Their mother died in agony in a nursing home. Now they’re demanding Ontario hire a long-term-care ombud

The sons of 95-year-old Judith Young - who died in an Oakville nursing home with two broken femurs and no explanation - are calling on the Ontario government to hire a long-term-care ombud with the investigative power to demand answers from the system.

Without an independent oversight office, Dr. J.E.M. (James Edward Massey) Young and his brother, Terence Young, the former Oakville MP and MPP, said families will remain alone in their struggle for answers from nursing homes and the institutions that are supposed to oversee them.

Most families," said Dr. Young, don't have the time or resources to contact the coroner's office, the police or the facility itself when something happens to a family member in long-term care. Our experience is an example of how very difficult it is to get answers or even information."

The Young brothers have the bureaucratic and medical expertise to seek answers. And yet, they've been fighting for four years to find out how their mother - who could not move on her own - ended up with two identical fractures in each thigh bone at the Chartwell Waterford Long-Term Care Residence, when no one in the home reported an injury or a cry of pain.

An orthopedic surgeon and a radiologist who examined Judith's X-rays at the behest of Dr. Young both told the Star she would have cried in pain after suffering twisting spiral fractures that are caused by a significant rotational force" and not simply the weak bones of an older woman. Judith's sons said their mother did not take any medication that would cause brittle bones.

Judith died on Nov. 9, 2017. Her sons believe that she was injured sometime between the evening of Friday, Nov. 3, and the following morning when day staff arrived. The Ministry of Long-Term Care inspector's notes quote day workers saying they had no reports of a fall but said Judith screamed when they dressed her that morning. Staff said they continued dressing Judith and twice took her to the dining room. She did not eat.

Investigations by the nursing home, Halton Regional Police and the ministry found no wrongdoing.

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." Instead, it is now using its undetermined" category for Judith's death. The new report said 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."

The ministry has said it will review the coroner's latest findings to determine next steps."

Since the story of his mother's death was published in the Star on Saturday, Terence said he has been taking calls from families sharing their struggle for information related to relatives' injuries and deaths. The Star has also received numerous readers' emails of unexplained injuries and deaths.

An independent Ontario ombud would be very, very busy," Terence said.

If there was an ombudsperson with legal expertise, they could guide families on their options and write a report, or a series of reports, to put all of these issues on the public record," he said.

Jane Meadus, a lawyer with the Advocacy Centre for the Elderly, said an ombud would only be effective if they had a strong investigative background and powers - otherwise it would likely end up as yet another bureaucratic exercise that leads nowhere.

Any push for an independent ombud should be combined with a nursing home whisperer," to help homes improve, said Dr. George Heckman, the Schlegel Research Chair of Geriatric Medicine at the Schlegel-University of Waterloo Research Institute for Aging.

What I've been finding in long-term care is the approach tends to be punitive and then the reaction therefore tends to try to weasel out of some responsibility and blame others," Heckman said, speaking about nursing homes generally. It can go all the way to the top."

Yes, there are punishments meted out and compliance orders, but I don't know if they ever get to the bottom of things," Heckman said. The independence of an ombud is good - but you also need the independence of the people to say, Here is how we are going to fix your problem.'"

Until that time, families are on their own.

Terence offered recommendations for those unaccustomed to challenging authority. He suggests taking detailed and dated notes of issues as a written record for future reference. He also recommends requesting meetings with the home's administrators, highlighting specific concerns and asking how the home intends to deal with them." Families should visit on different days at unexpected times. And, he said, the power of attorney could seek legal advice, if needed.

He knows that many families will struggle. Most people are intimidated by authorities because they feel that they are going to get into trouble if they challenge them," Terence said. But you have to stand up to authorities. It's not a matter of being angry - it's a matter of being persistent."

Few can afford the cost of a lawsuit, he noted. They're afraid if they go to a lawyer, they're going to have to write a cheque for $20,000. Which they usually will. That'll be gone. Then there will be a request for another cheque. You know, half of Canadians - and I remember this number from the 2019 election - have less than $200 left over at the end of every month. They can't afford to write a cheque."

But, he said, some lawyers will take a case on a contingency fee to be paid later - if there is a settlement. Meadus, of the Advocacy Centre for the Elderly, said she is seeing more lawyers take on these cases. I think these problems are going to be fixed in the courts," she said.

In 2019, the Young sons filed a lawsuit against Chartwell and four employees, alleging their mother suffered immensely because no one reported an injury, leaving her with inadequate pain medication until her broken femurs were X-rayed.

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 Chartwell spokesperson cited the compassion" of its employees and said the company has every confidence in the justice system to get the right result."

The Youngs took exception to the original coroner's report which, Dr. Young said, made their mother sound like she was old and going to die anyway."

Dr. Samir Sinha calls it a conspiracy of silence" created by ageism and ableism."

Older adults, especially those in their 90s, like Judith, are often looked upon as if their lives matter less because they don't have decades of life left and are living with dementia, said Sinha, director of geriatrics for Sinai Health and the University Health Network.

If this was a child-care facility for example, and this happened, would we have reacted in the same way? I think there would have been a fulsome investigation. Would we just have said, Well nobody saw anything so we're just giving up?' Well, no. We would not."

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