Province replacing office responsible for protecting vulnerable in care following ‘sickening’ findings
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Hey there, time traveller!
This article was published 26/07/2023 (775 days ago), so information in it may no longer be current.
The Manitoba government says it will disband the Protection for Persons in Care Office and replace it with an independent body that reports to the legislature after “sickening and repulsive” findings by the auditor general.
“There are few things more in important in society than protecting vulnerable persons,” Justice Minister Kelvin Goertzen told a news conference Wednesday.
To restore the trust of Manitobans, he said the province will replace the PPCO with an independent office.
The auditor general’s investigation found that the office responsible for protecting vulnerable people in care had dismissed allegations of sexual assault and physical and verbal abuse at personal-care homes as “unfounded,” saying they didn’t meet its definition of abuse.
The Protection of Persons in Care Act requires that founded cases of abuse are to be reported by the health minister to the adult abuse registry committee.
‘Unfounded’ and ‘founded’ clash in AG report
The Manitoba auditor general’s investigation of the Protection for Persons in Care Office covered a span of six years (2015-21).
Its report cited examples of abuse the PPCO had deemed “unfounded” — including cases investigators determined were “founded” that were changed to “unfounded” by a director who has since been replaced.
Among the cases highlighted Wednesday:
• A health-care aide at a personal care home kicked a resident in the shin, causing a large skin tear. The resident started bleeding. The wound was cleansed but continued to bleed. The facility contacted the Winnipeg Police Service, due to the serious nature of the incident and injury.
Although the PPCO determined the incident occurred and there was mistreatment, it was deemed an “unfounded” allegation of abuse because the victim made a full recovery, did not remember the incident, and the act of kicking did not interfere in a serious or substantial way with their well-being.
The Manitoba auditor general’s investigation of the Protection for Persons in Care Office covered a span of six years (2015-21).
Its report cited examples of abuse the PPCO had deemed “unfounded” — including cases investigators determined were “founded” that were changed to “unfounded” by a director who has since been replaced.
Among the cases highlighted Wednesday:
• A health-care aide at a personal care home kicked a resident in the shin, causing a large skin tear. The resident started bleeding. The wound was cleansed but continued to bleed. The facility contacted the Winnipeg Police Service, due to the serious nature of the incident and injury.
Although the PPCO determined the incident occurred and there was mistreatment, it was deemed an “unfounded” allegation of abuse because the victim made a full recovery, did not remember the incident, and the act of kicking did not interfere in a serious or substantial way with their well-being.
• Two health-care aides at a personal care home held down an elderly person forcefully on a bed to change their clothing from pajamas to day clothes. Both aides used threatening and vulgar language towards the resident, including: “You’re a f—-ing bastard, I am going to f—-ing kill you.”
Although the PPCO determined the incident occurred and there was mistreatment, it was deemed an “unfounded” abuse allegation because there was no apparent change in the behaviour of the resident.
The director of care at the facility was quoted as saying: “The alleged victim is so severely cognitively impaired, that despite how traumatic the experience was, it’s unlikely to interfere with his psychological integrity or well-being in a substantial way.”
• A health-care aide hit a patient with severe dementia in the face with a transfer lift remote control. The aide then lowered the transfer lift onto the person’s abdomen, pressing the metal onto the victim’s belly while they screamed. This resulted in lacerations to the victim’s face, as well as bruising and swelling on the abdomen and shoulders.
The police were called, charges were laid against the health-care aide for assault, and a “no contact order” was issued to protect the person who reported the incident.
The PPCO investigator deemed it a case of abuse, but the director of the office changed it to “unfounded,” saying the alleged victim did not require acute medical or psychological care after this incident.
“Though this was a serious incident, there was no evidence to support that it interfered in a substantial way with the patient’s well-being nor was it reasonably likely to. As such, this incident is unfounded for abuse.”
• A vulnerable patient was sexually assaulted by a care worker. The PPCO found the victim credible, and determined a serious sexual assault had taken place, but deemed the allegation as unfounded for abuse.
“The investigator noted many qualities of an emotionally traumatized victim throughout the investigation and noted that the (alleged victim), with psychological care and support, was able to move forward from the incident remarkably well. Given that the PPCO cannot establish that this incident impacted the (alleged victim) in a substantial way, the investigation is unfounded for abuse.”
While the Stefanson government said Wednesday it first learned of concerns about the Protection for Persons in Care Office in the auditor general’s report, earlier this year, it changed the definitions of abuse and neglect in the Protection for Persons in Care Act.
The moves “remove any ambiguity and room for interpretation, making it clear that actions alone may be deemed abuse or neglect, regardless of whether the patient experienced any serious harm as the result of those actions,” the auditor’s report noted.
carol.sanders@freepress.mb.ca
Auditor general Tyson Shtykalo said in the 41-page report that the processes used by the PPCO were “flawed and failed to reach reasonable conclusions.”
The report cited examples of investigations by the office, which is overseen by Manitoba Health, into allegations of residents being sexually assaulted, kicked in the shin, hit in the face with a remote control, pinned down and verbally abused. In each case, the office deemed the allegations as “unfounded.”
“We found the allegations were valid and were not isolated cases,” Shtykalo said in the report.
“I am deeply concerned by our findings and recognize the painful experiences the victims and families went through,” he said.
Some families and victims waited more than three years for investigations to begin, the report said. As of October, the office had allegations from 2018 waiting to be investigated. In 2020-21, it received 2,282 reports of abuse or neglect. It undertakes roughly 50 investigations per year.
The auditor general’s report made 12 recommendations to address systemic problems at the PPCO — including hiring more investigators. The office opened in 2001 with 15 investigators, and was down to just six investigators in July 2022, with four vacancies, the report noted.
Goertzen said the recommendations don’t go far enough to restore the trust of Manitobans and the office needs to close.
Premier Heather Stefanson called it “absolutely horrific” and said her government took action as soon as it received preliminary access to the auditor general’s report.
“We do not want to see our seniors treated in this way,” she said when asked about it at an unrelated event in Altona Wednesday. “We needed to act immediately on it and we did.”
Wednesday’s report was not the first to raise concerns about the Protection for Persons in Care Office, and how it was interpreting the definitions of abuse and neglect outlined in law.
In the last 10 years, three other reports have been published that drew attention to the office, Shtykalo noted.
“The three reports were released by the ombudsman of Manitoba, a task force external to PPCO, and the department (of Health),” the auditor general’s report said.
“Despite the issue being raised three times by three separate bodies over the course of 10 years, the PPCO still failed to take meaningful action to remedy the situation,” it said.
Investigation of the Protection for Persons in Care Office
Goertzen said a commissioner has been appointed to guide the creation of a new, independent investigation office that will report directly to the legislature. The process is expected to take former Manitoba Court of King’s Bench and Court of Appeal justice William Burnett 18 months to two years to complete.
The government will take a deeper dive into the PPCO’s past files with an investigation led by lawyer Kimberley Gilson. She will oversee current investigations. The backlog is expected to be cleared by next spring, Goertzen said, adding Burnett and Gilson will have $2 million to facilitate their work.
Liberal Leader Dougald Lamont called for a public inquiry.
“This is a catastrophe and it’s one that we’ve been warning about for years and years,” said Lamont, who has called for the creation of a seniors advocate and whose party in 2021 issued a report on abuse in care homes and the PPCO’s handling of cases.
“This is absolutely heartbreaking that it takes this level of investigation for the auditor general to find out these horrific levels of abuse are happening and no one is doing anything about it and it was allowed to go on for years,” he told reporters.
In a statement, NDP health critic Uzoma Asagwara, whose party also called for the creation of an independent seniors advocate, said the report shows the Stefanson government has failed to protect seniors in care.
Asagwara pointed to “massive vacancies” in the health department, as high as 40 per cent in 2022. PC government policies undermined the services seniors and all Manitobans rely on, the health critic said. “It is disappointing it took a scathing auditor general’s report for the Stefanson government to pretend to take action.”
— with file from Tyler Searle
carol.sanders@freepress.mb.ca

Carol Sanders
Legislature reporter
Carol Sanders is a reporter at the Free Press legislature bureau. The former general assignment reporter and copy editor joined the paper in 1997. Read more about Carol.
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