Coroner System Needs Overhaul

By Vicki McKenna, RN

After taking a two-week break, the Long-Term Care Homes Public Inquiry reconvened on July 16 in St Thomas. This week’s testimony focused on the role of the coroner’s office in investigating long-term care home deaths. There were some surprises, even for those of us who are so familiar with the health-care sector.

This week there was testimony about the impact of budget cuts to the coroner’s office and the subsequent impact on whether long-term care resident deaths are investigated. In June, the Commission heard testimony that nurses had flagged “sudden or unexpected” deaths to the coroner’s office and that the coroner had declined to carry out a death investigation.

We have heard so much about how underfunded and understaffed long-term care homes are, so it is not surprising that we are now hearing about cost-cutting measures to the coroner system. Still, what has been surprising are revelations about training and oversight for Ontario coroners and the fact that they cannot access medical records of the individuals whose deaths they may investigate until after an investigation is triggered.

For me, the testimony of local Woodstock coroner Dr William George, the coroner who declined to investigate the death of one of Elizabeth Wettlaufer’s victims despite it being flagged by a nurse, struck home. George admitted in cross-examination that he finds it difficult to consider that a long-term care resident could ever be intentionally harmed by a health-care provider.

That goes to the heart of how we, as nurses, feel about this case. It is unfathomable that a nurse could intentionally kill her vulnerable, frail patient and it has kept me up some nights.

This week, Ontario’s chief coroner, Dr Dirk Huyer, testified that, prior to 1995, every death in long-term care was investigated by a coroner. From 1995 to 2013, every tenth long-term care death was investigated.

Later in 2013, the rules changed to save $900,000 annually.

Now, doctors or nurses fill out a death record form and, if they answer ‘yes’ to a question about whether a death was sudden or unexpected, a death investigation may be triggered.

Again, it’s been startling to hear about the process by which Ontario’s coroners are appointed. Most are appointed for life and receive little training beyond an initial, brief course. Contrast this to the necessity of career-long learning and education for RNs.

In some way, Huyer’s own inquiry affidavit says what many of us believe.

I do not believe that it is possible to create an effective screening process within the long-term care sector to ensure the detection of homicidal actions of a person who is carefully taking steps to conceal their actions. The public give us potentially more credit than we are due for being able to identify something like a hidden or concealed or secret homicide where there isn’t information brought forward. – Dr Dirk Huyer

Huyer hopes to change the system, to have a reappointment system that would require continuing education, re-education, and force coroners to reapply for the position every three to five years. The Ontario Nurses’ Association hopes, now that the system is being laid bare to Ontarians and this Commission, the government will work with stakeholders to change the system for the better.

The Commission will sit until August 10 and then take another two-week break. Next week, there will be testimony from the pathologist followed by the College of Nurses of Ontario.

ONA is posting regular entries as the Inquiry unfolds.

Vicki McKenna, RN, is the president of the Ontario Nurses’ Association.