Their mother had identical fractures in both legs when she died. How did no one at her Oakville nursing home see or hear anything?

Judith Young left her room at 6:09 p.m. It was Friday night hymn sing at the nursing home, Judith's favourite event of the week.

At 7:26 she was back. Ninety-five, with dementia, Judith was chatty and quick with a joke, but could no longer move on her own. She needed two staff to transfer her from the wheelchair into bed.

A personal support worker brought a lift to her room at 8:02 p.m. The second worker arrived a moment later. They had a routine: hook the lift to the ceiling, slide Judith into the sling, hoist her up and then lower her into bed. The first worker left within five minutes. The second stayed until 8:16.

Workers would check on her again, but Judith was in bed for the night.

The next morning, two day staff arrived expecting Judith to sing a greeting, usually Doris Day's Que Sera Sera," but today she screamed when they tried to roll her over in bed. Later that afternoon, she told her son, I fell," an agonizingly imprecise description of the incident that caused the near-identical fractures curving through both of her femurs, the strongest bones in the body. Each bone split apart, jutting outward in a sharp point.

Judith died in her room at the nursing home five days later, on Nov. 9, 2017.

No one reported an accident or recent injury at the Chartwell Waterford Long-Term Care Residence in Oakville, according to Ministry of Long-Term Care documents.

Between the Friday evening hymn sing and daybreak, something went amiss.

The circumstances behind the death of Judith Knox Young, born into the Massey Harris/Ferguson empire of agricultural equipment and the philanthropic name behind Massey Hall, Massey College and the Massey Lectures, remain a mystery, although the Office of the Chief Coroner recently revised its original conclusion. In September, its new report no longer called her death natural." Ontario's Long-Term Care Ministry said it will review the coroner's latest findings to determine next steps."

In the days after Judith's death her sons contacted police and the ministry. They wanted to know how their mother ended up with identical breaks in her thigh bones and why the accident was not immediately reported, saying she would have screamed in agony. The Waterford's attending physician" quickly alerted the coroner, who had Judith's body sent from the funeral home to Hamilton General Hospital for an autopsy, according to the first coroner's report. The autopsy did not determine the reason for Judith's fractures.

As the years passed, the Young brothers collected documents from the coroner, police, the nursing home and Long-Term Care Ministry, including the inspector's interviews with at least 15 staff, some of whom were questioned twice. None said they witnessed an accident or heard a cry of pain in the moment Judith's legs were broken.

The lack of witnesses confused Judith's family for one reason: she could not move on her own. Judith spent her days in a wheelchair or bed, beside a dresser with framed photos of her five sons and their families. On her side table sat hard-bound versions of Winnie the Pooh" and The Wind in the Willows," books Judith once read to her boys and now, they read to her.

Using video from the Waterford hallway camera that offered a view of the door to Judith's room, the ministry inspector wrote a detailed timeline of workers coming and going.

At 7:40 a.m., on Saturday Nov. 4, 2017, two day-shift workers walked into the room.

The morning staff told the ministry inspector Judith needed help rolling onto her side in bed.

When we turned her, she was screaming in pain," the personal support worker said, according to the inspector's typed notes. Judith screamed, repeatedly, the notes said, as the two PSWs pressed forward with her morning routine.

We went on, and we dressed her up and we put the sling (under her) and she was really screaming, we hooked her and put her in the chair," the worker told the inspector, according to the inspector's notes.

Both PSWs told the inspector they saw no bruising and confirmed" Judith had not fallen.

At 8 a.m., one of the workers pushed Judith, now in her wheelchair, to the dining room for breakfast. She did not eat. Staff brought her back to her room two hours later. She was wheeled out for lunch ... at 12:15 p.m. and back ... at 1:28," the inspector's notes said. In her room, staff strapped Judith into the sling and transferred her to bed. Half an hour later, a nurse entered her room, bringing a vitals machine" that tracks blood pressure, heart rate, oxygen and temperature.

At roughly 3 p.m. on Saturday, the home's registered nurse called Judith's son and told him his mother had a lot of pain in her legs. The nurse seemed distraught," he said. She was very kind and caring."

Twenty minutes later, Terence Young walked into his mother's room. Judith lay in bed, her face clenched in something akin to agony, and he leaned down, pressing his cheek to her face.

What happened, Mom?" he asked.

I fell," she said, her eyes closed.

Four years later, those two words remain the only explanation for her broken femurs.

No Waterford staff reported an accident. The ministry inspector found no wrongdoing. Halton Regional Police reached the same conclusion.

Those three seem content to blame Judith Young for her own death," Terence told the coroner's office in February of 2019, requesting, or more accurately, demanding it redo its first investigation.

If authorities expected the pursuit for answers to ease with time, they did not account for the tenacity of Judith's sons, all accomplished in politics, the air force, acting, music or medicine.

Terence Young knows how to fight bureaucracy. He's the former Conservative MPP and MP for Oakville. His middle name, Hart, is a nod to his great-great-grandfather, Hart Massey. University of Toronto's Hart House also bears his name.

Terence is not easily deterred, particularly in the worst of times. In 2000, his 15-year-old daughter, Vanessa, died suddenly of heart arrhythmia. Terence discovered that a drug Vanessa had been prescribed for bulimia was linked to heart attacks. He fought the drugmaker in court for six years, wrote a book called Death by Prescription" and as an MP, launched a fight for drug safety legislation, with Vanessa's Law the result. He's now publishing a book on pharmaceutical secrecy.

Judith's eldest is Dr. J.E.M. (Ted) Young, a clinical professor of surgery at McMaster University and a 45-year head and neck and thoracic surgeon, recently retired from operating duties at St. Joseph's Healthcare Hamilton but still seeing patients.

In this battle, Terence and his brother, Dr. Young, had the bureaucratic wherewithal, perseverance and medical expertise to push back - a combination most families facing unanswered nursing-home questions do not possess.

We are doing this so no one else has to go through a similar experience," Terence said. Dr. Young wrote to Ontario chief coroner Dr. Dirk Huyer in December 2019, telling him that without a proper investigation into the reason for his mother's broken legs, other residents of LTC facilities will suffer similar consequences, (or already have)."

The suggestion of a minor impact" on the commode chair was ludicrous," Dr. Young told Huyer.

To Judith's sons, the official version in the coroner's original 2018 conclusion and later, the 2019 preliminary report by the coroner's geriatric and long-term-care review committee didn't add up. Operating out of the coroner's office, the review committee includes a mix of physicians, nurses, pharmacists and dietitians among others, who may make recommendations to help prevent future deaths.

Both coroners' reports said Judith died of pneumonia even though her sons said it was immobility from broken legs that forced her to lie in bed, leading to the lung infection. The reports said Judith's death by pneumonia was complicated" by the fractures but not caused" by them. As a result, her death was designated natural."

To Judith's sons, that conclusion meant the crippling pain their mother felt in her final days would be filed away as an uneventful nursing home death with no recommendations to stop future accidents.

The coroner's office did not respond to the Star's specific questions, saying it cannot comment on individual cases but added that each death investigation is important, and it takes time to do a thorough investigation to determine medical cause of death and manner."

Judith's son Dr. Young dealt with the original findings by writing letters to the coroner's office. With each more searing than the last, he deconstructed the coroner's early conclusions.

What is not in doubt," he wrote to the geriatric review committee on June 18, 2019, is that my mother's legs were fractured in her room by some misadventure almost certainly on the evening of November 3rd 2017, and that injury resulted in her death.

What is equally significant is the fact that if the injury had been discovered and reported then or the following morning, she would not have gone through three days with inadequate pain control and certainly would not have been dressed and taken to the dining room on two occasions on the 4th."

There was more. The first coroner's report was loaded with what Dr. Young called inaccuracies and biased comments, as if Judith's age, cognition, immobility and do not resuscitate" order somehow excused the injury and her excruciating pain.

It sounded as if everyone thought, Well, she's old, so she was going to die anyway,' " he said, in an interview.

The report quoted the home's attending physician - who works under contract and is not a Chartwell employee - saying that Judith was deteriorating during her final three months. (Her sons said she was a lively conversationalist who loved family visits.) The physician described Judith as a reliably unreliable historian." That term is sometimes used in the medical field when referring to people with dementia.

Dr. Samir Sinha, director of geriatrics for Sinai Health and University Health Network, said he will tear a strip off" medical students who use the poor historian" reference when speaking of older adults. It ties into the notion of ageism," he said.

Sinha did not treat Judith but said if an individual - of any age - suffers fractures in both thigh bones, they will immediately react.

It would be hard for me to think that a person who broke both their legs as not expressing pain in one way or the other unless they were dead."

In the 1930s, it was music that introduced Judith Knox to her future husband, a city of Toronto public health worker who aspired to become an Anglican minister. When she played the piano at a city soiree, he walked over and told her, You play so beautifully."

At the age of 19, she married George Young. Together, they managed St. Matthias Church on Royal York Rd. in Etobicoke and later moved to St. Anne's Church on Gladstone Ave.

It was here that Judith raised her boys: Ted, Terence, Peter, Denton and George, whose stage name Scot Denton (like his brother's given name) pays homage to Dentonia, the Toronto model farm built by Judith's grandfather, Walter Edward Hart Massey. It produced Canada's first pasteurized milk in the early 1900s, when children were dying from bacteria in the raw version.

Judith's sons and 10 grandchildren are plaintiffs in the $2.75-million lawsuit that the family filed against Chartwell and several staff on Oct. 31, 2019. This story is based on legal documents, interviews, reports from the ministry, police and coroner, and family letters disputing the coroner's original conclusion.

A Chartwell spokesperson responded to the Star's list of questions with a written statement that noted the compassion" of its employees and said, We are sorry about the passing of Judith Young ... and we understand the grief of her family.

The family has taken the step to file a personal injury lawsuit against Chartwell and four front-line members of staff. Following their decision to do so and based on previous investigations which resulted in no findings or charges, it would be inappropriate to comment on the matter for a media story outside the legal process initiated. Chartwell has every confidence in the justice system to get the right result."

Chartwell's statement of defence, filed on Dec. 16, said the nursing home provided excellent care and had nothing to do with Judith's injury and death. It said Judith was responsible, due to pre-existing medical conditions or circumstances" that arose before or after the workers' involvement and the natural progression" of her medical condition. It blamed her sons, saying they failed to follow directions of health-care professionals, disclose relevant information and seek medical attention on a timely basis or at all."

A year before Judith's death, an annual inspection found problems with the staff use of lifts in the home. The Ministry of Long-Term Care said it does not collect data on injuries from lifts, but is looking at data collection for quality of care and quality of life." Jane Meadus, a lawyer with the Advocacy Centre for the Elderly said those injuries are not unusual.

It is not uncommon for people to have these injuries that the long-term-care home claims they have no knowledge of, saying we don't know what happened,' " Meadus said. That is extremely upsetting and frustrating to the families."

With no answers, Judith's sons did what detectives do and returned to the scene - or in this case, the X-rays.

The coroner's first report said Judith suffered oblique" fractures that were so similar the radiologist thought the same leg had been X-rayed twice.

Oblique fractures are angled and often caused by a sharp blow. There were angles in Judith's broken femurs but the fractures also curved around the cortex, the dense outer surface of the bone. An orthopedic surgeon and a radiologist who recently examined the X-rays at the behest of Dr. Young both told the Star that Judith's breaks were identical spiral fractures, which are caused by a significant rotational force.

She had a twisting injury that spiralled around the bone," said the orthopedic surgeon, who in his 30 years of practice has seen two other cases of identical spiral fractures in both femurs.

When I looked at the X-rays, I just shook my head right away because those legs were twisted, whether by accident or she fell out of bed, there was a violent twisting here."

To the Young brothers, that twisting motion negates the coroner's suggestion of a minor impact fracturing the weak bones of an elderly woman.

Judith's son, Dr. Young, has a hypothesis. On the evening of Friday, Nov. 3, 2017, he believes staff were lowering his mother onto her bed when she likely landed on legs partly bent under her body - instead of safely pointing straight - creating the hard twist behind the spiralling fractures.

Terence agreed, using a sports analogy to describe the twisting impact: This is similar to when a football player is hit from the side and his cleats are firm in the ground (so) his leg can't turn, breaking his ankle or femur."

The Young brothers' theory was inspired by a previous incident the family's privately paid caregiver said she witnessed in Judith's bedroom - and stopped.

Kareen Butler told the Star she watched as workers using a ceiling lift moved Judith close to the bed, with her legs hanging down as she sat in the sling. Butler said she always holds a resident's legs straight, guiding them carefully so they don't get caught on the edge of the bed, in the sheets or twisted under the body. I ran over and stopped them and demonstrated how to do it properly," she said. The ministry inspector interviewed Butler about her concerns.

There is no doubt the bones of older adults can be fragile. Judith had not been diagnosed with osteoporosis, a condition that causes bones to become brittle and weak. Still, based on her age and the fact that she was no longer weight-bearing," her bones, said her son Dr. Young, had likely de-mineralized," through calcium loss.

But as the orthopedic surgeon said, bone density loss would not have created two identical spiral fractures without significant rotational force.

This was not just a little oops, I turned, and I fell and I broke both legs.' There's no way. No way."

Another theory emerged from the inspector's interview notes. A worker suggested that Judith was in pain due to a fall from bed eight months earlier. But the orthopedic surgeon said the X-ray showed her fractures were new - with no sign of bones attempting to heal.

Judith's double knee replacements would have created stress above her knee joints, he said, but the twisting movement required to create those spiral fractures means that Judith's injury was not happenstance.

To get both at once ... somehow she fell with the knees bent or was put down inadvertently forcefully, or forcefully," he said.

This lady had pain and would have screamed and cried out."

On Saturday, Nov. 4, 2017, nobody seemed to know what was wrong with Judith.

The mobile X-ray technician wouldn't arrive until Monday. After sitting though lunch in the dining room, without eating, Judith was given Tylenol for the remainder of Saturday and Sunday until Monday afternoon, when she was prescribed hydromorphone, a powerful drug that eases pain, Dr. Young said. The family did not want her sent to hospital, believing the physical movement would be anguishing.

On Monday, the technician took X-rays of her left leg. The coroner's report said Judith complained of pain in her right leg, so it was later X-rayed, too.

When Judith's private PSW, Butler, walked into the Waterford on Monday, she said another worker pulled her aside and told her Judith's legs had been broken. And I just went, Oh my God,' and I ran to her room ... There were other people in there and they were trying to change her and she screamed out."

Butler said Judith would have cried out during her injury and told staff she'd been hurt. Judith spoke up when she felt uncomfortable. And she loved to talk.

She was hilarious," Butler said. Just her comebacks, the way she could talk and tell jokes. All the boys are like that. They're a very close family. She was very proud of her boys."

The ministry inspector's notes backed up Butler's assessment, quoting staff saying Judith was chatty and more than able to express herself when she felt pain.

The home began palliative care. Judith's sons Scott and Denton arrived. Peter lives in Manitoba. Her eldest, Dr. Young, was thousands of kilometres away on a cruise ship. Terence photographed his mother's swollen legs and on Wednesday night, as his wife stood by the bed, Judith opened her eyes. Gloria!" she said, in a high voice. The next morning, the home called Terence to tell him that his mother had died.

Terence said he called Halton Regional Police, who also spoke with the coroner on Nov. 15, six days after Judith's death, according to a police report he later obtained. Terence didn't believe the injury was intentional, but said his mother suffered because the accident was not reported.

He needed answers.

Terence called the ministry, although the home also reported the injury. A long-term-care inspector arrived at the home on Nov. 21 to begin her complaint inspection." The inspector also visited on Nov. 22, 23 and 28, according to the inspection report.

On Nov. 30, the inspector spoke to Terence for an hour on the phone.

Explained to him how difficult it has been to verify what staff truly did as their memories were not good," the inspector's notes read. She told him she had good cooperation from the home, they did a good job, they got Chartwell involved."

A week later she called with an update on the latest staff interviews. There was no information of value, no one had any details," her notes said.

In one of her final comments to Terence, the inspector said, We both agreed that something happened, but proving how, when and by whom was the problem."

The ministry inspection report filed on Dec. 18, 2017, found no violations. A year later, police reached the same conclusion. Detectives deemed that there was insufficient evidence to support the laying of any criminal charges," a Halton police spokesperson said.

Ontario's Office of the Chief Coroner has a motto: We speak for the dead to protect the living."

To the Young brothers, it seemed like the coroner was speaking for everyone but their mother. They said the initial reports read as if Judith's broken bones and death mattered less because she was a woman in her 90s.

The first reports said Judith died from pneumonia complicated by bilateral distal femoral fractures" but not pneumonia caused by lying prone with fractures. It said distal femoral fractures are the second most common fragility fracture in the elderly" and for those at risk, low-impact" injuries lead to fractures.

On Oct. 7, 2021, the coroner's geriatric review committee sent the family an updated report with the new death category.

It said Judith died from pneumonia but this time the pneumonia was due to/as a consequence of" femoral fractures.

Now three pages instead of two, the new report concluded it seems probable that there was some force" on the left knee that likely caused Judith's injury and called the manner of her death a competition ... between accident and natural."

Judith's death is now officially undetermined."

The mystery continues. Judith's sons intend to solve it.

It is unthinkable for us to give up on finding out how Mom died," said Terence. Not just for her, but for all seniors in long-term-care homes."

Moira Welsh is a Toronto-based investigative reporter for the Star. Follow her on Twitter: @moirawelsh