
Preamble:
I as so many other citizens of Ontario were aghast and heartbroken when the May 20, 2020 report, signed by Brigadier-General C.J.J. Mialkowski revealed disturbing details about the state of long-term care in Ontario (COVID-19: Read the Canadian Forces report on long-term care | TVO Today).
During a press conference related to the report Premier Doug Ford was visibly shaken (Ford gets emotional addressing ‘extremely troubling’ report on long-term-care homes | COVID-19).
Ontario Premier Doug Ford says the province has launched an investigation that could lead to criminal charges against five long-term care homes rocked by COVID-19 Ontario long-term care homes in scathing report could face charges, says Ford | CBC News
As of January 2025 I have not heard of criminal charges being laid related to systemic failures through acts of omission or commission at Ontario’s Long Term Care Homes that led to the suffering and death of vulnerable seniors.
On December 13, 2024 I wrote to the Chief Coroner of Ontario (copying regional coroners) in conjunction with Patricia Spindel Chair SSAO.

Dear Dr. Huyer,
I am writing to you with respect to the role of the Office of the Chief Coroner and specifically the Geriatric and Long-Term Care Review Committee during and post the COVID 19 pandemic, specifically with respect to the findings of the Canadian military and public health units in Ottawa and Durham Region that led those Medical Officers of Health issuing notices to facilities in these locations to work with local hospitals to attempt to save lives.
I would like to know what the role, duties, and obligations of your Office and the Committee were, what investigations into the causes and factors leading to the deaths in these facilities took place, and if there is a summary report, how to obtain a copy of it.
Did the College of Physicians and Surgeons and College of nurses play any role in the investigations if there were any?
Did any member of the public, professional body, or government make a referral to your Office requesting an inquest into the deaths of residents in these facilities during the pandemic related to any suspected unique circumstances related to their death(s)?
Do you, as Chief Coroner, have the authority to act on your own motion to self initiate an inquest or inquiry into the causes and factors leading to so many deaths in these facilities - among the highest in the world - during the pandemic?
In the Geriatric and Long-Term Care Death Review Committees - 2020, 2021, and 2022 (below), I found no inquests referenced, identifying the causes and factors leading to the deaths of vulnerable residents of Ontario's Long-Term Care facilities, especially any references to systemic failures during and following the pandemic.
During the pandemic in Waterloo Region the Forest Heights Long Term Care Home was classified as red by the Medical Officer of Health with only 18 other facilities receiving this designation.
In June 2, 2020 a management order was issued for St. Mary's General Hospital at Forest Heights Long Term Care Home in Kitchener, Ontario. Management of the home, which was assigned for 90 days to St. Mary’s General Hospital, reverted back to Revera Inc. in September
Does your Office have any communications from Cambridge Memorial, St. Mary’s and Grand River Hospitals that intervened in this facility during the pandemic that would have led to unnecessary deaths requiring your Office's investigation?
Several other long-term care institutions currently have class action lawsuits against them alleging gross negligence during the pandemic. Were there referrals to your Office from any of these facilities, from loved ones, or from medical or nursing professionals requesting your Office investigate the circumstances surrounding the many deaths that occurred there? https://www.cbc.ca/news/canada/toronto/class-action-ltc-1.7143572
The guiding principles of The Geriatric and Long-Term Care Committee identifies the following aims and objectives
To assist coroners in the province of Ontario with the investigation of deaths involving geriatric and elderly individuals and others receiving services within long-term care homes.
To provide expert review of the circumstances of the care provided to individuals receiving geriatric and/or long-term care in Ontario prior to their death.
To produce an annual report that is available to doctors, nurses, healthcare providers, social service agencies, and others, for the purposes of death prevention awareness.
To review cases and help identify whether there are any systemic issues, trends, risk factors, problems, gaps, or other shortcomings in the circumstances of each case, in order to facilitate the development of appropriate recommendations to prevent future similar deaths.
To conduct and promote research where results and a comprehensive understanding may lead to recommendations that will prevent future similar deaths.
In the 2020 annual report https://www.ontario.ca/document/geriatric-and-long-term-care-death-review-committee-2020-annual-report “It is recognized that the issues identified and any resulting trends, are based on the cases that are referred for review. Other than the reviews of homicides within LTCHs which are mandatory (based on the policy of the Office of the Chief Coroner), all other cases are referred for review based on a discretionary, and therefore subjective, decision to do so. It is acknowledged that the discretionary nature of some referrals may result in trends based on issues or concerns that have been identified as areas requiring further attention and analysis.”
In light of the exceedingly high death rates in Ontario long-term care facilities, should it have been discretionary for these facilities and professionals employed by them to determine whether or not referrals are made to your Office? If this is considered not appropriate under the circumstances, do you have the authority and discretion to review these deaths without a referral in order to address the questions I have asked in this e-mail?
I am asking that this e-mail be shared with the Geriatric and Long-Term Care Death Review Committee in the hope that these questions can finally be addressed with a view to ensuring that such a tragedy never occurs again and that justice can be had for those who cared for us and for those who may follow us.
Yours truly,
Joseph Amatruda, Elder Advocate,
Seniors for Social Action Ontario
c/o 508 Baringham Place
Waterloo, ON
N2T 2J4
519 884 8529
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