Ontario’s Chief Coroner, Dr. Dirk Huyer, testified in the ongoing Wettlaufer inquiry this week, outlining how deaths in long-term care homes have been reported and investigated by his office to date, and making recommendations on what should happen going forward.

Complex Challenges Facing Coroners

Dr. Huyer, who began testifying this past Monday, outlined some complex challenges that coroners in Ontario face when attempting to determine whether a death requires an in-depth investigation. He said that this is particularly challenging in a long-term care context, especially where patients may have several enduring conditions that may complicate an evaluation of whether their death was sudden or unexpected.

The inquiry had earlier heard of at least one situation, connected to Wettlaufer, in which a coroner declined to perform an autopsy on a long-term care resident despite concerns from other medical professionals.

The resident in question had Alzheimer’s at the time of her death at age 79 in March 2014. Despite the Alzheimer’s she continued to be physically active and was able to walk around. However, days before her death, her blood sugar suddenly dropped drastically. The resident was taken to hospital where a doctor was unable to determine the cause of the change in blood pressure, and suggested that an autopsy be carried out in the event that the resident died. A nurse at the long-term care facility where the resident lived followed this advice and called the coroner’s office after the resident passed away, but was told that the office “did not feel this was a coroner’s case”.

Dr. Huyer explained that a death must be sudden or unexpected to warrant an autopsy, and that coroners have, in the past, told long-term care homes that no death in a home is unexpected. However, Dr. Huyer did note that sudden changes in a patient’s circumstances may be an indication that “a deeper probe is needed”.

The inquiry was also told that until 1995, every death in a long-term care home resulted in a coroner’s investigation. Starting in 1995, the coroner’s office adopted a practice of investigating 1 in 10 deaths at long-term care facilities. However, in 2013, this practice was suspended as a cost-saving measure.

According to CBC News, in 2007, more than 3,300 deaths in long-term care were investigated by one of 350 local coroners, compared to 927 in 2015.

Dr. Huyer noted that he was not sure whether an increased number of investigations would have resulted in the coroner’s office noticing a pattern of deaths in the long-term care facilities where Wettlaufer had been working.

Suggested Changes to the Current System

Dr. Huyer provided a synopsis of the current systems in place to track deaths in long-term care facilities, and to identify unusual patterns at individual homes.

He noted that while these systems are in place, unusual patterns of death in long-term care facilities are not always tracked or analyzed because some death reports are not electronically filed. Despite the fact that homes are mandated to send electronic reports of resident deaths to the Chief Coroner’s office, some homes still submit their forms via fax, and any such data is not included in analysis that is subsequently carried out.

A planned data analysis of deaths at long-term care homes has been on hold since 2014 because some homes are not filing death records electronically.

Dr. Huyer also noted that there is currently no obligation to track the death of long-term care home residents who end up dying in hospital rather than the home, even though a hospital death may be related to an incident that began in a long-term care home. Dr. Huyer recommends a change to the rules, to allow his office to be able to more fully understand trends and patterns.

Further changes that Dr. Huyer suggested include enhanced mandatory training and a performance review system. Currently, coroners are appointed for life, with no mandatory training beyond an initial five day course (or in the case of coroner’s appointed more than three years ago, a two or three day course). Dr. Huyer would like to see a reappointment system with required continuing education. Ideally, coroner’s should be reapplying for their positions every three to five years, and their work should be reviewed (currently, coroner’s are only reviewed if concerns are raised by a police officer, nurse, or member of the public).

Dr. Huyer additionally recommends a change in how coroners are compensated for death investigations. Currently, coroners receive $450 for every investigation performed. Dr. Huyer believes that they should be paid for the time it takes to perform an investigation, rather than receiving this flat fee.

We will continue to monitor any changes that may be pending to coroner’s investigations following the Wettlaufer inquiry. In the meantime, if you are an operator of a long-term care facility, and have questions about your legal obligations, contact Wise Health Law. We regularly represent and advise operators of long-term care facilities in a wide variety of matters including:

  • Investigating adverse events;
  • Responding to inquiries, complaints or threatened litigation;
  • Inspections and compliance orders from the Ministry of Health and Long-Term Care;
  • Coroner’s investigations inquiries, and inquests;
  • College investigations into regulated health professionals;
  • Inquiries or complaints from the Patient Ombudsman; and
  • Capacity assessments and proceedings before the Consent and Capacity Board.

Contact us online, or at 416-915-4234 for a consultation.


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