Nursing home death made worse by lack of accountability
January 11th, 2009
By Calgary Herald
I've never been good at sadness. Because of the way I grew up, displaced, dislocated and abused, I wore sadness like a bruise. For me the emotion brings with it tides of recollections that still tend to hurt, and it kindles the embers of the post-trauma that still lives in me from those years.
And so I'm learning to live for joy.
When I see sadness on the faces of those I love or care for it disturbs me. The effect of bearing wounds across decades is a vital empathy for other peoples' woes, other peoples' hurts. It's a strange grace but one I'm powerfully grateful for.
The mother of my friends was found frozen to death outside her Kamloops, B. C. seniors care home the day after Christmas.
She was 84 year-old and had suffered from Alzheimer's disease for the last 14 years.
Her name was Juliette (Julie) Bombardier and she was a great-grandmother, grandmother, wife, friend, confidante and valued member of her community.
Somehow Julie managed to get out of doors that were ostensibly locked, but are often propped open by staff who pop outside for a quick smoke.
In the early morning hours, dressed in a nightgown, she expired in a snowdrift, a mere 10 metres from that door. She died there, alone and unprotected. Nearly three hours after the search for her was initiated, my friends were there when she was discovered.
The sadness I saw stricken on their faces was hard to see.
This is a family that cares for each other deeply. Julie raised her kids to be gentle, generous, kind, loving and forgiving.
Their mother's legacy is an open-heartedness that's missing a lot these days and they let their emotions roll openly. My heart ached for them.
But the real tragedy in Julie's death is not the loss itself. It's the refusal of the company that runs the nursing home to take responsibility, to be honest.
Instead of saying, "there was a failure in our system that resulted in a death and we're taking immediate steps to prevent it happening again" and honouring the loss of Juliette Bombardier, they rely on the standard "we're conducting our own internal investigation". There doesn't need to be an investigation. The system failed. Period.
See, my people say that there is no right or wrong in things. There is only honour or dishonour.
The obfuscation and shrugging off of direct responsibility is a dishonouring of Julie's death and a dishonouring of her family's grief.
That's the straight truth of it.
You don't have to be a First Nations person to understand that -- you just need to have loved somebody.
They tell us that all the doors were locked until staff had finished their search of the building.
What they are asking all of us to believe is that an 84-year-old dementia patient, often unable to recognize her own loved ones, managed to negotiate her way through a secure facility, passed trained supervisory staff, out a locked door and then somehow managed to lock it behind herself again and froze to death.
To suggest we believe that is a dishonouring of everyone.
There are a lot of seniors in care in such facilities all across the
country. They are not just Alzheimer's patients, stroke victims, addled, debilitated, frail, helpless or needy. They're somebody's grandmother, somebody's mother and somebody's friend. They are not numbers in a ledger, not a part of somebody's financial bottom line -- they are a part of our collective history and they are valuable.
We're all going to be seniors some day, if we're lucky.
The truth is the demographic of the country shows that there are soon going to be a whole lot more of us entering that territory.
When we become afflicted or just plain old, we're going to want to know that care facilities are just that -- caring.
Sure, there are those who say that we warehouse our old ones and a tragic loss is somehow our fault.
It's not. The ones who think that way have never borne the incredible burden of tending to the needs of someone 24 hours a day. They've never felt the pain of watching a loved one decline despite all your best efforts.
So we extend trust to those who are trained to bear that trust and we give them our walking, talking, cultural and familial encyclopedias to watch over and care for. When they don't, it's their fault--and they need to own that.
Juliette Bombardier did not deserve to die alone. No one does. Instead, she deserved care, nurturing, comfort and security.
She deserved to be honoured and when they allowed her to die in a snowdrift, without taking immediate responsibility for that tragedy they continue to dishonour her.
The weight of woe can recede like a glacier.
Sometimes you bear it a long time.
Honouring a loss makes it easier for everyone.
Richard Wagamese, a former Calgary Herald columnist, is the 2007 recipient of the Canadian Authors Association Award for fiction and a former National Newspaper Award-winning columnist.
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Mandigo acquitted of all charges in nursing home death -ON
Dec 17, 2008
by Michael Erskine
GORE BAY-It took the jury barely 90 minutes, including the time to eat a delayed lunch, to return a verdict of not guilty in the criminal negligence trial of Ted Mandigo. Mr. Mandigo had been charged on January 31, 2007, in relation to the death of Myles Patterson, a 65-year-old resident of the Manitoulin Lodge long-term care facility in Gore Bay.
Mr. Patterson had been forgotten outside in temperatures which witnesses told the court dropped to -20 Celsius. Mr. Patterson, who was wheelchair-bound after a recent health setback, had gone outside to smoke. Mr. Mandigo, a personal support worker with 15 years' experience at the nursing home, had assisted Mr. Patterson and other residents outside, but then was expected to leave them alone while he attended other duties.
"It was a tragedy waiting to happen," said defence lawyer Berk Keaney. "The nursing home failed to provide any shelter; there was no automatic door opener; they didn't have any kind of buzzer or way for the people outside to let anyone know they wanted in."
Coupling those failures with an expectation that staff leave patients to their own devices while completing other complex tasks, such as bathing and cleaning other patients inside, provided an atmosphere where the occurrence of some kind of tragedy was only a matter of time, the defence argued.
The words spoken by another personal support worker at the home during an interview with investigating officers were particularly telling. "It probably could have happened to any one of us," Leo Orford had said. "Thank God it wasn't me." Under questioning on the stand by the Crown, Mr. Orford qualified those words by suggesting that he liked to believe he would not have forgotten Mr. Patterson under the same circumstances. "I would like to hope not," he said. "I like to think I would not forget, but everyone is human."
During testimony by the Crown's witnesses, the court also learned that each witness had been previously interviewed by the nursing home's administration, and that representatives of the private operator of the home were present during police interviews with staff.
A large number of precautions and protocols have since been put in place by the nursing home to prevent any such incident from reoccurring. Those precautions included having a buzzer installed, but no automatic door opener has been put in place. Smoking is not permitted if the temperature drops below 5 Celsius and patients outside smoking are to be kept under observation (termed 'eyeballed').
The death of Mr. Patterson was contributed to by hypothermia resulting from being left outside in temperatures ranging between -16 and -20 Celsius on January 16, 2007. When rescued by nursing home worker Tanya James, Mr. Patterson was described as being drooped over with spittle frozen to his face. His jacket was partially zipped up and he was wearing no gloves or hat.
Nursing home staff confirmed that Mr. Patterson was his own man, and refused steadfastly to wear a hat or gloves when going outside.
Mr. Patterson was normally accompanied on his smoke period by another resident in a wheelchair. That resident had been given a whistle by his family so that he could signal when he wanted to go in. Mr. Patterson had no such whistle.
Mr. Keaney described the events that evening as a perfect storm. Had Mr. Patterson not forgotten his jacket, Mr. Mandigo would not have had to go back to get it for him. Mr. Patterson would likely have finished his cigarette before his companion with the whistle, and, as was his wont, Mr. Patterson would have come back in before all of the other smokers were inside. As there were no procedures in place to provide a check or safeguard the return of residents, Mr. Patterson was not noticed missing until the practical nurse was preparing to give him his medicine before bed.
Although he had made it to the door from the courtyard, Mr. Patterson had no way of signaling staff that he was still outside. He remained outside in the darkness, as the lights in the courtyard were switched off.
The court heard of the efforts made by the staff to raise Mr. Patterson's core temperature back up to 36.1 degrees Celsius after he was brought back inside. The person in charge of the nursing home at the time of the incident interviewed staff as to what had happened before calling the home's administrator, Karen Lehoux. She explained that she wanted to be able to answer her supervisor's questions when asked. Ms. Lehoux called a physician to attend Mr. Patterson after she was called.
Mr. Mandigo admitted that he had forgotten Mr. Patterson outside.
The description of events after Mr. Patterson was discovered also revealed some disturbing things about the nursing home environment.
Mr. Patterson was taken to the warmest room in the complex, a room described as being over the furnace room and one which, in the words of Mr. Orford, was actually over-warm. The thermostat of that room had no real control over the room's temperature.
Unable to immediately remove Mr. Patterson's clothing because of his grip on the wheelchair's arms, the staff held their hands over his ears and placed their hands on his hands. Efforts included a tepid bath to carefully restore his core temperature.
Mr. Patterson was described as being coherent and able to communicate when he was brought back in from the cold.
Despite the efforts of the staff and attending physician, Mr. Patterson, who had recently suffered a dramatic decline in health, passed away in hospital the day following the incident, January 17, 2007.
The defence counsel declined to call any witnesses, maintaining that the testimonies of the Crown's own witnesses were sufficient to prove that the Crown had not proven its case.
Mr. Keaney, in his charge to the jury, pointed out that the onus was on the Crown to prove beyond a reasonable doubt that Mr. Mandigo's actions constituted a criminal act.
The Crown maintained that Mr. Mandigo had a duty to provide the necessities of life to Mr. Patterson, and that he had failed in his duty and did so over an extended period of time, and was therefore guilty of criminal negligence and failure to provide the necessities of life.
Mr. Keaney maintained that Mr. Mandigo's failure to check to see if Mr. Patterson had been brought back inside from the smoke period was simply a human mistake, with terrible consequences, that could have happened to anyone in the circumstances. It was not enough, he said, to look at the actions out of context-those actions had to be interpreted in the context of an overworked and understaffed regime, he said, an environment which lacked proper policies and safeguards to prevent such an accident from occurring.
The court heard testimony that it was very common at the time of the incident for different staff to assist residents back into the building after those residents had finished smoking.
Although the shift on which Mr. Patterson was forgotten outside was described by a number of witnesses as being "no busier than any other shift," an additional staff member was assigned to that shift by the home's for-profit operator following the incident.
In the end, after hearing all of the evidence over the course of three days of testimony, the jury returned their verdict of not guilty in less than an hour and a half.
In documents filed before the Superior Court by Little Current lawyer Joseph Chapman, a civil suit names the Manitoulin Lodge long-term care facility and its administrators, Jarlette Health Services.
The civil suit does not name Mr. Mandigo, who lost his job of 15 years at the Manitoulin Lodge following the incident.
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Family of dead man files lawsuit

April 10th, 2007
Written by Mark Douglas

The case of a death at a nursing home on Manitoulin Island is already in the criminal courts -- now it's taking on an even wider scope.

The family of a man who died after allegedly being left in the cold outside his nursing home, Manitoulin Lodge in Gore Bay, is now suing, seeking damages against the home and its operator.

65-year-old Miles Patterson was found outside the home suffering from hypothermia on January 16th -- he died the next day in hospital.

The OPP laid charges for that death on January 31st.

51-year old Ted Mandigo, an employee of the home at the time, is still working his way through the courts, charged with criminal negligence causing death and failing to provide the necessities of life.

Then today -- new reports say Patterson was outside the home for a smoke break, an item Premier Dalton McGuinty has commented on.

McGuinty says he understands that some long-term care facilities don't have the money to build specially ventilated rooms for smokers.

He says the government had to make some tough choices with its smoking ban, and one of those was to protect workers at nursing homes from second-hand smoke.

Health Minister George Smitherman says the smoking ban also protects the vast majority of seniors living in care-homes who do not smoke.

But MyChoice-dot-ca, a tobacco-industry sponsored lobby group, says many seniors have been forced outside in dangerous, icy conditions since the provincewide smoking ban became law last June.
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Death puts spotlight on anti-smoking law TheStar.com - News - Death puts spotlight on anti-smoking law
Nursing homes not building special rooms, forcing smokers outside

February 02, 2007
Phinjo Gombu, staff reporter

A worker at a Manitoulin Island long-term care home has been charged with criminal negligence causing death in the case of a resident who died after he went out into the cold to smoke.

The charges that include failing to provide the necessaries of life were laid in the death of Murray Miles Patterson, 65, a resident of the Manitoulin Lodge in Gore Bay who died Jan. 17 at an area hospital.

If Patterson's death is linked to the fact he went out for a smoke, it would bring under scrutiny the Smoke-Free Ontario Act, which became law last year.

The stringent guidelines allowing smoking in long-term care facilities and psychiatric hospitals include creation of ventilated smoking rooms.

But with most facilities deciding not to build them, a situation has arisen where many elderly, frail and often sick long-term smokers who can't kick their habit have been forced outside – sometimes into the bitter cold – to smoke their cigarettes.

Patterson, a stroke victim, was taken to hospital on Jan. 16 with hypothermia after he was found in the courtyard of the home. It occurred "sometime after the established smoking period" outside, Manitoulin Lodge said in a release yesterday.

It said the health ministry had conducted a review and "unmet standards" were found.

Residents told the Sudbury Star that Patterson had gone outside with two other residents for a smoke and hadn't returned with them. The forecast for that day was minus 16C.

The health ministry says only 1.5 per cent or 10 of the province's more than 620 long-term care facilities have been given permission to construct the smoking rooms after they met the new standards. Another 16 applications are in the pipeline.

"We fought the (new law) as valiantly as we could," said Pat Prentice of the Ontario Association of Resident Councils, a group that tried to have less restrictive rules in place for construction of smoking rooms.

Among the group's fears was that residents would furtively smoke inside buildings – in closets and stairwells – rather than go outside, increasing the possibility of fires.

A significant number of the homes had no smoking policies before the act came into effect. Many with older smoking rooms decided against building new ones because of the associated costs and complications.

Margaret Toni, director of care for Regency Care with 15 long-term care homes in the GTA, said as much as they'd like to build the rooms for residents, they can't for lack of funds.

Under the law, money for smoking rooms must come from the home's "accommodation budget" which funds food, general housekeeping, utilities and administration.

The province, which funds all long-term care homes has made no provisions for extra construction money.

One administrator of a downtown long-term care home, where many residents smoke, said a 22-foot-by-16-foot room that meets provincial standards would cost about $180,000.

Another administrator said they had only recently opened and built smoking rooms under the old guidelines, and were wary of investing in the new ones because the rules could just as easily change again.

Reg Paul, a senior official with the City of Toronto's Homes for the Aged division, said only three of the city's 10 homes have been retrofitted with smoking rooms at a cost of $300,000.

Paul said the homes were chosen after a survey showed 69 per cent of all smokers were concentrated in the three facilities.

Health Minister George Smitherman said nursing homes that let residents out to smoke in the cold have an obligation to ensure they are safe.

He suggested it's a "copout" to blame the government's anti-smoking law for the death.

Charged with failing to provide the necessaries of life and criminal negligence causing death is Ted Mandigo, who no longer works at the home. He appears at Gore Bay court on Feb. 26.
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OPP probes nursing home death; Resident, 65, was left outside Gore Bay facility when he went for a smoke

January 25, 2007
By Laura Stradiotto

Local News - Police are investigating the circumstances surrounding the death of a nursing home resident who was found outdoors in a courtyard Jan.16.

Detectives from the Ontario Provincial Police's crime unit in Orillia were at the Manitoulin Lodge in Gore Bay on Wednesday.

Nursing home resident Murray Myles Patterson, 65, was transported to the Mindemoya Hospital on Jan. 16 and died a day later.

In a statement released Wednesday by the Manitoulin Lodge, officials said the resident was discovered in the courtyard "sometime after the established smoking period."

The nursing home said first aid and medical care were provided on site, and extended condolences to the family.

Manitoulin residents The Sudbury Star spoke to said Murray went out for a smoke with two other residents. While the two residents returned indoors, Murray did not accompany them. By the time someone realized Patterson was missing, he was found outdoors suffering from the cold temperature.

Weather forecasts reported the temperature dropped to -16 C on the evening of Jan. 16. A post-mortem examination was conducted on Wednesday in Sudbury, but results were not final.

"It's a little more than just a resident of a long-term-care facility passing on," said Const. Al Boyd of the Manitoulin Island OPP. "There are some suspicious circumstances."

Boyd said there should be no concern for the safety of other residents or the community of Gore Bay. He explained "it's not your normal person dying of (natural) causes in a long-term-care facility."

Police were also interviewing witnesses at the nursing home.

Patterson was a single resident at the nursing home. He suffered from physical disabilities that prohibited him from living independently, said Boyd.

According to his obituary, Patterson was born in Burpee Township. He leaves behind his wife, Gail, three children and eight grandchildren and five living siblings.

Boyd called the investigation a "high-profile" case.

"It's an investigation that is very intensive because it's a high-profile situation where there is a suspicious death of a resident of a long-term care facility," said Boyd.

News of the suspicious death comes as public hearings are being held across the province surrounding proposed new legislation at long term care facilities.

The proposed Long-Term Care Homes Act would require, among other things,Ontario's 613 nursing homes to have a registered nurse on duty around the clock and mandates annual surprise inspections.

Nickel Belt NDP Shelley Martel said she's hearing the same concerns across Ontario. She said significant understaffing at Ontario nursing homes is having a negative effect on the quality of care staff can provide residents.

U nions representing nurses and other long-term care workers have criticized the bill for not setting minimum staffing levels. They are demanding the government require 3.5 hours of care a day for each resident and pay for the staffing.
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