Fatal Choices: COVID-19, Nursing and the Tragedy of Long-Term Care By Mario Possamai Table of Contents Executive Summary ......................................................................................................................... 4 Chapter 1: COVID-19 — A Preventable Tragedy ....................................................................... 8 Chapter 2: The Failure to Learn From SARS: “I am angry all the time” ......................23 Chapter 3: The Failure to Prepare ............................................................................................32 Chapter 4: The Nexus of the Disaster .....................................................................................43 Chapter 5: Long-Term Care, A Troubled Past ........................................................................52 Chapter 6: Survey of Registered Nurses in Long-Term Care ..........................................67 Chapter 7: Case Studies — Anson Place and Madonna Care ...........................................74 Chapter 8: Filling the Vacuum of Government Inaction ....................................................85 Chapter 9: Recommendations from the Front Lines ......................................................101 Chapter 10: Conclusion .............................................................................................................. 119 FIGURES Figure 1 — First Wave vs Second Wave .................................................................................14 Figure 2 — Cumulative Case Count of COVID-19 in Long-Term Care ...........................29 Acknowledgment and Dedication This report is dedicated to registered nurses in long-term developed, overseen and executed with distinction, care. Their courage, dedication, leadership and integrity has a complex legal strategy that has made a significant been a source of light and inspiration amid the darkness difference in keeping registered nurses, residents and other of the worst public health disaster in a century. They have health care workers safe in long-term care. She has inspired been battle-tested by an insidious new pathogen and by the highest standard of professional performance in her employers who refused to adequately protect staff and colleagues, and in myself. residents unless ordered to do so by courts and arbitrators. We owe them a huge debt of gratitude. I would also like to thank Nicholas Baxter, a thoughtful member of the ONA legal team who has been invaluable This report is also dedicated to the victims of COVID-19, in drafting, researching and editing this report. His legal their families, friends, colleagues and communities. learning and judgment have made a huge difference. I could not have completed this report without his enormous In the SARS Commission final report, Justice Archie dedication, energy, commitment — and infectious sense Campbell wrote: of humour. “SARS taught us lessons that can help us redeem our A special thanks to Nicole Butt, Legal Counsel and Manager failures. If we do not learn the lessons to be taken of Litigation, and Marcia Barry, Senior Legal Counsel, at from SARS, however, and if we do not make present ONA. They provided invaluable advice and input into a governments fix the problems that remain, we will variety of ongoing and historical issues in long-term care pay a terrible price in the face of future outbreaks of and were generous with their time in reviewing the report. virulent disease.” Nicole and Marcia embody the legal profession at its best — as guardians of justice, striving for a more just society. It is a tragedy that we did not learn sufficiently from SARS to redeem Ontario’s failures from the 2003 outbreak. My thanks to Dave Campanella, ONA’s economist and data analyst, who provided a rigorous analysis of COVID-19’s May the aftermath of COVID-19 be different. May the grim toll and the data that underpinned this report. anguish and suffering of COVID-19 not be forgotten. My thanks to Tanya Beattie, RN, BScN, MPA, Research/ This report is also dedicated to my friend and mentor, Nursing and Health Policy Officer at ONA, and Christina Justice Archie Campbell. Assisting him on the SARS Pullano, RN, BScN, MN (student) for their invaluable insights Commission was an honour and the highlight of my career. into the history of the nursing profession and its role in “Archie,” as I had the honour to call him, was very ill as he long-term care. completed the Commission’s final report in December 2006 and would die a few months later. I have never witnessed My thanks to Vicki White, ONA’s librarian, who was such courage and grace under fire. As no one else I have indefatigable and meticulous in her research. met, Archie lived up to the dictum of Marcus Aurelius, one of his favourite authors whom he read in the original Latin: When completing a report of this nature in the face of an “Live a good life.” extremely tight deadline, a huge burden falls on to the shoulders of editors, graphic artists and proofreaders. “It takes a village to raise a child,” goes a wise African The ONA editing and graphics team is second to none. I proverb. It also takes a village to prepare a report like this have rarely seen a team perform so well under so tight a one under an extremely tight deadline. deadline. I owe a debt of gratitude to: Holly-Ann Campbell, Executive Lead, Communications and Government Relations, Beverly Mathers, CEO of the Ontario Nurses’ Association Ruth Featherstone, Communications Officer, Melanie (ONA), provided valuable advice and comments on the final Levenson, Communications Officer, Katherine Russo, drafting of this report. Her support throughout this project Communications Officer, and Shannon Balmer, Labour was greatly appreciated. Relations Assistant. I would like to thank Sharan Basran, Senior Executive, Legal, Thanks also to the design team from ImageStudio Creative at ONA, for her unflagging support, commitment and wise Communications Inc.: Deana De Ciccio, Art Director/Graphic counsel. Her insights in drafting and reviewing the report Designer and Brandon Brind, Creative Director/Principal. were indispensable. Throughout COVID-19, Sharan has Executive Summary Ontario vs. SARS Peers Ontario and its SARS peers — China, Hong Kong and A Litany of Failures Taiwan — recorded a combined 94.8 per cent of all SARS cases, 94.0 per cent of its deaths, and 91.7 per This report examines the tragedy of COVID-19 in long- cent of all cases involving health care workers. These term care in Ontario through the lens of the SARS four jurisdictions had the opportunity to learn from the outbreak of 2003 and the subsequent findings of the experience of SARS and prepare for a future pandemic. SARS Commission; the perspectives of registered nurses; the experiences of jurisdictions that learned from SARS; The evidence suggests that China, Hong Kong and and the recommendations and warnings of unions and Taiwan leveraged the lessons of SARS to both effectively worker safety experts that were repeatedly ignored. prepare for and respond to COVID-19. Ontario did not. The tragic result: As of January 23, 2021, Ontario had Ontario and its long-term care sector have paid a more COVID-19 cases (210,276) than China (100,298), heavy price in preventable COVID-19 death and Hong Kong (10,321) and Taiwan (895) combined. disease because of a litany of failures to both heed the preparedness and containment lessons of the 2003 When the pandemic struck, Hong Kong took a SARS outbreak, and fix the sector’s endemic problems. precautionary approach and regarded COVID-19 as an These avoidable failures constituted a series of fatal entirely new pathogen. It acted decisively to protect choices, creating an environment ready-made for a novel its long-term care residents and staff, shutting its care pathogen to run rampant, and setting off the worst homes to most visitors. Nearly everyone in Hong Kong public health crisis in a century. was wearing a mask by mid-February 2020 to limit community spread of the virus. As of November 29, Among the many failures, Ontario ignored the key finding 2020, Hong Kong, with more than 76,000 nursing home and recommendation of Justice Archie Campbell’s SARS beds, had seen 30 resident COVID-19 deaths. Ontario Commission: the precautionary principle. When facing has about the same number of long-term care beds: a new pathogen with unknown characteristics and 77,257. As of that date, Ontario had 2,301 long-term care transmission dynamics — especially when evidence of resident deaths in both the first and second waves, plus airborne spread is growing — the principle calls for erring 10 health care worker deaths. on the side of safety and caution. Starting in late January 2020, China protected its health Ontario’s failure to heed the precautionary principle had care workers at an airborne level. It suffered only one destructive knock-on effects that crippled the pandemic wave of COVID-19, with the number of cases remaining response in long-term care — and in the province at relatively stable since life began returning to normal large. Registered nurses and other health care workers during the summer. As of May 8, 2020, 3,514 health care were forced to wear surgical masks and not N95 workers with COVID-19 were clinically or laboratory respirators. This meant they weren’t properly protected diagnosed in China, about 4.4 per cent of all Chinese against a pathogen that most everyone, including COVID-19 cases. Most of these cases occurred before international and national public health agencies and China