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Spotlight 1

Breakdown in coordinated care

Illustration of three silhouettes representing a medical professional, a patient and a service worker.

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

What went wrong?


Patient Ombudsman was contacted by a hospital physician regarding a patient whose condition led the physician to believe they had experienced severe neglect. The patient was admitted to the hospital’s intensive care unit in grave condition with respiratory, cardiac and neurological symptoms in addition to multiple serious pressure wounds. The physician believed that the pressure wounds must have developed over weeks or months.


Because the patient was actively receiving care from several health providers, Patient Ombudsman was concerned about how the patient could have arrived at such a state. The patient was living in supportive housing where they received daily assistance with personal care and was receiving home care professional services. They had also had several recent hospital admissions and emergency department visits. Patient Ombudsman initiated an own motion investigation to determine how this occurred and whether any deficiencies at a system level affected the patient’s care.

The records reviewed and interviews conducted by Patient Ombudsman describe a vulnerable patient with a number of chronic conditions who was isolated from their family, and resistant to care and social support. They had been living in supportive housing for a couple of years, but their condition had declined markedly in the months prior to a complaint to Patient Ombudsman. As their condition deteriorated, the patient had four separate hospitalizations in just over two months and began to receive increasing levels of home care services from the LHIN (now known as Home and Community Care Support Services (HCCSS)) above the services they were receiving from their supportive housing provider. There was also an incomplete long-term care home application.

What went wrong

Patient Ombudsman found a number of factors led to the patient’s poor outcome:

Unclear communication including internally within provider organizations, among providers, and between providers and the patient’s substitute decision maker (SDM). In this instance, the SDM had a distant relationship with the patient that resulted in communication delays.

Lack of clear accountability for coordinating and providing the patient’s care and failure to problem solve proactively and collaboratively.

Delay in receiving a completed long-term care home application and failure to contact the Ontario Public Guardian and Trustee (OPGT) when the delay left the patient at significant risk.

Poor or no escalation of concerns about suitability of level of care offered through the supportive housing provider to relevant parties that could act.

Lack of contingency planning for a vulnerable individual.

Compounding social determinants of health, including food insecurity, income and income distribution, social exclusion, and lack of a social safety network.


Patient Ombudsman made several recommendations to both the hospital and the HCCSS. Patient Ombudsman also made some suggestions to the supportive housing provider that are optional because they are not within our jurisdiction. These included:

To protect vulnerable patients during transitions, the hospital should:

Ensure SDMs are involved and notified when vulnerable patients are being discharged, no matter what setting the person is returning to.

Work with other providers early on in discharge planning processes.

Work to ensure that vulnerable patients are flagged to the HCCSS for appropriate post-discharge follow up.

Notify HCCSS Care Coordinators when it seems like a patient is receiving HCCSS services or seeking placement in long-term care from the community.

Make all inquiries needed to ensure that discharge destinations are safe.

Confirm that receiving staff will be present when patients are discharged to other health care providers.

Involve HCCSS in cases of admissions for geriatric “failure to thrive.”

Work to ensure that long-term care home planning and placement processes can begin in hospital, where appropriate.

To ensure patients are in receiving appropriate care and supports in the community, HCCSS should:

Clarify roles and responsibilities, understand how issues can be escalated between providers and determine who is responsible for planning future care arrangements. In particular, determine when HCCSS will become the lead agency for care; manage wound care while understanding maximums in place for supportive housing providers; and ensure all parties are informed in the long-term care home placement process.

Organize early care conferences among providers where there appears to be challenges in providing care and ensuring SDMs understand the risks involved.

Provide additional guidance and education to staff regarding contacting the OPGT when the patient is in a crisis situation and clarifying its policies and processes on SDM availability.

Do its best to ensure SDMs understand risks and timeframes for decision-making.

Ensure other providers are aware of challenges in crisis placement in long-term care.

Contact the OPGT within a reasonable time when there are challenges communicating with an SDM during a crisis placement into long-term care. A general timeframe of seven days would be appropriate where there is a crisis designation.

Patient Ombudsman made a number of optional suggestions to the supportive housing provider that were largely reciprocal to the suggestions made to the HCCSS given the need for both providers to collaborate and engage on these issues.