About three weeks after moving her father into a Windsor, Ont., retirement home, Joanne Vandereerden didn’t expect she’d get a call telling her that the 80-year-old had been rushed to hospital after falling out of his third-storey window.
Nearly two years later, the family is still looking for answers.
“How did this happen? We put him there to be safe,” said Vandereerden, whose dad died the day after the fall.
“This should never have happened. He was in great health. We could have had many more years with him, and now we don’t.”
Her sister, Susan Dixon, said “never in a million years” did she think this would happen to their father, James Clarke.
“It was devastating,” Dixon told CBC News.
The daughters and their lawyer are waiting to hear whether an inquest that they requested in September 2022 will be granted.
Investigations by the Retirement Home Regulatory Authority (RHRA), a committee with the coroner’s office and the Windsor Police Service, found the home complied with regulations and there was no criminal negligence.
Even though these investigations came out with some recommendations, the family wants to see concrete change and believes a coroner’s inquest is the best way to get that. They also plan to file a lawsuit against the retirement home.
“It would answer some questions about what exactly failed in this process that this was allowed to happen,” said Colleen Caza, the family’s lawyer, who’s with Goldstein DeBiase.
The lawyer said an inquest would help give the family closure.
Vandereerden said Clarke had been diagnosed with dementia in December 2021, but was still in the early stages. In April 2022, Clarke ended up in hospital after some behavioural issues and he had a tendency to wander.
About two weeks into his hospital stay, Clarke was moved to a “secure unit” at Lifetimes on Riverside Retirement Residence, which the family says took in people needing memory care. The family said this was supposed to be temporary until a spot opened in long-term care.
Shortly into Clarke’s stay, the family said, his care plan was updated to include check-ins every 30 minutes, including overnight.
But an investigation shows that on the night Clarke plunged to his death, these checks didn’t take place.
CBC News has not seen a copy of the RHRA’s inspection, but it said in an email that the home was found to be compliant.
CBC News has obtained a copy of the investigation by the coroner’s office’s Geriatric and Long-Term Care Review Committee. The report cautions “the opinions expressed herein do not necessarily take into account all of the facts and circumstances surrounding the death.”
It said that in an interview, a personal support worker (PSW) on duty that night said Clarke was last reported to have been seen sleeping in bed at midnight on May 15, 2022.
Light was on but no noise was heard
The report states the PSW’s last attempted check-in on Clarke was at 3 a.m., and at that time, the PSW was not able to open the resident’s door with a key.
“The light in the room was on but no noise was heard,” the report says.
“The PSW did not return with support to attempt to open the door.”
It was later discovered that Clarke had stuffed something into the key lock of his unit, to prevent people from entering.
They also found out he had dismantled his window, including the mechanism that prevented the window from opening more than two inches.
‘Just wanted to crawl out the window and go home’
“He probably thought he was on the main level and just wanted to crawl out the window and go home,” said Vandereerden.
“He went out the window and landed on his face. Everything in his head was broken and his skull was cracked.”
At 5:30 a.m., a staff member heading in to work found Clarke lying on the pavement in front of the home.
The committee’s report says he was described as “non-responsive, but shaking and obviously injured.” An ambulance brought him to hospital.
At the hospital, Vandereerden said the doctor came in and told her Clarke had “catastrophic” injuries.
“He looked bad,” she said.
“It was really bad … we were just in shock. And to see him in that way so damaged, his face was totally unrecognizable.”
The Geriatric and Long-Term Care Review Committee’s report states “neurosurgery recommended a conservative plan care plan,” and that the family changed it to “comfort care.”
“He was extubated and … died from his injuries.”
He died on May 16.
Committee finds death was not preventable
“Short of constant supervision, given the failures of the mechanical window barrier in place, the decedent’s death would not have been prevented even with ideal [dementia observation system] charting and direct intermittent observation by the PSW as planned,” reads a statement from the committee report.
The report did acknowledge Clarke’s death may have been prevented if there was a tamper-proof window locking mechanism in place.
It said various health-care facilities have policies around the design of windows in “secure perimeter units.” It lists B.C. as an example and says that it has standards around making windows impact-resistant and installed to “withstand tampering.”
The report says these standards are not in place in Ontario retirement homes.
In an emailed statement, Lifetimes on Riverside’s general manager, Jaclyn Elford, said the death was “an unfortunate incident.”
The committee gave the home one recommendation: to perform a “quality review of the circumstances” of the death, “including consideration of perimeter security.”
What the committee recommended
Elford said the home has started the review and will give a response to the committee’s recommendation by the April 13 deadline.
“Any learnings from this review will help us continue to improve the care, safety and comfort of residents,” Elford said in an email.
The coroner’s office said in an email that the Geriatric and Long-Term Care Review Committee provided another three recommendations to other bodies and government ministries.
Two of them were directed at the Ministry for Seniors and Accessibility and the RHRA, and said they should “review the need for security standards for retirement homes that provide secure units. This should include window security.”
It also recommended that as patients have more complex needs, they need to “consider appropriate regulation (physical aspects of accommodation, minimum staffing levels and qualifications, medication delivery), to improve the safety of residents.”
The report stated that during Clarke’s stay, the facility, which has the capacity for 136 residents, is staffed overnight with one nurse float, a PSW float and one PSW dedicated to Clarke’s floor.
A spokesperson for the Ministry for Seniors and Accessibility responded to a request for comment on the recommendations.
“As it is within the RHRA’s authority to establish policies and procedures that address recommendations in the report, they are best positioned to respond to them,” a spokesperson said.
The Geriatric and Long-Term Care Review Committee also gave a recommendation to the Ministry of Health and Ontario Hospital Association, stating that when dementia patients are sent to retirement homes, “decision-makers must consider that these residences do not offer dementia or behavioural management services and are not staffed for such.”
The coroner’s office said there is no legal requirement for these recommendations to be implemented, but that the organizations or bodies need to respond within six months.
It said none of them have yet gotten back, but they have until April.
No timeline offered on possible inquest: coroner
The coroner’s office said it’s hard to know how long it will take before the family knows whether there will be an inquest as “each case is unique, but all information, reports, and records need to [be] reviewed to make the decision.”
When asked how the retirement home was found to be in compliance when the resident was not checked in on as per their care plan, the RHRA said there are no requirements in the Retirement Homes Act that outlines “how frequently staff must routinely check on residents.”
“The frequency of checks or care is based on the agreement between the resident and the home with consideration to a resident’s care needs and a home’s internal policies,” the RHRA said.
Graham Webb, lawyer and executive director of The Advocacy Centre for the Elderly, said this situation points to a “systemic issue.”
“The shortcoming is in how we are using retirement homes. Retirement homes should not be used as a substitute for the health-care system, they shouldn’t be a private pay health-care system,” he said.
‘We’re trying to make change’
“We do need systemic change in the way that we use retirement homes … [they] should not be used as a last ditch resort for people who don’t fit anywhere else within the system,” Webb said.
He wants to see an inquest in this situation as he believes it can be informative and is more likely to lead to law reform.
Vandereerden and Dixon said they just want to make sure this doesn’t happen again to anyone else.
“We’re trying to make change,” said Vandereerden.
“We’re very discouraged that there’s so many roadblocks and minimal measures and no real recourse.”