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Ontario Auditor-General Bonnie Lysyk holds a news conference at the Ontario Legislature in Toronto on Nov. 25, 2020.Chris Young/The Canadian Press

Ontario’s response to COVID-19 has been “disorganized and inconsistent,” lagged those of other provinces and sidelined key health officials, the province’s Auditor-General says in a new report.

A confusing command structure and the province’s long-standing failure to make key changes after the 2003 outbreak of severe acute respiratory syndrome (SARS) hurt the provincial government’s efforts to combat COVID-19, Auditor-General Bonnie Lysyk’s report says.

Ontario Premier Doug Ford responded to the report by accusing the Auditor-General of overreaching, calling her report inaccurate and saying her criticisms were unfair to the health officials working on the pandemic response.

The report, which was released on Wednesday, says the government’s “health command table” – a group created to oversee and guide the pandemic response that mushroomed to as many as 500 participants – is overly cumbersome, which led to confusion, delayed decisions, and moves that contradicted expert advice or best practices. The table, made up of staff from a range of ministries and agencies, was also “not dominated by public health expertise,” the report says.

It also concludes that the province’s Medical Officer of Health, David Williams, has not been leading the response to COVID-19 even though he is Ontario’s top public-health official. It says Dr. Williams, who has been a secondary presence at press conferences, has not used his full powers under the province’s public-health legislation to direct the response. The report also says the role of Public Health Ontario, an agency set up to deal with pandemics, has shrunk and its advice has been ignored.

It also concludes that “Ontario’s COVID response was often disorganized and inconsistent because of variations in management and operations among [regional] public health units.”

Mr. Ford has frequently praised his government’s pandemic plan as the best in the country and defended Dr. Williams against criticism from many health experts. Just this week, his government has pushed to extend his contract until next September over objections from the NDP.

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Ontario Premier Doug Ford arrives for a news conference in Toronto, on Nov. 20, 2020.Nathan Denette/The Canadian Press

On Wednesday, Mr. Ford said he makes the final decisions, but rejected the notion that Dr. Williams was not leading the response. Mr. Ford said the top doctor has been “riding shotgun” with him since the beginning and his government is taking his advice.

Mr. Ford also pointed out that Ontario – excluding the territories and the Atlantic provinces – has the lowest per capita rate of COVID-19 in Canada, and in all of North America.

The Premier said Ms. Lysyk’s report contained many inaccuracies, accused of her of throwing “hand grenades” at Dr. Williams and Health Minister Christine Elliott, and of overstepping her mandate, which is to do value-for-money audits of provincial spending.

“Stick with the job we hired you for. Don’t start pretending you’re a doctor or a health professional. Because I can tell you, you aren’t,” the Premier said. “Stick with the numbers. Stick with the number-crunching.”

The report reveals that the province’s command table structure was set up on the advice of a management consulting firm, which the government identified on Wednesday as McKinsey and Co., with a $1.6-million sole-sourced contract. Ontario also paid the company $3.2-million to assist with recovery planning and reopening the education system. The report says that costs were “higher than standard industry rates.”

Ms. Lysyk said she found the government’s response to her report a “little unexpected,” but stood by it as factual and accurate.

She said her goal is not to assign blame, but to ensure structural problems are fixed. She disagreed with the suggestion that her report was beyond her remit.

“Everyone was caught off guard during this, and people make the best decisions they can in a type of crisis,” she said. “But what we’re saying, in a time of crisis, the systems that people needed weren’t in place.”

The report echoes recent calls for the government to release the public-health advice it receives from Dr. Williams, his advisers and Public Health Ontario before cabinet debates it. This would allow the public and external health experts to see whether Mr. Ford follows his experts’ recommendations, and if not, why not.

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Ambulances sit in front of the emergency department at Victoria Hospital in London, Ont., on Nov. 25, 2020.Geoff Robins/The Canadian Press

On Wednesday morning, Ms. Elliott said Dr. Williams was already free to make his advice public. But he has said repeatedly that he could not release his recommendations for health measures before cabinet makes a decision.

Mr. Ford later said the government’s decisions were already transparent, but he would bring the idea to cabinet and “have an answer over the next few days.”

Many of Ontario’s problems, the Auditor-General’s report says, are long-standing: outdated emergency plans, staffing shortages, a lack of lab capacity, and antiquated IT systems. Other issues it raises have already made headlines: testing delays, problems with contact tracing, and a reopening plan that did not take into account expert advice.

Until July, the province’s health command table met only via teleconference, which meant it was “not always clear who was speaking or whether the speaker had expertise in the subject matter being discussed,” the report says. Some participants were unaware whether they were full members or just “attendees.”

The report said problems with the decision-making process led to several missteps. As an example, it cites the expansion of testing to include even people without symptoms “despite limited benefit.”

Early in the pandemic, the province also failed to quickly update guidelines on testing recent travellers who were returning from places other than Wuhan, China, where the virus originated, despite evidence of spread in other countries. Ontario was also slower than other provinces to acknowledge that the virus was spreading domestically via community transmission, the report says.

And the province waited two weeks after the first outbreak at a long-term care home – identified March 18 – before requiring all nursing home workers to wear masks. More than 2,200 people have died of COVID-19 in long-term care centres in Ontario, and the army was called in to help short-staffed facilities where conditions for residents were dire.

The report says Dr. Williams rarely used his sweeping powers to issue health directives, choosing to leave rules covering temporary farm workers, for example, to local medical officers of health. Those officials, who are in 34 different local health units across Ontario, urged him to provide more direction in a May letter.

The reports says those separate health units are still not sharing best practices. Proposals to streamline the province’s 34 health units after SARS never came to fruition, while other provinces have more centralized systems. Mr. Ford’s 2019 budget pledged to start consolidating health units as part of a plan for deep provincial funding cuts, but some of them were restored after an outcry.

In response to the report, opposition parties accused Mr. Ford of lying to the public when he said he always follows health advice.

NDP deputy leader Sara Singh said she was “deeply horrified” by the findings, and questioned whether Dr. Williams should be allowed to stay on.

Liberal Leader Steven Del Duca, a former cabinet minister, defended the previous Liberal government, which the report said had failed to enact recommendations. He said people in Ontario are “not looking in the rear-view mirror.”

“For close to nine months, Doug Ford has been in charge … and he has neglected repeatedly to listen to public-health leaders,” he said.

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