Saskatchewan’s ombudsman says a long-term care home in Regina did not properly assess the risk of a fall or follow fall prevention policies before the death of 87-year-old Jessie Sellwood in 2013.
The report, released Friday, also found the Regina Qu’Appelle Health Region (RQHR) and the Ministry of Health were not monitoring the Extendicare Sunset care home to ensure proper policies were being followed.
READ MORE: Family wants to hold system accountable after fall led to death
Regina’s Extendicare Sunset was investigated by the provincial ombudsman, Mary McFadyen, after former health minister Dustin Duncan requested a review following concerns from Sellwood’s family.
Sellwood died in December 2013 after a bad fall at Extendicare Sunset in Regina while being assisted by one care aide.
After falling on Dec. 23, Sellwood was taken to Pasqua Hospital in Regina. She was given pain medication, sutures and sent back to Extendicare Sunset.
According to the report, upon returning to the home, Sellwood complained of leg pain, leg swelling and nausea. She was taken back to the hospital where she was diagnosed with a fractured leg.
She was once again returned to Sunset where she died in the early morning of Dec. 27.
The doctor who completed the certificate of death listed it as an “accident.”
Despite the Coroner’s Act, 1999, saying the coroner is to be notified if any death occurs due to an accident, the care home did not notify the coroner and “did not appear to be aware of the circumstances under which a coroner must be notified.”
The care home was also supposed to deem the fall a critical incident within three business days and report it, due to Sellwood’s death being associated with a fall in a long-term care facility.
READ MORE: Sask. families say seniors care issues being ignored
However, RQHR found it to be a critical incident in May 2014, five months after Sellwood’s death. The coroner was contacted at this time.
“We found several instances of care and staff action that failed to meet the standards established by the Ministry’s Guidelines, and by RQHR’s and Extendicare’s own policies – and managers did not seem to be aware of these breaches,” McFadyen said in the report.
The report also said Sellwood’s family had a difficult time getting answers about her care, saying,”the family endured a lengthy, disjointed and unsatisfactory review process and did not get timely, satisfactory answers to their questions.”
McFadyen made seven recommendations in the report. These include:
- Extendicare taking immediate steps to ensure all policies for its Saskatchewan facilities meet requirements.
- That RQHR implements a process to review all unexplained and unexpected deaths in long-term care homes.
- That care home staff know what information can be released to the family following a death.
The report also said senior officials with RQHR and Extendicare should apologize to the family and explain any changes they are making to improve conditions.
Back in 2014, Sellwood’s family said Jessie required a mechanical lift, but only one care aide was assisting her when she fell, instead of two.
“In the health district, you’re not accountable,” Jackie Lewis, Sellwood’s daughter-in-law, said in 2014.
“These homes are not accountable.”
Communicating With Care Public Report
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