External review points to communication problems for ’unacceptable’ home-care delay

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This article was published 26/10/2023 (729 days ago), so information in it may no longer be current.

A series of miscommunications and failure to prioritize palliative patients led to “unacceptable” delay in providing home care to a dying woman last winter, an external review has found.

The review was completed in late June and released late last week to Eric De Schepper, the Winnipeg widower who sounded the alarm after his spouse, 62-year-old Katherine Ellis, died without receiving home-care services last February. About three days after Ellis died, a home-care worker who hadn’t been informed of her death showed up for an initial visit.

The 54-page consultant’s report makes 21 recommendations to streamline the Winnipeg Regional Health Authority’s home-care program, including immediately making dying patients’ requests top priority, along with “hospital hold” patients being discharged from hospital with regular home-care service.

Many of the longer-term recommendations are still under consideration, such as establishing a dedicated palliative-care service for terminally ill home-care clients.

De Schepper said he was pleased with the review and its recommendations. Positive change has already started, he said.

“They’re making, already, a big difference,” he said Thursday, explaining he’s talked to a couple of individuals who went through the process of requesting palliative home-care services recently “and the transition was really smooth.”

“The key issues that led to the ordeal that Kathy and I experienced, they’re being addressed,” De Schepper added.

“If the recommendations from this review are being implemented, the chances that something like what happened to Kathy will happen again to someone else are close to zero.”

A timeline of events is laid bare for the first time in the review, which shows “things pretty much went haywire right from the beginning,” as De Schepper put it.

He requested home care respite visits on Jan. 25, two weeks after Ellis was discharged from St. Boniface Hospital while terminally ill with pancreatic cancer. The initial request was received by home care, but it was mistakenly never sent to the appropriate official. Then, despite involving a palliative patient, the request was logged as low priority and wasn’t looked at until Feb. 7.

A series of communication problems occurred over the next several days, until a broadcast news outlet contacted the WRHA on Feb. 16 and asked about a palliative patient who’d been waiting more than 16 days for respite care. Subsequently, De Schepper was informed a home-care visit would be scheduled for Feb. 21 at 10 a.m.

Ellis died Feb. 18, and De Schepper contacted the home-care program’s after-hours service just before 2:30 a.m. on Feb. 19 to tell them she’d died and visits were no longer needed. But the visit was never officially cancelled, in part because of semantics: the after-hours service was instructed only to cancel visits that were scheduled “up to” 10 a.m., not including 10 a.m.

The visit wasn’t cancelled subsequently because scheduling systems were inconsistent, and the visit appeared to some staff to be “unconfirmed.” The health-care aide who showed up at 10 a.m. on Feb. 21 hadn’t been told Ellis had died.

Communication was a key problem, and the home-care program immediately made palliative requests top priority and are moving to a scheduling app rather than a paper- and phone-based system, said Luba Bereza, the WRHA’s director of centralized home-care services and regional palliative care.

“It was a series of small errors that led to a very large, significant error,” Bereza said, adding the agency understands how distressing this was for Ellis and De Schepper.

“We did not meet the need for this family during the most vulnerable time, and that really is unacceptable.”

The Procura scheduling app is expected to start rolling out in January and complete implementation by the end of March. The scheduling app was first announced as a partnership with the Victoria Hospital Foundation in late July, and Bereza said it has taken time to get a team together to provide training and work on the rollout.

She said vacancy rates are improving and 308 home-care workers have been hired since January, including 133 uncertified workers hired via a new training program launched last winter. The vacancy rate went from about 20 per cent to 16 per cent as of the end of September, Bereza said.

The review suggested the WRHA increase its use of private-agency staff as a backup option, which the consultant found would be cheaper and serve patients better. The service uses private-agency staff as a backup, but is capped at two per cent of overall home-care service, and there are no plans to increase that threshold, Bereza said, saying the recommendation is still under review.

The WRHA provided a redacted copy of the review for release. It took several months for the results of the review to come to light because De Schepper said he asked that it not be released until after this month’s provincial election.

De Schepper declined to participate in the review; he said he feared participating would trigger him following Ellis’s death, and cause a conflict of interest as he awaited the results of his Ombudsman’s complaint.

katie.may@winnipegfreepress.com

Palliative Home Care Review