from Rick Cash

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Carlos Osorio/Reuters/Reuters

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