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Investigation into the Deaths of Four Residents of a Toronto Retirement Home

Archived News Release

Investigation into the Deaths of Four Residents of a Toronto Retirement Home

Ministry of the Solicitor General

Dr. Andrew McCallum, Chief Coroner for Ontario, today released the results of the investigations into the deaths of four residents of the In Touch Retirement Home that occurred in 2010.

In November 2010, the deaths of three residents were reported to the Office of the Chief Coroner amid allegations of abuse and neglect by retirement home staff.  Coroner's investigations into these three deaths were initiated.  Subsequently, a fourth death took place to the In Touch Retirement Home. This death was reported to the Office of the Chief Coroner and was investigated at that time.

In the first three cases, the investigations were limited to a review of medical and other records as the Office of the Chief Coroner was not previously notified of these deaths.  In the fourth case, a post mortem examination was able to be performed.  In each of the four cases, there was no evidence identified to support the allegations of abuse or neglect.  The three initial deaths were due to natural disease processes and the fourth death was determined to be accidental due to choking.

During the course of these investigations, a number of issues were identified with respect to residents of retirement homes in general.  They included:

  • Lack of a complaint mechanism
  • Lack of requirement for assessment/reassessment of residents needs
  • Lack of a process to facilitate referrals to other facilities when care needs exceed the capability of the retirement home

While these investigations were being conducted, the Government of Ontario passed the Retirement Homes Act (RHA) and appointed five members to the Retirement Homes Regulatory Authority, including a CEO/Registrar.  Regional Supervising Coroners for Toronto, Drs. Dan Cass and James Edwards, met with the CEO/Registrar to review the concerns identified through the investigations.  It was determined that the RHA includes:

  • A complaint process to ensure the investigation of concerns regarding care provided to retirement home residents
  • A requirement for completion of residents' needs assessments and reassessments
  • A requirement to inform residents of options when care needs increase, including application to long term care homes

It has been determined that the concerns identified through the investigations by the Office of the Chief Coroner have been addressed through the above legislation; therefore, no further action, including a coroner's inquest is required at this time.  The Office of the Chief Coroner will remain vigilant regarding these and any other issues that may arise, in keeping with its public safety mandate.

"If any retirement home resident, substitute decision maker or member of the public has any concerns regarding the care provided at a retirement home, there is now a place to go to have those concerns addressed through an impartial investigation," said Dr. McCallum.

To access the full report, please go to:  www.ontario.ca/CoronersReports.

For more information on Ontario's death investigation system, please visit: www.ontario.ca/safety

Media Contacts

  • Dr. Dan Cass

    Regional Supervising Coroner - Toronto West

    416-314-4105

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