No inquest called into deaths at Ontario facility By KAREN HOWLETT Friday, May 20, 2005 Updated at 2:30 PM EDT Globe and Mail Update Toronto — Ontario's Chief Coroner is not calling for an inquest into the deaths of 10 residents of an Oakville home for intellectually challenged adults. However, the coroner's office concludes that funding cutbacks imposed by the provincial government might have played a role in safety and management problems at the home. Dr. Barry McLellan, the Chief Coroner, launched an investigation in January after a long-time autistic resident of Oaklands Regional Centre wandered away last fall and drowned in a nearby creek. In a report released Friday, he says the investigation revealed that a reduction in management and nursing support and funding for security "might have impacted" the quality of services provided to residents. He has called on the government to clarify the nature of services to be provided by Oaklands and to clear up uncertainty surrounding the fate of the home itself, which has hurt staff morale. "It became apparent during the investigation that the confusion resulting from inconsistent messages regarding the future of Oaklands had an impact on the staff and the provision of services to its residents," the report says. Dr. McLellan also recommends that Oaklands review the qualifications of staff, procedures for administering medication, and develop an education program for staff about the unique health care needs of its residents. At the same time, Dr. Bonita Porter, Deputy Chief Coroner of Inquests, went out of her way to absolve staff of any blame. "It was most evident they were dedicated professionals at Oaklands," she told reporters at a news conference. The Chief Coroner's report follows two reviews released in February that found shortcomings at Oaklands and called for increased staffing, security and training. Those reviews were ordered by Community and Social Services Minister Sandra Pupatello in the wake of the death of Randy Mogridge last November. Ms. Pupatello said the ministry has spent about $1-million on upgrades and new staff at Oaklands. She said in an interview that she was awaiting the coroner's report before deciding whether Oaklands would remain open. "We'll be reviewing that [report] and making a decision one way or another," she said. Oaklands opened its doors in 1975. The Ontario Government took over the institution in 1985 after it failed to act on recommendations to correct safety and management procedures. As of last December, it had 156 employees caring for 67 residents. The coroner's office launched its probe three months after Mr. Mogridge's body was pulled from the murky waters of an Oakville creek, only a few hundred metres from Oaklands. Mr. Mogridge, 46, had been missing since Oct. 24, when he walked out of the assisted-living centre, where he had lived for 24 years. He had the mental capacity of a three-year-old and also suffered from bipolar syndrome. A coroner's panel also probed the deaths of nine other residents at the provincially run facility between January, 2000 and last November. The report says three residents died as a result of tragic accidents--Mr. Mogridge, another resident who got trapped between a mattress and the bed rails and another who drowned in a bathtub. Three others died from natural disease. Another resident died in hospital from natural disease but the death was not reported to a coroner. The remaining three patients died from complications of gastrointestinal blockages or perforations. One resident had an "acute event" that could not have been predicted. The other two died from complications of a disease known as pica - ingesting non-food substances. As a result of the pica-related deaths, the coroner's office has recommended that Oaklands develop procedures for dealing with pica. In addition to being developmentally challenged, each of the deceased individuals had complex medical histories, the report says. Sheila Masters, Oaklands executive director, said she welcomed the coroner's recommendations.