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Patient Ombudsman
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Patient Ombudsman Years 4 & 5


Informing change in a time of crisis

Remembering Cathy Fooks

A legacy of unparalleled dedication to excellence in health care and patient experience.

A tribute to Cathy

Patient Ombudsman’s message

Meeting an ever-growing demand for help navigating a health care system that is increasingly complex and continuously evolving.

Craig Thompson’s message

How we got here

5 years of impact

Patient Ombudsman opened its doors and phone lines on July 4, 2016 and began receiving complaints from patients (including long-term care home residents) and caregivers about their health care experiences. Over the last five years, we have worked hard to champion fairness in health care and listen to patients, caregivers and health sector organizations (HSOs).

“I am very pleased with the resolution. And I thank you for being a part of this process. I have not wanted to cause any trouble or grief, I just want to be cared for medically, the same as everyone else is…This resolution is exactly what I was hoping and looking for…I always felt that you truly cared about me and what I was going through.”

The Patient Ombudsman’s authority is set out in the Excellent Care for All Act, 2010. Our role is to receive, respond to and help resolve complaints from current or former patients or their caregivers about their care or experiences with HSOs. The HSOs within our jurisdiction currently include public hospitals, long-term care homes and home and community care support services organizations.

Over our first five years, Patient Ombudsman has evolved and developed our response to complaints to better meet the needs of Ontario patients and their caregivers. The foundation for our ongoing development was laid in our first three years with three significant accomplishments: the development of our first set of strategic aims and objectives; the development of the Fairness Triangle; and our Service Charter.

Complaint overview

Record numbers, unique challenges

At the end of March 2020, Patient Ombudsman began tracking a significant increase in complaints about the impact of COVID-19 on Ontario’s long-term care homes. We reported weekly on complaints related to COVID-19 and shared our reports with health system leaders. The complaints highlighted serious concerns in long-term care homes, including inadequate infection prevention and control practices, lack of access to appropriate personal protective equipment, communication gaps and significant staff shortages that were affecting resident care.


Graph of complaints between April 2019 to March 2021, broken down by health sector organization. Year 4 (April 2019 - March 2020) had 2,470 complaints. Year 5 (April 2020 - March 2021) had 3,595 complaints. The share in Long-term Care Home complaints increases starting March 2020, with peak complaints between April 2020 and July 2020.

Complaints about long-term care homes typically make up less than 10% of the complaints received by Patient Ombudsman. By the end of April 2020, 33% of complaints were about long-term care homes. To gain a better understanding of the complexity of these concerns, Patent Ombudsman issued its first public call for complaints on April 27, 2020.

Impact of COVID-19 on the care and health care experience of long-term care home residents

Patient Ombudsman also launched its first large-scale, system-level investigation of the impact of COVID-19 on the care and health care experience of long-term care home residents in June 2020. The results will be released in 2022. In October 2020, Patient Ombudsman released the first of three special reports on the impact of COVID-19 on the experiences of patients and caregivers.

Read the first special report

Spotlight issues

Opportunities for improvement

Patient Ombudsman monitors the complaints we receive to identify emerging issues. Our “Spotlight” stories shine a light on the kinds of cases we receive, how we achieve resolutions, and where HSOs can look for opportunities to improve patient and caregiver experiences.

Spotlight 1/5: Breakdown in coordinated care

A patient living in supportive housing is admitted to hospital in grave condition, with wounds that suggest severe neglect.

What went wrong?
Illustration of three silhouettes representing a medical professional, a patient and a service worker.
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Spotlight 2/5: Trauma informed response to reports of sexual assaults in hospitals

Patient Ombudsman received 29 complaints reporting sexual assaults by other patients or staff in public hospitals, mostly on mental health units.

How can hospitals do better?
Illustration of a person in silhouette gazing downwards, surrounded by shapes and lines creating a sense of sadness or distress.
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Spotlight 3/5: Indigenous cultural safety

We received 27 complaints reporting a wide range of experiences concerning a lack of culturally competent care for Indigenous patients.

What’s the best way forward?
Illustration of a person with long hair in silhouette surrounded by line drawings representing elements of nature: birds flying, the sun, plants, and landscapes.
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Spotlight 4/5: Use of force by hospital staff

There were 58 complaints reporting use of force by hospital security staff–mostly involving patients with mental health or addiction issues.

What’s the answer to de-escalate?
Illustration of two people in silhouette, with lines surrounding their heads presenting dialogue. One person with more aggressive jagged lines is grabbing the other.
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Spotlight 5/5: The impacts of isolation

More than 500 complaints about restrictions on visitation were reported, mostly arising from the COVID-19 pandemic.

How do we find the right balance?
Illustration of a person in silhouette looking out a window, surrounded by a series of revolving circles.
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Complaint Details

Thousands of complaints, one dedicated team.

Multiple conversations, reviews of health records, building agreement–our frontline team ensures complainants are heard, and helps facilitate meaningful change where it’s needed.

Complaints by health sector organizations

Bar graph showing complaint amounts by health sector organization by year. Public hospitals have the most complaints.

Complaints per 100,000 population by Health Region

Map of Ontario demonstrating complaints by region (North, East, West, Central, Toronto). Toronto has the most complaints.

As noted in previous years, Patient Ombudsman receives complaints from across the province. However, the office receives more complaints per 100,000 population about HSOs in the Toronto and North regions. The disproportionate number of complaints about Toronto region are largely related to complaints about hospitals and may reflect, in part, the concentration of academic teaching hospitals in Toronto that care for patients from across the province.

Most frequent concerns raised by patients and caregivers in Years 4 and 5

Between March 2020 and March 2021, Patient Ombudsman added additional complaint categories to identify concerns related to the COVID-19 pandemic.

In hospitals and long-term care homes, concerns about restrictions on visitation were by far the most frequent complaints. Even after public health measures were relaxed and provincial policy guidance encouraged HSO to consider the important contribution loved ones make to patients’ health and well-being, complaints have continued.

Public Hospitals: 3,613 complaints
Top issues about Public Hospitals
  • # 1 Diagnosis/Treatment : 573
  • # 2 Quality of care : 385
  • # 3 Discharge/Transfer : 381
  • # 4 Complaint process : 254
  • # 5 Access or admission : 207
  • # 6 Sensitivity/Caring/Courtesy/Respect : 199
Top issues related to COVID-19
  • # 1 Visitation : 242
  • # 2 Communication : 92
  • # 3 Discharge/Transfer : 79
  • # 4 Infection prevention and control : 79
  • # 5 Quality of care : 67
  • # 6 Testing : 48
Long-term Care Homes: 858 complaints
Top issues about Long-term Care Homes
  • # 1 Quality of care : 90
  • # 2 Alleged abuse/assault : 51
  • # 3 Communication : 33
  • # 4 Personal security or safety : 31
  • # 5 Sensitivity/Caring/Courtesy/Respect : 31
  • # 6 Complaint process : 21
Top issues related to COVID-19
  • # 1 Visitation : 193
  • # 2 Infection prevention and control : 139
  • # 3 Communication : 100
  • # 4 Staffing shortages : 89
  • # 5 Quality of care : 74
  • # 6 Personal protective equipment : 50
Home and Community Care: 478 complaints
Top issues about Home & Community Care
  • # 1 Access* or admission : 77
  • # 2 Coordination/Continuity : 71
  • # 3 Staffing/Resources/Services : 60
  • # 4 Communication : 31
  • # 5 Quality of care : 26
  • # 6 Complaint process : 19
Top issues related to COVID-19
  • # 1 Access* : 28
  • # 2 Staff Shortages : 20
  • # 3 Discharge/Transfer : 19
  • # 4 Infection prevention and control : 19
  • # 5 Communication : 8
  • # 6 Operational/Service/Policy : 8

* Includes complaints about the level or amount of service

The most frequent complaints about public hospitals, long-term care homes and home and community care have remained stable over the past five years, with diagnosis/treatment as the top complaint about public hospitals, quality of care as the top complaint for long-term care homes and access or admission as the top complaint about home and community care. Complaints about access to home and community care are largely complaints from patients and caregivers who are seeking higher levels of service.

Patient Ombudsman saw only a modest increase in the number of complaints about home and community care, mostly related to service levels and staff shortages.


Adapting to changes

“My family greatly appreciates all the effort you put into helping us find answers. Thank you for your attempt even though we know that there will not be any clear-cut answers. The update you shared with us yesterday was a great step forward into understanding what happened at the hospital that night. We truly could not have gotten this far without your help.”

The COVID-19 pandemic has placed stresses on the health care system unlike anything seen before, and the impact on patient, resident and caregiver experiences has been profound. By proactively planning and being quick to adjust, Patient Ombudsman has been able to maintain services throughout the crisis and assist more patient and caregivers than ever before. We’re grateful to the patient and caregivers who shared their stories with us and the HSOs that worked with us to address their concerns.

In the coming months, Patient Ombudsman will be releasing the final report of its first major system-level investigation examining the impact of COVID-19 on the care and health care experiences of long-term care residents, as well as completing the investigations suspended as a result of the pressure of the pandemic.

Patient Ombudsman will be refreshing its strategic directions to guide the work of the office, resuming outreach to marginalized patient populations and renewing efforts to develop and improve our services.