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At her home in Vaughan, Ont., Alessandra Lamanna-La Marca holds a picture of her mother, who died at Hawthorne Place Care Centre in northern Toronto in May of 2020.

Tijana Martin/ The Globe and Mail

The last time Alessandra Lamanna-La Marca saw her mother was during a four-minute video call.

She knew immediately something was wrong. Her mother had been confined for the past month to her room at her nursing home. Now, she looked uncomfortable and responded to questions with one-word answers, smiling only when her 21-month-old grandson waved hello.

The days following the call remain a blur for Ms. Lamanna-La Marca. Her mother was rushed to hospital, lethargic and unresponsive. She died four days later, on May 1, 2020. She was 69.

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Ms. Lamanna-La Marca has no idea whether COVID-19 killed her mother, or whether it was sepsis from a urinary tract infection. (Her mother had been diagnosed with both.) And she can’t stop wondering whether neglect hastened her mother’s demise. She has not seen a death certificate and there was no coroner’s investigation. “That’s what keeps me up at night,” she said in an interview. “Just not knowing.”

Hawthorne Place Care Centre is shown in late May, 2020, a few weeks after Maria Luisa Lamanna's death there.

Fred Lum/The Globe and Mail

Maria Luisa Lamanna lived at Hawthorne Place Care Centre, an older nursing home in the northwest end of Toronto where an outbreak of the novel coronavirus spiralled out of control, killing 51 residents. She is one of thousands of vulnerable people who died alone in virus-stricken, understaffed nursing homes in Canada. Many who lost their lives suffered from dementia, impairing their ability to advocate for themselves. Visitors were banned during lockdowns, and doctors contracted to care for residents rarely entered the premises. Residents, as a result, died in droves, witnessed only by staff.

COVID-19 has laid bare weaknesses in how deaths are reviewed in nursing homes, also known as long-term care homes. Canada had the worst record for COVID-19 fatalities in these homes among other wealthy countries during the first wave of the pandemic.

Even so, no province, with the notable exception of Quebec, has ordered public hearings into the disproportionate toll the coronavirus took on residents. Investigations by provincial coroners and medical examiners have been rare, leaving allegations of neglect inside some homes largely unexamined.

In the absence of proper assessments of these deaths, nursing home operators have rarely, if ever, lost their licences, no criminal charges have been laid and grieving families have had nowhere to turn in their searches for answers.

Six provinces have made it more difficult, if not impossible, for families who lost loved ones to sue nursing homes and hold accountable those who run them. British Columbia, Alberta, Saskatchewan, Ontario, New Brunswick and Nova Scotia have each introduced legislation that grants immunity to nursing home operators from civil lawsuits related to COVID-19, provided the operators were acting in good faith.

Medical experts say the pandemic has underscored the need for a more robust system for investigating nursing home deaths. “Time is of the essence,” said Nav Persaud, a family physician and former investigating coroner in Toronto. “Investigating these deaths as they were happening ought to have been a priority.”

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Families of Orchard Villa residents in Pickering, Ont., hold a candlelight vigil last summer for Elder Awarness Day. Orchard Villa was one of Ontario's hardest-hit homes in the early stages of the pandemic.

Melissa Tait / The Globe and Mail


Provincial coroners and medical examiners have broad powers to investigate deaths, including by ordering public hearings that can point to systemic failings and make recommendations aimed at preventing similar fatalities. Their mandate is not to assign blame, but to improve public safety.

But hearings into nursing home deaths in Canada are costly, time-consuming and rare.

Only four inquests and two fatality inquiries related to deaths of residents have taken place nationally over the past 16 years, a Globe and Mail analysis found.

Coroners and medical examiners also conduct closed-door investigations, away from public scrutiny, and this is usually the way sudden and unexpected fatalities, or those that involve homicide or suicide, are handled. Nursing homes are required under provincial law to notify officials of every death.

The last public inquest into a nursing home death in Ontario was in 2005. A jury spent 34 days looking at the way staff had been trained to manage cognitively impaired residents.

The case involved a 74-year-old man who, just hours after he had been admitted to a nursing home in June of 2001, pried the metal base off a table and used it to club his two roommates to death. The coroner’s jury recommended that the government create specialized facilities for elderly people who are prone to aggression.

Ontario used to probe every 10th death in nursing homes automatically. A coroner would visit the home where the death had occurred, review medical records, interview family members and staff and possibly examine the body.

The province stopped these routine checks in 2013.

While no research or statistical analysis was done regarding the efficacy of the automatic probes, anecdotal evidence suggested they did not significantly enhance public safety, Ontario Chief Coroner Dirk Huyer told a public inquiry in 2018. He estimated that the investigations cost taxpayers about $900,000 a year.

In 2015, the first full year after the end of the automatic probes, coroners investigated 927 long-term care deaths, compared with 3,326 in 2007, according to an exhibit filed at an inquiry into former nurse Elizabeth Wettlaufer, who administered lethal doses of insulin to eight nursing home residents. In 2019 – when 23,120 nursing home residents died in Ontario – the number of investigations dropped to 691.

Dr. Huyer testified that coroners no longer needed to visit nursing homes as often as they had in the past, because the government had enhanced its oversight of the sector and ramped up inspections.

The Ministry of Long-Term Care conducted comprehensive inspections of most homes in 2015, 2016 and 2017. These resident quality inspections (RQI) were in addition to those triggered by complaints from residents or their families, or by critical incidents that homes must report, such as injuries.

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Ontario Chief Coroner Dirk Huyer.

Richard Lautens/The Canadian Press

The enhanced oversight protocols were short-lived, however, leaving Ontario out of step with other provinces. In the fall of 2018, just months after Premier Doug Ford entered office, the ministry all but eliminated wide-ranging inspections. Instead, it began to focus on responding to critical incidents and complaints. Only nine of the province’s 627 nursing homes received RQIs in all of 2019, said Jane Meadus, a lawyer at the Advocacy Centre for the Elderly in Toronto.

Ontarians have been left with a severely weakened oversight system, with fewer inspections of nursing homes and fewer investigations of deaths of residents.

“We’re losing that ability to have inquests or investigations,” Ms. Meadus said. “It’s a whole breakdown of the system.”

Manitoba, by comparison, conducts reviews of roughly 80 of its 125 nursing homes every year. Quebec assesses the quality of living environments in its 412 homes over a three-year cycle. And New Brunswick subjects each one of its 71 homes to an annual inspection.

Ontario went into the pandemic with an oversight regime that left it up to operators of nursing homes to flag any deaths that required investigating. As the virus spread, family members struggled against a system not necessarily interested in working for them, said Samir Sinha, director of geriatrics at the University Health Network and Sinai Health System, and chair of a committee that is developing new national long-term care services standards.

“Everything just kept on getting dismantled, so that there really became no mechanism in place for accountability,” he said. “We were just leaving it up to the homes and hoping for the best.”

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The virus was particularly lethal in Ontario, where it killed 3,793 nursing home residents. An independent commission that examined the impact of COVID-19 on nursing homes in the province called for a new model to restore the public’s faith in Ontario’s stewardship of the sector. The commission said for-profit companies, which own two-thirds of the province’s homes, should no longer be in the business of caring for residents. The for-profit sector should continue building facilities, it said, but should leave operations up to organizations that are mission-driven, not profit-driven.

Mr. Ford has not formally responded to the commission’s report, released in April. His government is forging ahead with plans to build new nursing homes and refurbish existing ones – an initiative that critics say merely rewards many of the same private operators whose homes have had high pandemic fatality rates. Of the 80 contracts awarded in March alone, 35 went to for-profit companies.


Ontario Premier Doug Ford, middle, and other MPPs bow their heads for a silent tribute to COVID-19 victims at Queen's Park in May of 2020.

Nathan Denette/The Canadian Press


Other countries have held nursing home operators accountable for COVID-19 deaths. Massachusetts’ top law enforcement official has brought criminal charges against the former leaders of a home for military veterans. Spain and Switzerland have also opened criminal investigations.

Several reports in Canada have found evidence that nursing home residents died of neglect. Police, however, have remained conspicuously silent everywhere but in Quebec.

The Canadian Armed Forces provided the first set of outside eyes on what was happening inside Ontario’s and Quebec’s long-term care sectors, after the federal government deployed the military to several nursing homes.

In a report released in May of 2020, the military chronicled horrific conditions in five homes in Ontario, ranging from poor infection-control practices to abuse of residents. A second report that same month described orderlies in Quebec seniors’ homes disappearing during their shifts and employees ignoring safety instructions.

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The military also alleges that dozens of residents at two homes in Ontario died not from COVID-19, but rather from neglect and dehydration.

Representatives of the homes – Hawthorne Place, where Ms. Lamanna-La Marca’s mother lived, and Downsview Long Term Care Home, a Toronto facility where 65 residents died of COVID-19 – have challenged the reports, saying no residents died of dehydration.

Barry Goldlist, a Toronto geriatrician and member of the Geriatric and Long-Term Care Review Committee in the Ontario coroner’s office, said it is not uncommon for patients with dementia to lose their ability to eat and drink shortly before they die. But he said diagnosing dehydration is difficult without blood tests. “There can be no doubt that many of those people who died could have survived if there had been more care,” he said.

The coroner’s office has not referred any deaths during the pandemic to the geriatric review committee, spokesperson Stephanie Rae said.

People wear personal protective equipment at the Tendercare Living Centre in Scarborough.

Carlos Osorio/The Globe and Mail

The military was not alone in sounding the alarm about neglect at nursing homes.

Family doctor Silvy Mathew said in an interview that there were simply not enough staff members at Tendercare Living Centre in Toronto to provide medical care to residents, let alone feed and hydrate them. She worked three shifts over Christmas at the nursing home, where an outbreak of COVID-19 killed 81 residents. The first day, there were only two personal support workers and one nurse to care for an entire wing of 25 residents sickened with the virus.

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“I don’t think anyone deliberately tried to kill people,” Dr. Mathew said. “But did they die from lack of support and care? Yes.”

In Manitoba, the government appointed Lynn Stevenson, B.C.’s former associate deputy health minister, to review Maples Personal Care Home in Winnipeg, a facility owned by for-profit operator Revera Inc. where 55 residents died of COVID-19.

Dr. Stevenson’s 74-page report, released in January, says staff shortages and the absence of family members and volunteers to help feed residents “may have contributed” to a lack of meal intake.

According to the report, it was difficult for Dr. Stevenson to accurately address the question of dehydration without a more in-depth chart review. “However, observations of residents by non-Maples clinicians indicated dry mouths and symptoms of dehydration, including lack of skin elasticity,” the report says.

Ontario’s response to the pandemic stands in stark contrast to Quebec, where the province’s chief coroner is revisiting what happened in the spring of 2020, when just over 4,900 Quebec nursing home residents died of COVID-19. Other residents died of dehydration and neglect brought on by the chaos of infection and staff shortages.

The coroner’s inquest has selected seven long-term care homes for review. So far, it has revealed that employees at one home who wore face masks on their own initiative were ordered to remove them, and that another facility admitted several patients even after COVID-19 had been detected.

Police have investigated the operators of one of the homes, Résidence Herron in Dorval, where 47 people died. The inquest into the home has been delayed until September, while the province’s prosecution service reviews the file.


Pamela Bendell holds a family picture at her home in Pickering. Her mother, June, died at Orchard Villa.

Tijana Martin/ The Globe and Mail


As soon as Pamela Bendell read the Canadian Armed Forces’ report about Orchard Villa, a nursing home in the Toronto suburb of Pickering where 206 residents became sick with COVID-19, including 70 who died, she knew that some passages referred to her mother.

The report, released in May of 2020, singles out one resident who choked to death while being fed lying down. The report says staff in the home were not always sitting up residents before feeding them, which may have contributed to the patient’s death.

Ms. Bendell said she was surprised to read a different version of events several weeks later in a coroner’s report, which she shared with The Globe. The coroner’s office agrees that June Bendell choked to death on May 8, 2020, but says she was in an upright position, not lying down. She was 90.

The coroner’s report says the investigating coroner interviewed a personal support worker, “who confirmed that Ms. Bendell had been positioned upright” before she was spoon-fed a nutritional drink. The worker said Ms. Bendell was reclined only after attempts were made to resuscitate her.

Ms. Bendell has marked her copy of the report with comments, and underlined many areas where she disputes the coroner’s findings, including his conclusion that her mother was upright when she was fed. Her mother suffered from Lewy Body Dementia and had become rigid, which meant she had to be elevated during meals to avoid choking.

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Pamela Bendell points to a section of the Canadian Armed Forces report on Orchard Villa.

Tijana Martin/The Globe and Mail

On a sweltering afternoon last month, Ms. Bendell joined other families outside Orchard Villa, which is located in a leafy subdivision, to oppose the owner’s plans to renovate the home. Southbridge Care Homes, a for-profit operator, has applied to the province to renew its operating licence for 30 years and add 87 beds to the 233-bed facility.

The government should not reward for-profit operators who failed residents, Ms. Bendell said. “A life at any age should be valued. Unfortunately, the older a person is when they pass, the hows and the whys associated with their death become irrelevant.”

Cathy Parkes, the leader of the group opposing Orchard Villa’s expansion plans, has urged Durham Regional Police to launch a probe into the home, but to no avail. Her father, Paul Parkes, died of COVID-19 at the home. “It’s frustrating for sure,” Ms. Parkes said in an interview. “I guess you have this fantasy that the police are there to serve and protect and help you when things like this happen.”

She now plans to take matters into her own hands and work with a group pursuing private prosecution – a legal procedure that allows an individual or private organization to launch criminal proceedings, if it can show sufficient grounds.

As for Ms. Lamanna-La Marca, she is well aware that, in the absence of vigilant oversight of nursing homes, family members are residents’ eyes and ears.

Her suspicion that her mother had been mistreated was bolstered by an inspection report she received from Ontario’s Ministry of Long-Term Care, in response to a complaint she had made. The report says the nursing home had not followed the province’s COVID-19 protocols for monitoring residents twice a day for symptoms of COVID-19. Staff had failed to check her mother’s temperature on 10 occasions over a two-week period.

Ms. Lamanna-La Marca telephoned Hawthorne Place every day during the lockdown to speak to her mother, she said, but most of the time nobody answered.

“How long did she not eat? How long did she not drink? I don’t know any of that,” she said.


More: A voice of warning from long-term care

Maureen Ambersley was a long-term care nurse at Extendicare Mississauga, where her son recorded this audio of her in May, 2020, describing the shortcomings there. She was infected in an outbreak and died this past Jan. 5. The Globe and Mail

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