A 75-year-old resident of a Winnipeg personal care home died after a health-care aide wrapped a call bell cord out of her reach, in what police called a case of criminal negligence causing death, court documents say.
Kathleen McCarthy died of chronic respiratory failure at Kildonan Long Term Care Home on July 19, 2021, after going into medical distress when an oxygen source came out of her nose and she wasn’t able to get it back in.
A staff member had wrapped the call bell cord around the box out of reach so that McCarthy couldn’t use it to call for help, a police affidavit says.
Police said the three health care aides “neglected their responsibilities as employees of the Kildonan Personal Care Home which caused the death of Kathleen McCarthy.”
McCarthy moved into the Kildonan home a decade ago after suffering a brain aneurysm. She had mobility issues and depression and was confined to her bed.
“That was basically the end of her full life,” said Bill McCarthy, Kathleen’s 79-year-old brother, in a phone interview with CBC News from his home in Dieppe, N.B.
McCarthy remembers his sister fondly.
“She was the kind of lady who enjoyed company, enjoyed a crowd,” McCarthy said.
“You knew she was there,” he said.
“Quite joyful. People who were with Kathy were happy to be with her.”
In court documents obtained by CBC News, Winnipeg police allege three health-care aides committed criminal negligence causing death.
They said one aide was responsible for initially wrapping the call bell cord out of reach, while the other two knew McCarthy couldn’t reach the cord but didn’t untie it.
CBC News is not identifying the workers because they were never charged with a crime.
- Do you have a tip for the investigation unit? Email us at firstname.lastname@example.org or call us at 204-788-3744.
The details are contained in an affidavit officers used to get court authorization for a production order compelling Revera, the for-profit company that owns the Kildonan care home, to hand over the internal call box records between 6 p.m. and 11 p.m. on the day McCarthy died.
The affidavit says McCarthy was known to pull on the call bell cord about every 10 minutes, so getting a record of the calls that day would show investigators when the cord was out of reach and for how long.
Investigators referred the case to the Crown but the Crown wouldn’t authorize charges, a Winnipeg police spokesperson told CBC News.
The court filings say on July 19, 2021, at around 6:30 p.m., a health-care aide went to McCarthy’s room after she “had repeatedly pulled on her call box cord.”
The worker tended to McCarthy’s needs then wrapped the call box cord and left the room at approximately 7 p.m.
The affidavit says she told another worker what she had done and explained it was because McCarthy was yelling. She asked the worker to go into McCarthy’s room if she heard her yelling, then went on her break.
The second worker didn’t intervene or unwrap the cord, the affidavit says.
A third health-care aide went into McCarthy’s room because she kept yelling. He noticed the cord wrapped around the box but didn’t unwrap it either, the affidavit says. The worker returned to his regular duties but went home early that night because his neck was sore.
McCarthy was pronounced deceased two hours later, around 10 p.m., after a fourth health-care aide went into her room.
“McCarthy’s lips were purple, eyes closed and she didn’t answer to her name. McCarthy’s oxygen was out of place, not in her nostrils, and lay on her chest,” says the police affidavit dated Nov. 23, 2021.
The court filings say McCarthy had a history of chronic anxiety, which led her to frequently call out and use the call bell.
“McCarthy had a history of pulling the bell as she always pulled the oxygen out. They had to put the oxygen in as McCarthy would turn blue if it was out,” the affidavit says.
The health-care aide who tied the cord around the box said she untied it around 9 p.m., but when a different aide found McCarthy deceased at 10 p.m., she reported the cord was tied around the box, the affidavit says.
One of the aides reported the incident to the union and the union notified Revera, which called police to investigate.
“People in personal care homes are very frail and they need that emergency support, so to have it taken away is deeply problematic,” said Laura Tamblyn Watts, CEO of CanAge, a Canadian seniors advocacy organization.
If personal care home staff are overworked or are not sure how to deal with a high needs patient, they should address it with their director of care and not take things into their own hands, Tamblyn Watts said.
“What we’re seeing more and more is staff trying to make do, trying to stretch their time among lots of people, which, as we know, means a lesser quality of care for everyone,” Tamblyn Watts said.
Revera told police that call bells are connected to a cordless phone in communal areas that staff can respond to, and there are records of the calls.
Larry Roberts, Revera’s director of communications, told CBC News that as soon as the Kildonan management team found out what had happened, they notified the Winnipeg Police Service, Winnipeg Regional Health Authority and the resident’s family.
He would not comment on the employment status of the three aides, but wrote in an email that they “followed our policies and procedures with respect to the disciplining of the employees.”
The Canadian Union of Public Employees, which represents the health-care aides at the nursing home, wouldn’t say if they still work there.
The union spokesperson would only say the employer has provided additional training to all staff with respect to call bell protocols and encouraged members to report any concerns about wrongdoing in the workplace that they have witnessed.
A provincial spokesperson for both Manitoba’s health minister and the minister for seniors and long-term care said they were made aware of McCarthy’s death, and that the Winnipeg Regional Heath Authority investigated it as a critical incident.
Family sympathizes with workers
Kathleen McCarthy, or Kathy as she was also called, was the youngest of four kids. Originally from Moncton, N.B., she spent a few years in Vancouver before coming to Winnipeg in the mid-1980s.
She had mobility and health issues from the brain aneurysm she suffered while at her winter home in California.
She was later medevaced to Winnipeg and admitted to the Kildonan personal care home.
Bill McCarthy never visited his sister at the care home but received regular updates from her partner.
“There was never a word of complaint about the home, never a negative word of the home,” he said.
He was sure his sister was well looked after.
“Being in her condition, if you have to end up somewhere … she ended up in a good somewhere, and in addition to doing the work, I had the feeling that people cared,” he said.
Bill McCarthy believes the health-care aide who tied his sister’s call button cord probably did it because she was overwhelmed and had other residents to care for.
“I’m sure that if that buzzer was taken from Kathy, the person who took it from them was doing it for the greater good and was probably deadly, deadly shocked when they found out that it could be connected to a consequence,” he said.
He does not think any of the aides should be charged, but he does believe the care home needs to review their processes for dealing with high needs patients, so that workers don’t overlook those who don’t need as much time.
Tamblyn Watts said since the start of the COVID-19 pandemic, personal care homes have lost 30 to 35 per cent of their staff, and those who remain are stretched thin.
“If this is a one-off, because staff were incredibly stretched, didn’t have education, were trying to take care of too many residents, that’s not something that we can solve with one single criminal charge against a person,” Tamblyn Watts said.
She believes charges should be laid when appropriate, even though it may have a chilling effect on an already struggling industry.
Tamblyn Watts also believes care homes need to rethink how they look after seniors.
For example, McCarthy had a history of pulling the oxygen cord out of her nose and routinely needed workers to put it back in.
Call bell technology is outdated and personal care homes need to invest in something better, like bed sensors that can detect movement or when someone needs to be turned over, she said.
“This is a very old-fashioned idea of vulnerable person, probably with cognitive impairment, has to grasp something in their hand and push a button,” Tamblyn Watts said.
Call bell technology is from the 1930s and ’40s and was intended for younger people with, say, a broken leg who needed to call staff for a glass of water, she said.
“They’re not really meant for people who are very frail and elderly with cognitive impairment to be able to self-regulate when they’re in need. They usually can’t,” she said.