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Arrivals are greeted by workers in full personal protective equipment at Sunnycrest Nursing Home in Whitby, Ont., on Dec. 9, 2020.Frank Gunn/The Canadian Press

The Ontario Ministry of Long-Term Care sent out a survey to every nursing home in the province last summer, asking if they had measures in place to curb the spread of the highly contagious coronavirus and enough staff to care for residents.

The self-assessments were supposed to help the sector confront an anticipated second wave of the pandemic. But the ministry did not follow up with homes identified as high risk or share the survey results with anyone, including local public-health officials, hospitals and its own bureaucrats responsible for inspecting the facilities.

The government ultimately failed to heed lessons from the first wave of COVID-19, concludes a report from the independent commission into long-term care. And the consequences were devastating. More long-term care residents in Ontario died in the second wave than in the first – a scathing indictment of how government inaction allowed the virus to gain a stubborn and deadly foothold in the sector not once, but twice.

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The government’s response to the pandemic was “slow, unco-ordinated and lacking in urgency,” says the 322-page report released on Friday evening. “The province’s long-term care homes, which had been neglected for decades by successive governments, were easy targets for uncontrolled outbreaks.”

The three commissioners, led by retired associate chief justice Frank Marrocco, say in their report that Ontario, a wealthy province with a sophisticated health system, should have learned lessons from the early days of the pandemic. As a result, their report says, it was reasonable to expect that the second wave would be less punishing. “That was not the case.”

The report highlights one example, Sunnycrest Nursing Home in Whitby, east of Toronto, to show how the elderly continued to die at “alarming rates” from mid-September until March 14, when the second wave ended. The virus has killed 3,758 residents and 11 employees in nursing homes.

The ministry’s surveys last summer identified Sunnycrest as a high-risk home that was unprepared for a second wave, the report says.

Robert Kyle, medical officer of health for Durham Region, said in an interview on Sunday that he does not recall receiving the survey results. He noted that public-health units and hospitals have played a far bigger role in managing nursing home outbreaks than the ministry.

“It’s a bit of mystery why we were not in the loop,” Dr. Kyle said.

Rob McMahon, a ministry spokesman, said in an e-mail on Sunday that the survey results helped the government with its COVID-19 preparedness plan last fall. He did not say why the ministry did not share the survey results with others.

At Sunnycrest, Dr. Kyle declared an outbreak of COVID-19 last Nov. 23 and dispatched staff from Lakeridge Health to the home four days later. Hospital staff confronted an alarming situation: Workers at the home did not know how to properly put on and take off personal protective equipment; there was no list identifying which residents were sick with the virus; and the home had no infection prevention and control protocols – its IPAC lead was off sick with the virus.

All but one of the home’s 119 residents tested positive for COVID-19, including 34 who died. The victims include Violet Lorraine Anderson, who died alone in her room on Dec. 30, her daughter told the commission.

Diane Anderson Campbell said her mother suffered from dementia, but recognized her loved ones and could walk and dress herself unaided until she became sickened with the virus.

To avoid confusing and distressing her mother, Ms. Anderson Campbell said her family made the “heart-wrenching” decision to stop telephoning her. “We were not there on the phone, on video, or in person when she passed,” she said.

Ms. Anderson Campbell is among dozens of family members, residents and staff in long-term care who testified, providing a “first-hand oral history of the loneliness, anguish and fear that, for them, forever marked this time in Ontario’s history,” the report says.

Many of those who lived and worked in long-term care homes during the pandemic will continue to be traumatized and require counselling and support, the report says, adding that home owners should pay for such services.

Many residents experienced what is known as “confinement syndrome” as a result of being confined to their rooms for extended periods without access to recreational programs or visits from family, the report says.

The commissioners gave the last word to a group of nursing home residents on April 1. Wilbert said he has not had a hot meal at his home since the pandemic began. “One week, we had nothing but sandwiches,” he said.

Judy misses her two granddaughters, 4 and 6. “They don’t understand why I can’t come outside and play with them and hug them and kiss them,” she said.

Ethel waited eight months to get a wheelchair and hasn’t been to her hairdresser since the pandemic started. “You may not think it is important, but to a woman, it is,” she said. “A hairdo gives you a new lease on life.”

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