Family seeking inquest into Maples personal care home death over concerns of malnourishment

Jim Ottenbreit is worried his sister, who tested positive for COVID-19, may have died from malnourishment, not the disease, at Maples Long Term Care Home and he wants an inquest to find out. 

Ottenbreit belongs to one of four families who have expressed concerns to CBC News about their loved one being malnourished at Maples.

“I started to realize … she may have starved to death,” he said. “That’s just the scariest thing. I can’t get it out of my mind.”

His 69-year-old sister, Donna O’Connell, died just after midnight on Nov. 4, a week after testing positive for COVID-19.

Her death came as a shock to the family, because just hours earlier Ottenbreit said staff told the family she was given oxygen but there was nothing to be concerned about and she was doing OK. 

His concerns around his sister’s care and subsequent death deepened this week, after a paramedic whistleblower recounted a “nightmare” crisis at the home, exposing concerns over understaffing and basic resident needs not being met.

“Then I started to connect the dots,” Ottenbreit said.

On the evening of Nov. 6, multiple ambulances were dispatched to the home to treat 12 residents in distress. 

When paramedics arrived, two patients were dead. Three residents were taken to hospital, while others were given intravenous fluids for severe dehydration. 

Paramedics remained on scene for several hours treating residents and encouraging them to eat and drink, according to Chief John Lane of the Winnipeg Fire Paramedic Service. 

A total of eight residents died in 48 hours that weekend, according to the Winnipeg Regional Health Authority.

A team from the Winnipeg Police Service entered the home on Saturday night to conduct a “preliminary assessment” of the situation.

Meanwhile, Revera, the for-profit company that owns the home, initially reported Maples was at near full staffing levels. However, it was later confirmed the care home was in fact short eight of the required 15 health care aides last Friday.

Donna O’Connell was well known in the North End where she used to drive a taxi cab for Duffy’s. She died last week at age 69. (Submitted by Jim Ottenbreit)

Ottenbreit believes this crisis had likely been building for some time prior to the fatal events that took place that weekend.

Ottenbreit, who used to visit his sister three times a week, said the care home seemed “chaotic” and understaffed.

His sister was losing weight in recent months and he was concerned about how much she was eating and whether it was being monitored.

“She was very frail,” he said. “I was taking her food, I was taking her drinks to drink. I actually brought it up with the staff there that she wasn’t eating and she wasn’t drinking and that she needed to see a doctor.”

Ottenbreit is not sure if that ever happened and worries inadequate staff levels meant after he stopped visiting due to the outbreak, she likely wasn’t getting proper meals.

“So many occasions I went to my sister’s room and her lunch was still sitting there, whether it was from that day or the day before,” he said.

This week, families of Maples residents said they were told by management on a virtual town hall conference call that staff had stopped documenting residents’ food and drink intake, adding that security guards were assisting with meals.

On Friday, a team of 20 members of the Red Cross will be deployed to assist with feeding, companionship and keeping residents isolated in their rooms.

Ottenbreit believes his sister, who lived with dementia and cirrhosis, would not have died if she was given adequate care and nutrition, because by all accounts from staff at the care home she wasn’t struggling with COVID-19.

“I’m completely devastated,” he said. 

Lawyer filing inquest request

Ottenbreit’s lawyer, Neil Kaplan, told CBC News he is filing a formal request for an inquest with the Office of the Chief Medical Examiner next week.

“It’s a tragedy,” he said. “I use the analogy where we are able to protect our professional sports stars, put them in a bubble, keep them safe … but yet something could have been done to make some sort of bubble for these care homes.”

Revera extended its condolences to Ottenbreit and his family in a written statement to CBC News. 

“Residents in long term care receive food and fluids according to the dietary plan that is part of the care plan developed with the resident, their decision makers and the clinical team,” wrote Revera’s communication director Larry Roberts.

Care homes understaffed at the best of times

Geriatric specialist Dr. Samir Sinha says even before the pandemic, Manitoba care home staffing of 3.6 hours of care per resident per day was inadequate. Sinha says it should be a full four hours and that number increases when there is an outbreak. 

Dr. Samir Sinha, who led Ontario’s seniors care strategy, says the WRHA needs to send skilled hospital staff into care homes that are struggling to care for residents because of COVID-19 outbreaks. (Aaron Vincent Elkaim/Canadian Press)

“When a home goes into lockdown and everyone’s in their own room, the staffing needs don’t stay the same. They go way up,” said Sinha who heads the geriatric department at Mount Sinai Hospital in Toronto. 

Sinha says there are a number of cases in other jurisdictions where residents did not die of COVID-19, but instead died from not having their basic human needs met. 

“They might not be eating or drinking as often as they would … and we know that those sorts of things can actually hasten someone’s death,” said Sinha, who is also a faculty member at the University of Toronto and Johns Hopkins University in Baltimore, Md.

He said some residents living with dementia need a lot of help with feeding especially when they no longer go to the dining room at meal time. 

“[They] may not even realize you’re hungry. [They] may forget that it’s time to eat. [They] may not even be aware, in extreme cases, of foods in front of [them], of how to actually put it in your mouth,” Sinha said. 

He said the WRHA needs to step up and redeploy the skilled staff it freed up by cancelling surgeries to make sure personal care home residents are getting proper care which can make the difference between life and death. 

He hopes an inquest can answer some of the questions he has following the “nightmare” scenario last Friday. 

“How did it end up being where we had to rely on paramedics to literally spoon feed residents who were starving to death?” asked Sinha.

“It just it boggles my mind to see the lack of effort, the lack of planning and almost the lack of care that I think is really rooted in societal ageism.”

The WRHA, which funds and oversees the Maples care home, declined to speak to specifics due to privacy concerns.  

“We are actively engaged on the ground at Maples and other PCHs to directly ensure the safety and care of residents and staff,” a WRHA spokesperson said in an email.

The spokesperson said the WRHA is overseeing onsite management, augmenting current staffing resources, ensuring all infection prevention and control measures are rigorously maintained and prioritizing family communication and ongoing information sharing.

Process takes time: Office of Chief Medical Examiner

The Office of the Chief Medical Examiner says the process for calling an inquest is set out in legislation and can only be considered when the investigation is complete.   

“We would be reviewing any reports prepared by agencies with oversight of personal care homes prior to a decision,” wrote Mark O’Rourke, director of the Office of the Chief Medical Examiner. 

He said the process takes time and it is unlikely that an inquest will be considered until the public health emergency has ended.  

Ottenbreit is determined to get answers.

“I want them to be accountable,” he said. “Not just for my sister’s passing, but for everybody.”

To date, 22 residents have died in the COVID-19 outbreak at Maples Long Term Care Home.