Globe and Mail By KAREN HOWLETT Saturday, May 21, 2005 Page A12 Ontario's chief coroner has decided against calling an inquest into the deaths of 10 residents of an Oakville home for intellectually challenged adults. The coroner's office launched an investigation in January after a long-time resident of Oaklands Regional Centre wandered away and drowned. Randy Mogridge's body was pulled from the murky waters of an Oakville creek only a few hundred metres from Oaklands, ending a frantic, two-week search. Mr. Mogridge, 46, had been missing since Oct. 24, when he walked out of the assisted-living centre that had been his home for 24 years. He had the mental capacity of a three-year-old and also suffered from bipolar syndrome. Cyndy Naylor of Guelph is upset that there won't be an inquest into the deaths of the 10 residents, including her 22-year-old son, Josef, who died in November of 2003 after he swallowed a Halloween decoration while a resident of Oaklands. "For us, this is not a good day," she said. "Your child dies and you pay the ultimate price and it still doesn't matter." In a report released yesterday, Chief Coroner Barry McLellan says the Ontario government should ensure Oaklands has adequate resources if it decides to keep the home open. However, he does not explicitly link funding cuts to a litany of safety and management problems cited in the report. A reduction in management and nursing support and funding for security "might have impacted" the quality of services provided to residents, the report says. Bonita Porter, deputy chief coroner of inquests, said at a news conference yesterday that uncertainty about whether Oaklands would remain open has hurt staff morale. But she absolved staff of any blame for the deaths that took place over a five-year period beginning in January, 2000. "It was most evident that those involved with Oaklands were dedicated professionals," Dr. Porter said. The report makes 11 recommendations, including reviewing staffing levels, procedures and training to improve the quality of care for people with developmental disabilities. It also points to the need for specialized medical staff. Dr. Porter said a reduction in medical staff at Oaklands has led to an increased reliance on non-health-care staff to deal with the unique needs of its residents. The report also identifies problems with its own procedures for reviewing coroners' investigations. A coroner reviewing a number of deaths at Oaklands in 2000 had asked for additional resources but it is not clear whether that request was considered, the report says. This may have been a "missed opportunity" to identify issues earlier at Oakland, Dr. Porter said. Community and Social Services Minister Sandra Pupatello said yesterday that she will decide whether to keep Oaklands open after reviewing the coroner's report. Her office launched its own probe after the death of Mr. Mogridge and has spent about $1-million upgrading the security systems at Oaklands and hiring new staff. Oaklands opened its doors in 1975. As of December, it had 156 employees caring for 67 residents. The coroner's report says that in addition to Mr. Mogridge, two other residents died in accidents -- one got trapped between a mattress and the bed rails and another drowned in a bathtub. Mr. Naylor and another resident died from complications of a disease known as pica -- ingesting non-food substances. Three others died from natural causes. One resident died in hospital, but the death was not reported to a coroner. Sheila Masters, Oaklands executive director, said she welcomed the coroner's recommendations. "It's been a very difficult several months for everybody," she said.