Sister of Ontario man found dead says apology not enough after home-care nurse failed to follow protocol

An Ontario woman says she's still distressed over a year after finding her 64-year-old brother dead in his bed, later learning that a nurse who had been providing him with home care failed to follow protocol.

John Ford of Drayton, a community of about 2,200 residents in Wellington County, died on March 26, 2024. Though the coroner said his death was due to natural causes, Ford's sister, Bonnie Ford, wonders if it could have been prevented.

The day before Ford's body was discovered, an Ontario Health at Home nurse contracted from SE Health showed up at his home as part of biweekly visits to change his wound dressing.

After Ford didn't answer the door, the nurse left and didn't follow the agency protocol of calling a family member or supervisor, SE Health later said.

The nurse returned to John's home the next day. After he still wasn't responding to her being at the door, but she heard his television was on, she called Bonnie Ford. John's sister then called police to do a welfare check on him.

"Part of me thought, 'Maybe he missed the nurse, maybe he went somewhere without telling me, maybe he forgot to turn off the TV.' But I knew — he's always there for the nurse. He would pick up the phone. He never left his TV on," Bonnie said.

"He would never have missed a nurse's visit because that was kind of law to him. If the nurse was coming, he was going to be available, just as he had made himself available for the last 10 years or so."

Bonnie said she doesn't know the exact time her brother died or if his death could have been prevented, adding that getting answers from the nursing agency has been frustrating.

She said she's been asking what the protocols are for home-visit nurses and whether her brother slipped under the radar.

"I've been asking Ontario Health at Home and SE Health to have a sit-down conversation to explain their policies and their procedures. It's been almost two years. It's just unacceptable."

More than a year after her brother's death, on Feb 27, Bonnie received a letter from SE Health that offered "sincere condolences" for John's death. It also admitted a mistake had been made.

"The staff member (new to our team) that was providing care to your brother did not follow our established process," the agency wrote. "In particular, when the scheduled home visit did not occur, she should have escalated this to our co-ordination team that day. That being said, it remains unclear whether this action would have provided life-saving measures."

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The agency apologized about being late with its response, and said the nurse and all staff have been re-educated on procedures.

SE Health Care told CBC News it can't comment on the Ford case.

"In general, we can confirm there are clear protocols and contractual guidelines that all home-care service providers must follow when staff are unable to locate a patient for a scheduled visit," Farah Ismail, one of the company's vice- presidents, said in an email.

Bonnie said she has filed a complaint to Ontario's patient ombudsman and the College of Nurses of Ontario, which has told Ford that an investigator would be looking into her complaint.

"I would have gladly gone over on the 25th, if she'd [the nurse] called me to tell me she can't find him," Bonnie said. "It's not enough for them to just say, 'Sorry for your loss. She didn't follow protocol.' That's not enough for me and anybody else who has gone through this."