Ontario Ombudsman 2012-13 annual report

7/28/2019 Ontario Ombudsman 2012-13 annual report

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2012-2013

Annual Report


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12012-2013 Annual Report

July 16, 2013

The Honourable Dave LevacSpeakerLegislative AssemblyProvince o OntarioQueens Park

Dear Mr. Speaker,

I am pleased to submit my Annual Report or the period o April 1, 2012 toMarch 31, 2013, pursuant to section 11 o the Ombudsman Act, so that youmay table it beore the Legislative Assembly.

Yours truly,

Adr Mari

Ombudsman

Bell Trinity Square483 Bay Street, 10th Floor, South TowerToronto, OntarioM5G 2C9

Telephone: 416-586-3300Complaints Line: 1-800-263-1830Fax: 416-586-3485TTY: 1-866-411-4211

Website: www.ombudsman.on.ca

Facebook: Ontario OmbudsmanTwitter: @Ont_Ombudsman


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Table o Contents

2 Ofce o the Ombudsman

Ombudsmans Message....................................................................................5

The Multipurpose Ombudsma......................................................................................5The Barometer ....................................................................................................................6

The Horsey ........................................................................................................................6

The Oil Can .........................................................................................................................6

The Saety Valve .................................................................................................................7

Our Indoor Voice ................................................................................................................7

Special Weapons and Tactics .............................................................................................7

Unfnished Business ...........................................................................................................9

No Rush or MUSH ...........................................................................................................10Anybody but the Ombudsman ..................................................................................10

Hospital horrors .........................................................................................................12

Long-term care lapses ..............................................................................................12

Ornge air ambulances ying out o reach ..............................................................13

Give us a C childrens aid societies.....................................................................14

OMLET still cooking ..................................................................................................15

Closing Thoughts ..............................................................................................................16

The Year in Review ............................................................................................17

Beyod Scrutiy: The push or MUSH ......................................................................... 17M Municipalities ..........................................................................................................18

U Universities ..............................................................................................................18

S School Boards .........................................................................................................19

H Hospitals .................................................................................................................19

Long-Term Care Homes ...................................................................................................21

Childrens Aid Societies ....................................................................................................21

Police ................................................................................................................................22

Operatios Oeriew.....................................................................................................23Complaint Trends and Signifcant Cases in 2012-2013 ...................................................24

Ministry o the Attorney General ...............................................................................24Ministry o Community Saety and Correctional Services ........................................24

Ministry o Community and Social Services .............................................................26

Ministry o Children and Youth Services ...................................................................28

Ministry o Energy .....................................................................................................29

Ministry o Health and Long-Term Care ....................................................................30

Ministry o Government Services / Ministry o Health and Long-Term Care ............31

Ministry o Natural Resources ...................................................................................32

Ministry o Training, Colleges and Universities .........................................................32

Ministry o Transportation .........................................................................................33

Traii ad Cosultatio.............................................................................................35

Commuicatios ad Outreach ...................................................................................39


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Special Ombudsma Respose Team ........................................................................44SORT investigations completed in 2012-2013 .................................................................44

The Code Ministry o Community Saety and Correctional Services .....................44

In the Line o Duty Ontario Provincial Police andMinistry o Community Saety and Correctional Services ........................................46

Dental implants Ministry o Health and Long-Term Care .......................................48

Ongoing SORT investigations ...........................................................................................49

Adults with developmental disabilities in crisis Ministry o Community and Social Services .............................................................49

Monitoring o drivers with uncontrolled hypoglycemia Ministry o Transportation ........................................................................................50

Completed SORT assessments in 2012-2013 .................................................................50

Slots at Racetracks program Ontario Lottery and Gaming Corporation ................50

Updates on previous SORT investigations .......................................................................51

Non-emergency medical transportation services Ministry o Health and Long-Term Care, Ministry o Transportation ........................51

Caught in the Act Expansion o police powers or Toronto G20 summit Ministry o Community Saety and Correctional Services .......................................52

Monitoring o long-term care homes Ministry o Health and Long-Term Care .......52

Oversight Underminedand Oversight Unseen Ministry o the AttorneyGeneral and Special Investigations Unit ...................................................................53

Between a Rock and a Hard Place Care and custody o children

with severe special needs Ministry o Children and Youth Services ......................55

Case Summaries.................................................................................................56

Ministry o the Attorney General .......................................................................................56

Ministry o Community and Social Services .....................................................................59

Ministry o Energy .............................................................................................................66

Ministry o Finance ...........................................................................................................66

Ministry o Government Services .....................................................................................68

Ministry o Health and Long-Term Care ............................................................................69

Ministry o Labour .............................................................................................................71

Ministry o Natural Resources ..........................................................................................72Ministry o Training, Colleges and Universities .................................................................72

Ministry o Transportation .................................................................................................73

Your Feedback......................................................................................................74

Appendix 1 Complaint Statistics.........................................................78

Appendix 2 How We Work........................................................................86

Appendix 3 About the Ofce...................................................................87

Appendix 4 Financial Report ................................................................88


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Ombudsmans Message

The Multipurpose Ombudsman

The stories in this report, arising rom the19,726 cases we received in 2012-2013,demonstrate how my Ofce uses a varietyo tools to resolve individual and systemicconcerns. Picture a Swiss Army-style kniewith all sorts o useul accountability gadgets:

A barometer, a horsey, an oil can, a saetyvalve and more. Like a barometer, my Ofcealerts citizens, legislators, and governmentorganizations to trending complaints beoreproblems escalate into crises. Like a horsey,we nip at bureaucratic heels and nudgeofcials to change direction. Like an oil can,we reduce riction, acilitate resolution andsmooth over bureaucratic tangles. And like asaety valve, we act as a last resort to protectcitizens rights, health and welare and

orestall systemic disaster.Phot

obybrianWiller


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The Barometer

In 2012-2013, we continued to work proactively with government organizations

particularly those that generate a large volume o complaints to address systemic issues.A case in point is the Family Resposibility Ofce (FRO), which once again topped thelist as the most complained-about Ontario agency. We met regularly with FRO ofcialsto discuss persistent problems such as a lack o aggressive enorcement, poor recordkeeping and administrative errors. Our eorts were inspired by people like one womanwho was owed nearly$35,000 in child support that the FRO unwittingly held in a genericaccount, and another who fnally received more than$12,000 ater we persuaded theFRO to step up its enorcement eorts. These and similar cases can be ound in the CaseSummaries section o this report.

We also kept close watch on the Ministry o Transportations progress in tackling theghost licence issue that we revealed last year. A single complaint rom a man convicted

o drunk driving led to the discovery that the Ministry had generated more than 1,000,000dummy licence records since 1966 whenever it could not match notices o drivingoences, collisions or medical suspensions with existing Ontario driver licences. Wealerted the Ministry to the risk that some o what it calls master licences could beduplicates, meaning some individuals who were supposed to be under suspension mightstill be on the roads with valid licences. Our red ag prompted the Ministry to review andreconcile its records to better protect public saety. More on this case and others can beound in the Operatios Oeriew section o this report.

The Horsey

Many complaints that we receive require the horsey approach - direct and ocused

prodding to wake ofcials up and get them to move in the right direction. This techniqueis oten successully applied to stand up or the little guy those too vulnerable andwithout the means to make themselves heard.

For instance, we uncovered a computer glitch that shortchanged a man thousands odollars in Ontario Disability Support Program benefts. We also convinced the Ofce o thePublic Guardian and Trustee to do the right thing ater it wrongly charged legal ees to aclient or talking to our Ofce about his complaint.

The horsey technique is well suited to cases o rulitis slavish bureaucratic devotion tothe rules, to the exclusion o good judgment. We used it in a particularly acute case thisyear, where the Ofce o the Registrar General was reusing to issue a birth certifcate or

a mans baby daughter without an application rom the mother, who had died shortly aterchildbirth.

The Oil Can

By contrast, many cases are resolved through a smoother approach, where bureaucraticmachinery is lubricated by an injection o compassion, common sense and creativesolutions.

We continued to help many amilies o adults with developmental disabilities, by acilitatingcommunication between them, the Ministry o Community and Social Services, theMinistry o Children and Youth Services and the host o agencies involved in their servicesand care. Our case-by-case eorts paid o with enhanced protocols and practices to helpchildren with severe disabilities transition rom the child beneft system to services oradults, even as we launched a broader systemic investigation on this issue.

Our oil can was also applied to convince Hydro One to address unair overbillings andto help students with disability grants through the Ministry o Training, Colleges andUniversities.


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The Saety Valve

In cases where lie, health and welare are at stake, my Ofce is oten the last resort or

desperate citizens. This year, we helped a 72-year-old man with a rare orm o cancer getmoney or specialized out-o-country treatment ater his request was denied, even thoughthe Ministry o Health and Long-Term Care had paid or similar therapy or others. Oureorts also sparked the Ministry to improve its processes to ensure proper tracking othese cases in uture.

In another case, although Ontario Health Insurance Plan coverage was provided orgenetic testing in the U.S. to beneft siblings o a 14-year-old boy who had died suddenly,the Ministry o Health and Long-Term Care denied coverage or amilies in similarcircumstances while it pondered its unding policy. Through escalating discussions upthe chain o command at the Ministry, we were able to coax it to change its practice andreview such requests on a case-by-case basis.

Our Indoor Voice

While my Ofce is best known or its outside voice that is, our reports on systemicinvestigations by our Special Ombudsman Response Team a great deal o our workis accomplished through a subtle and collaborative approach. We help thousands oOntarians with straightorward, sensitive or complex issues through confdential, inormaldispute resolution.

For instance, since 2009, we have had discussions with the Ministry o Health and Long-Term Care about developing a program or people who need dental implants or medicalreasons, oten as a result o severe conditions such as cancer. The Ministry had always

considered all dental implants to be cosmetic and thus ineligible or Ontario HealthInsurance Plan coverage. But this past April, it launched its new Oral and MaxilloacialReconstruction Program to und certain prostheses to restore oral unction or patientswho have no treatment alternatives. This quiet victory or vulnerable people represents theculmination o three years o behind-the-scenes talks, inormal investigation and exertiono moral suasion.

In a similar ashion, we encouraged the Ministry o Community Saety and CorrectionalServices to address delays and inefciencies in its private security licence applicationand complaint processes, and we prompted the Death Investigation Oversight Councilto improve its communication strategies and use clear, evidence-based reasons in itsdecisions.

Special Weapons and Tactics

There are cases, however, where shuttle diplomacy and alternative dispute resolutionwill simply not get the job done. These are the cases where our Special OmbudsmanResponse Team, or SORT our systemic feld investigation unit excels.

Our latest ongoing SORT investigation into how the Ministry o Community and SocialServices responds to an apparent lack o services or adults with developmental disabilitieswho are in crisis had drawn well over 800 complaints as o the writing o this report.These cases, which we frst identifed as a trend in 2011-2012, include many heart-rendingstories o amilies with nowhere to turn and young adults with severe special needs endingup in shelters, hospitals and even jail.

SORT also tackled difcult and thorny issues in the two major investigations that resultedin reports in 2012-2013 operational stress injuries among police, and the use oexcessive orce against inmates in correctional acilities.


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My reportIn the Line of Duty, issued in October 2012, revealed serious gaps in how theOntario Provincial Police and the Ministry o Community Saety and Correctional Servicesaddress operational stress injuries among police, including depression, addictions, anxietyand post-traumatic stress disorder. The SORT investigation uncovered a persistent stigmaagainst aected ofcers and a lack o support services or them and their amilies. TheOPP and the Ministry have taken my recommendations seriously, and SORT will monitortheir progress as they work towards substantive reorm.

Please convey to the complete investigative team who participatedin this inquiry how gratiying their work has been to the policingcommunity. Generations o police ofcers will have their lives greatlyenriched because o their eorts I know that through your eorts,lives will be saved.Retired OPP Detective-Inspector Bruce Kruger, whose complaint sparked theIn the Line of Dutyinvestigation

Last month, I released The Code, my report on SORTs investigation into how theMinistry o Community Saety and Correctional Services responds to allegations oexcessive use o orce. This investigation arose rom a disturbing trend we identifedin 2010 involving cases where correctional sta assaulted inmates and covered up the

incidents. We discovered an entrenched code o silence amongst some correctionalofcers who helped colleagues hide brazen acts o assault against vulnerable inmates.The Ministry has undertaken to implement my recommendations, and I will monitor itsprogress closely.

Ombudsman Andr Marin is greeted by ormer OPP Detective-Inspector Bruce Kruger (right) ater the

release o the Ombudsmans report,In the Line of Duty, October 24, 2012.


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No Rush or MUSH

Public debate continued to rage this year over whether my Ofces mandate should

be extended to the MUSH sector municipalities, universities, school boards andhospitals and long-term care homes, as well as childrens aid societies, police and otherorganizations collectively receiving tens o billions o dollars annually in public unds.

We were orced to turn away 2,541 cases relating to these organizations in 2012-2013,many o them raising serious issues involving the health and welare o Ontarios mostvulnerable citizens the sick, the elderly, children and youth. No other ombudsman inCanada has such a limited mandate.

I am not the frst Ontario Ombudsman to recommend elimination o the arbitrary historicalexceptions shielding the MUSH sector rom my Ofces scrutiny. The eort began with thefrst Ombudsman, Arthur Maloney, who observed in his 1979 Blueprint or the Ofce o the

Ombudsman o Ontario:

it is my considered view that the Ombudsmans jurisdiction shouldsimilarly be extended to include such organizations as hospitals,universities, boards o education, nursing homes and other suchbodies fnanced in whole or in substantial part with public unds.

Popular grassroots opinion appears solidly behind extending Ombudsman jurisdictioninto the MUSH sector. Many MPPs have also shown strong support or this change.The Standing Committee on Government Agencies is poised to consider Bill 42, theOmbudsman Amendment Act (Childrens Aid Societies), 2013, introduced by NDP MPPMonique Taylor, which would bring childrens aid societies within this Ofces jurisdiction.

And since 2005, more than 100 petitions and 14 private members bills have supportedmodernization o my Ofces mandate to include the MUSH sector.

Anybody but the Ombudsman

Last June, I was extremely encouraged by the comments o then Premier McGuinty, whoinitiated discussions with my Ofce about opening the MUSH sector up to Ombudsmanoversight, and told me, It is ot a matter o i, but whe this new jurisdiction would begranted. However, less than a year later, his successor Premier Kathleen Wynne rejected theoverture made by the leader o the New Democratic Party to extend my Ofces authorityover hospitals and long-term care homes. The result was an accountability compromise

NDP MPP France Glinas (Nickel Belt) speaks to Ombudsman Andr Marin at a Meet the Ombudsmanevent at Queens Park, May 1, 2012.


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no independent external oversight in this area, but the promise o some other, as-yet-undefned accountability measures in uture. However, the Deputy Premier, the Minister oHealth and Long-Term Care, was later quoted as saying she wouldnt close the door on the

Ombudsman as a means o addressing complaints in the health and long-term care system.Political wrangling aside, there is simply no well-articulated, rational justifcation orbarring Ombudsman oversight in the MUSH sector. Sadly, it seems that anybody butthe Ombudsman is the rallying cry or some government insiders. Perhaps the mostvehement and ever-pitched example o this came rom Transportation Minister GlenMurray, who spoke heatedly against Bill 42s proposal to extend Ombudsman oversight tochildrens aid societies, saying such cases require sensitivity and prudence:

The Ombudsman is someone who is on the ront page o the paper,whose tactics are to advocate or an individual, and hardly an ofce thatshows that kind o discretion.FromHansard, April 11, 2013

The Minister later apologized or this inaccurate public attack on my Ofces integrity.

The act is, since I took ofce in April 2005, I have deliberately worked to enhance publicawareness o the Ombudsmans Ofce and how it can assist Ontarians. It is throughdemonstrating our value openly, oten and in clear language, that we have been able toinuence positive changes in the law, policy and practices or the beneft o Ontarios citizens.

When I issue ofcial reports, answer journalists questions or use social media, I am usingthe tools at my disposal to get the job done as eectively as possible, just as a carpenteruses a hammer. The style o our reports, the compelling personal stories that are included,and the clear language o our communications all help engage the interest and imaginationo citizens and legislators, which is essential or an ofce that relies on both public inputand political will to spark systemic reorms.

Our approach has not only allowed us to achieve results or the thousands o people whocome to us confdentially it has also been emulated around the world by the hundreds owatchdog organizations that have sent their sta to us or training.

More on this can be ound in the Commuicatios ad Outreach and Traii adCosultatio sections o this report.

Deputy Ombudsman Barbara Finlay appears with host Steve Paikin on TVOs The Agenda to discussIn the Line of Duty, November 6, 2012.


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Hospital horrors

Ontarians put their aith in hospitals to treat the sick and injured with competence,sensitivity, and proessionalism. Regrettably, a year does not go by without some systemicscandal erupting in the hospital sector, whether it is an outbreak o C. difcile, prolongedemergency room wait times, or this years controversy over monitoring o chemotherapydoses or cancer patients.

In 2012-2013, according to news reports, a 22-year-old man lapsed into a coma, 12 hoursater being released with head injuries rom Toronto Western Hospital. An 82-year-oldgrandmother died at Mount Sinai Hospital ater alling out o bed unsupervised. A newbornbaby at Humber River Regional Hospital was pronounced dead, only to be discoveredalive some 90 minutes later.

Hospitals routinely respond to these horrifc cases by launching internal inquiries.Typically, the results o these reviews remain confdential, leaving the public with

unanswered questions and diminished confdence in the health care system. Unlike everyother province in Canada, Ontario has let its 150 hospital corporations immune romOmbudsman oversight.

Internal patient relations ofcials owe their allegiance to their employers and do nothave the means or the will to carry out credible independent investigations or report onmaladministration. Consider the recent news story o the 80-year-old patient o the LondonHealth Sciences Centre who claims he was told to clean his own messy toilet and waschastised by an ofcial in the hospitals complaints department or going to the media. Thehospital ofcially denied the report, but without an independent, impartial inquiry, the truthwill never be confrmed. And even i existing internal complaint mechanisms are enhanced,as the Premier has implied they might be, they will not replace the need or external

investigative oversight under the Ombudsman Act.

Our Ofce has the unique ability to observe systems holistically and identiy trends andbest practices. We have the statutory powers, the experience, and proven track record osuccess to promote necessary changes.

This past year, the Ontario Hospital Association board o directors considered proposalsto extend my Ofces mandate to hospitals. While there may be some angst expressedabout this prospect, I believe with time there may also be acceptance. In cases wheregovernment has taken over hospitals by appointing supervisors (thereby giving ustemporary oversight o those acilities), we have always worked productively with theseofcials. Not only do we assist citizens in resolving concerns, we are also a saety valve oroten beleaguered administrators, who can reer cases to us to acilitate resolution. In ourexperience, citizens are much more likely to accept our assessment that administratorshave acted reasonably or lawully than to take the word o involved ofcials.

Long-term care lapses

Ontario will soon be the only province whose Ombudsman has no authority to investigatelong-term care homes, leaving the 76,000 residents o some 640 homes with no recourseto independent oversight. The only other holdout, New Brunswick, has passed newlegislation and will soon extend its ombudsmans mandate.

As with hospitals, we continue to hear nightmare tales o abuse and neglect arising romOntario long-term care homes, but are powerless to act. Among the many stories that

made headlines, an 87-year-old woman was trapped in an out-o-service elevator in along-term care centre in Mississauga or more than 29 hours. A 72-year-old woman wasbeaten to death, and a 91-year-old assaulted, by a ellow resident in a Scarborough long-term care home.

And Camille Parent, concerned about his 85-year-old mothers unexplained injuries, hid avideo camera in her room at a long-term care home in Peterborough. The video revealedegregious, degrading treatment by several workers, who have since been fred. TheMinistry o Health and Long-Term Care launched an investigation, but Mr. Parent said hewould preer independent oversight:


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Number one thing Id like to see is the Ombudsman get involved andtake the whole investigation away rom the Crown.Camille Parent, speaking to CTV National News, May 19, 2013

Ornge air ambulances ying out o reach

Ornge is a ederally incorporated non-proft company. As such, it does not come within myjurisdiction. But Ornge carries out an essential public service, transporting about 18,000patients each year by land and air ambulance, and receiving $150 million in taxpayerdollars annually to do so.

Since 2005, my Ofce has received 29 complaints about Ornge fve o them romwhistleblowers. The issues identifed were extremely serious and reective o the agrantbreach o public trust committed by Ornge administrators, the extent o which only came

to light in December 2011. Twele o these complaints were received in 2012-2013,including claims o inadequate equipment maintenance and inspection, and problematicdispatch practices.

Over the years, we have heard complaints about the purchase o inappropriate helicopters,stonewalling o investigators, poor service, inadequate inection control, misappropriationo unds, muzzling o Ornge sta and conicts o interest involving Ornge administrators.We reerred complainants to the Ministry o Health and Long-Term Care or the AuditorGeneral when appropriate, although many expressed dissatisaction with the quality o theMinistrys supervision o Ornge. Had we been able to delve into the issues they raised, wemight have been able to address some o the problematic practices that were eventuallyuncovered.

On May 15, 2013, I was invited to speak to the Standing Committee on GeneralGovernment about Bill 11, theAmbulance Amendment Act (Air Ambulances), 2013. The billcalls or increased accountability measures relating to designated air ambulance serviceproviders like Ornge.

During my presentation, I observed that it is not sufcient to replace the truly independentexternal oversight that the Ombudsmans Ofce provides with the innersight o internalmechanisms. Ornges own history demonstrates this dramatically, and new accountabilitymeasures so ar have allen short.

Ombudsman Andr Marin and Deputy Ombudsman Barbara Finlay appear beore the Standing Committeeon General Government regarding Bill 11 and oversight o Ornge, May 15, 2013.


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Now, whats wrong with Bill 11? Nothing and everything. It consists oan elaborate series o baby steps that will improve internal checks andbalances not a bad thing, but alling short o true oversight. We are

ahead by a ew yards, but ar rom a touchdown.Ombudsman Andr Marin, submission to the Standing Committee on General Government, May 15, 2013

Ornges new Patient Advocate, or example, is a sta position, responsible or dealing withcompliments and complaints. Similar to patient relations sta in hospitals, this individualis an employee without any eective authority. While internal complaints processes serve auseul purpose, they are a poor substitute or an independent parliamentary Ombudsman withrobust powers o investigation and public reporting. Bill 11 proposes authorizing government toappoint special investigators but again, they would report through the Ministry.

The Ombudsman is the watchdog or the elected members o the Legislative Assembly andan advocate or airness, not the Ministrys pet on a ministerial leash.

The Auditor General was given the ability to monitor Ornges fnances and the Inormationand Privacy Commissioner will soon have authority over related inormation and privacyissues. There is no justifcation or denying potential complainants recourse to my Ofce aswell, which perorms a complementary but entirely separate role rom these ofcers.

Give us a C childrens aid societies

The province o Ontario is the legal guardian to more than 8,300 children and youth connectedto child protection services, which are delivered by 46 independent, non-proft organizationsrun by locally elected boards o directors. Protection o children is a grave responsibility, andone that everywhere else in Canada is carried out by government. Ontarios system is unique.


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Since 2005, my Ofce has received 3,550 complaints and inquiries about childrens aidsocieties. Ontarios childrens aid societies receive provincial unds in excess o$1.4billion each year, but since they are considered private agencies, they all outside o my

mandate.Media stories chronicling the deaths and abuse suered by children involved withOntarios child protection system have inspired advocacy groups and successiveparliamentarians to call or Ombudsman oversight o childrens aid societies. Since April2005, some 60 petitions and 7 private members bills have been tabled in the LegislativeAssembly to this eect. Support or Ombudsman involvement in this area is strong, asevidenced by NDP MPP Monique Taylors Bill 42, the Ombudsman Amendment Act(Childrens Aid Societies), 2013, passing second reading in April 2013.

Within the child welare community, the possibility o Ombudsman oversight is a liveissue. This was evident this year, when our Ofce was asked to do a presentation or theOntario Association o Childrens Aid Societies on what Ombudsman oversight might

mean or them.

The argument against Ombudsman oversight o childrens aid societies has always beeneeble. None o the existing oversight mechanisms the Ministry o Children and YouthServices, the Provincial Advocate or Children and Youth, the Child and Family ServicesReview Board, the courts, the Ofce o the Chie Coroner and the Pediatric Death ReviewCommittee provide or broad-based investigation into systemic and individual issueso airness and administration. Whats more, the latter two only become involved ater achild dies.

Admittedly, Ombudsman oversight is not a cure-all. But it is a powerul and provenmethod or promoting accountability and transparency. As we do or hundreds o other

provincial organizations, my Ofce can act as an early warning system, proactivelymonitor complaint trends, expose systemic aws and obtain speedy resolutions, beorea crisis hits. This important resource should not be barred to children and youth in care,their amilies, and concerned members o the public.

I know its too late or me, but I want uture generations to beprotected. There are too many kids being abused and nobody isbeing held accountable or it. The Ombudsman should be able toinvestigate this.Former CAS ward who was abused by oster ather, quoted in the Toronto Sun, March 21, 2013

Childrens aid societies in Ontario also ace serious fnancial pressures, and there isgrowing recognition that the system requires an overhaul. In recognition o the publicunding that they receive, they are already subject to fnancial monitoring by the AuditorGeneral. The time is ripe to make them accountable to the Ombudsman as well, to givevulnerable children in care and their amilies the same access to independent oversight asthose involved with provincial agencies.

OMLET still cooking

Although municipalities remain outside o my Ofces mandate, we are the investigatoror complaints about closed municipal meetings in all municipalities that have notappointed their own investigators. In 2012-2013, our Open Meeting Law EnorcementTeam (OMLET) which investigates whether municipalities have complied with the openmeeting requirements o the Municipal Act, 2001 dealt with 305 complaints, more thandouble last years 119. Due to the volume o these cases, I released my frst separateOMLET Annual Report in October 2012. I will release my next one this coming all. Amongthe issues it will address are the legislative loophole that allows municipalities to reject theindependent oversight o my Ofce in avour o investigators o their choosing, and thelack o consequences or those that hold illegal closed meetings.


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Closing Thoughts

Ombudsman oversight is an established, efcient, multipurpose accountability tool,

eective in helping citizens navigate Ontarios government programs, policies andpractices, shining light on unairness and maladministration, and promoting positivesystemic change and good governance.

I remain hopeul that, rather than resorting to inerior internal accountability devices, thegovernment o Ontario will recognize the benefts o putting the Ombudsmans Ofce touse in all areas that sorely need our intervention.

Ombudsman sta participated in a number o charitable events in 2012-2013, notably the CanadianBreast Cancer Foundation Run or the Cure in October (or breast cancer research) and Movember

(or prostate cancer research and mens health awareness).


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The Year in Review

Beyond Scrutiny: The push or MUSHAs the accompanying chart reects, the Ombudsman received 2,541 complaints andinquiries in 2012-2013 about the MUSH sector, comprising municipalities, universities,school boards and hospitals, as well as long-term care homes, childrens aid societies andpolice. Although MUSH organizations deliver essential public services directly aectingOntario citizens, they continue to operate without Ombudsman oversight unlike in mostother provinces. Ontario remains dead last in Canada in allowing its Ombudsman authority

over this sector.

DEAD LASTHow Otarios Ombudsma madate compares to others i key areas o jurisdictio

Municipalities UniversitiesSchoolBoards

PublicHospitals

Long-TermCare Homes

ChildProtectionServices

PoliceComplaints

ReviewMechanism

ONTARIO NO NO NO NO NO NO NO

British Columbia Yes Yes Yes Yes Yes Yes No

Alberta No No No Yes Yes Yes Yes

Saskatchewan No No No Yes Yes Yes Yes

Manitoba Yes No No Yes Yes Yes Yes

Quebec No No No Yes Yes Yes Yes

New Brunswick Yes No Yes Yes No Yes Yes

Newfoundland

and LabradorNo Yes Yes Yes Yes Yes Yes

Nova Scotia Yes No Yes Yes Yes Yes Yes

Yukon Yes No Yes Yes Yes Yes No

MUSH SECTOR CASESRECEIvED DURIng FISCAL YEAR 2012-2013 TOTAL: 2,541

Universities

Long-Term Care Homes

School Boards

Police

Hospitals

Childrens Aid Societies

*Municipalities

0 200 400 600 800 1000 1200

* Excludes cases received about closed municipal meetings

55

70

133

365

369

472

1077


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This situation reects a serious accountability gap. Most MUSH agencies are subject toinormation and privacy legislation and fnancial oversight by the Auditor General. ButOntarians concerned about general maladministration and unairness cannot complain

to us about MUSH organizations unlike the hundreds o other provincial bodies we dooversee.

This anomaly has not escaped the notice o citizens and parliamentarians. The push orOmbudsman oversight in the MUSH sector has continued to gain traction. Since 2005,some 14 private members bills have called or Ombudsman scrutiny o various MUSHorganizations. The most recent, Bill 42, the Ombudsman Amendment Act (Childrens AidSocieties), 2013, introduced by NDP MPP Monique Taylor, was reerred to the StandingCommittee on Government Agencies ater second reading on April 11, 2013. A previousversion o this bill also received second reading, but died when the Legislature wasprorogued in October 2012.

As well, a record 41 petitions calling or increased Ombudsman authority in the MUSH

sector were presented in the Legislature in 2012-2013, bringing the total number o suchpetitions since 2005 to 106.

Despite our limited mandate, our Ofce assists complainants with MUSH sector issues byreerring them to help where possible. Although we cannot investigate them, we track thecomplaints and the issues raised, and summarize them each year in this report.

M Municipalities

The City o Toronto remains the only municipality in the province with its own in-houseOmbudsman. However, across the province, citizens have no recourse to external,independent investigative scrutiny o municipal matters.

While we can address complaints about improperly closed meetings or some 189municipalities that use our services as a closed meeting investigator, we were orced toturn away 1,077 complaints and inquiries about other municipal issues.

These included living conditions in public housing, the calculation and collection oproperty taxes, sewer and water charges, the state o roads, parks and recreationalacilities, the adequacy o bylaw enorcement, local procurement practices and garbagecollection services, and allegations o conicts o interest.

There are our provinces and one territory whose ombudsmen have the authority toinvestigate municipal matters. For example, in 2011-2012, the Ombudsman o Nova Scotiaound nine municipalities had made unauthorized expenditures o public unds, and theB.C. Ombudsperson sparked a municipal bylaw change to ensure interested propertyowners were notifed about proposed gravel pits.

U Universities

In 2012-2013, our Ofce received 55 complaints and inquiries about universities. Althoughcolleges o applied arts and technology come within the Ombudsmans investigativeauthority, universities do not, because o their governance structure.

Students complained to us about a variety o issues including ees, the quality oinstruction, internal academic appeals, complaint processes and grade disputes.

Two provincial ombudsmen have authority in this area. For example, in 2011-2012, theB.C. Ombudspersons intervention led to a revised appeal policy or students acingsuspension.


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S School Boards

We received 133 complaints and inquiries about Ontario school boards in 2012-2013,

including concerns about student suspensions, lack o adequate special educationsupports, the use o blocker shields on students with autism, inadequate response tobullying, and busing problems.

Ombudsman ofces in our provinces and one territory can deal with complaints aboutschools. For example, in 2011-2012, the Nova Scotia Ombudsman reviewed the processor selecting school bus stops, and the B.C. Ombudsperson helped improve a schooldistricts process or responding to complaints about bullying.

Some Ontario school board ofcials have begun to recognize the value o Ombudsmanoversight. In spring 2012, the Toronto Catholic District School Board considered (butlater rejected) creating an independent third-party ombudsman. In 2013, a school trusteesought support rom the Ottawa-Carleton District School Board to extend our Ofces

mandate to school boards, as well as other MUSH bodies, but was unsuccessul.

Uder superisio: Although the Ombudsman does not normally have jurisdiction overschool boards, that changes when the Ministry o Education appoints a supervisor to takecontrol o a board. On August 28, 2012, it appointed a supervisor or the Windsor-EssexCatholic District School Board. We received 7 complaints about this board in 2012-2013,primarily about employment-related issues. We made regular inquiries with the supervisorto monitor the boards progress in implementing administrative improvements.

H Hospitals

Our Ofce was orced to turn away 369 cases involving hospitals in 2012-2013. These

covered an array o issues, including emergency room, surgery and cancer treatment waittimes, billing practices, breaches o patient confdentiality, poor inection control, dischargeplanning, and inadequate communication.

Ontario is alone in barring its Ombudsman rom considering complaints relating tohospitals. Meanwhile, Saskatchewan provided its Ombudsman with authority to reviewdecisions o a broader range o publicly unded health entities in 2012, including someprivately owned health care organizations. Other ombudsmen obtained concrete resultsor citizens who complained about hospital administration. For example, in 2011-2012, theOmbudsman o Nova Scotia tackled concerns about patient charting and autopsy reportdelays. The B.C. Ombudspersons work led to improvements in a hospitals admissionpractices. Quebecs Ombudsman addressed emergency room wait times, quality o

services in addiction treatment acilities, and the transer o elderly residents to long-termcare acilities in a bid to unclog a hospitals emergency services.

Your personal interest, the dedication o your management team,and the quality o your actions demonstrate yet again yourcommitment to work with complete impartiality in the deence ocitizens rights and to improve the quality o public services. I sincerelyhope that this additional authority will be granted to the Ombudsmano Ontario.Quebec Ombudsman Raymonde Saint-Germain, letter to Ombudsman, April 2013


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And in the U.K., the Parliamentary and Health Service Ombudsman released a report aboutsystemic problems in that countrys hospitals in April 2013, ater looking at 400 seriouscases. The Ombudsman ound that hospitals routinely treated patients and their amiliesinsensitively and without compassion.

But in Ontario, opponents to Ombudsman oversight continue to argue that it wouldduplicate such existing mechanisms as public reporting on patient saety measures, qualityindicators and wait times, compliance with accreditation standards and accountabilityagreements, internal patient relations processes, reedom o inormation obligations andreviews by the Auditor General.

All o these measures have value, but they do not replace the need or Ombudsmanoversight, nor do the patient relations ofcials at some 150 Ontario hospital corporations.Indeed, we continue to receive complaints about the internal complaints processesestablished by hospitals, particularly about their lack o responsiveness and objectivity.And while hospitals have been subject to the Freedom o Inormation and Protection oPrivacy Actsince 2012, quality o care inormation remains shielded rom disclosure.

None o the existing accountability tools in the hospital sector provides recourse to anindependent, external overseer with the Ombudsmans statutory mandate and powers toconduct impartial investigations o individual and systemic issues, publicize results, andexert moral suasion to correct unairness and maladministration.

Its really troubling that there is no ombudsman or health-care issuesin Ontario. I there was more accountability, wed all be saer.Richard Kadziewicz, letter to Toronto Star, April 15, 2012

Uder superisio: Our Ofce does have temporary jurisdiction to accept complaintsabout hospitals where the province has taken direct control and appointed a supervisor.The Hotel-Dieu Grace Hospital in Windsor was under supervision until July 20, 2012, and

we received 2 complaints about it, which were resolved. The Niagara Health System alsoremained under supervision in 2012-2013 and was the subject o 31 cases received byour Ofce, a signifcant decrease rom last years 81. These included concerns about poorcommunication, breach o privacy, inadequate response to complaints, and a need orrepairs in some acilities. Our Ofce triaged all o these complaints, obtained relevant acts,and ollowed up with the supervisor where necessary.

Quebec Ombudsman Raymonde Saint-Germain speaks to Ontario Ombudsman managers about her ofcesmandate to investigate hospitals, April 10, 2013.


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Long-Term Care Homes

In 2012-2013, our Ofce received 70 complaints and inquiries about Ontarios long-

term care homes, most rom relatives o residents concerned about everything rominadequate care and understafng to poor record keeping and allegations o abuse. Wecould not directly investigate these issues, but reerred complainants elsewhere when wecould.

Ontario will soon be the only province whose Ombudsman has no oversight o long-termcare homes once New Brunswicks new legislation is implemented. Other ombudsmenhave achieved signifcant results or their citizens in this area. For instance, in 2012, theOmbudsman o Saskatchewan addressed an unair and rushed relocation o long-termcare residents, and the B.C. Ombudsperson reported on a three-year investigation intothe care o seniors, including recommendations designed to improve resident care. Thesame year, in Quebec, ater an 83-year-old resident died in a special unit or individualswith dementia, the Ombudsman identifed major aws in living conditions and services,leading to corrective action.

Despite our lack o ability to investigate the homes themselves, our Ofce continuesto ollow up on our investigation into how the Ministry o Health and Long-Term Caremonitors them. Details on this can be ound in the Special Ombudsma ResposeTeam section o this report.

Families that have witnessed inexcusable institutional neglect o theirbeloved parents, and horrifc deaths o loved ones in nursing homes,understand the critical need or the provincial ombudsmans oversight

over hospitals and long-term acilities.Ellen Watson, letter to Toronto Sun, January 24, 2013

Childrens Aid Societies

This year, the Ombudsman received 472 complaints and inquiries about childrens aidsocieties across the province. These came rom youth in care, parents, grandparentsand other people concerned about ailures to investigate neglect and abuse, inadequateor biased investigations, problematic child apprehensions, sta misconduct andharassment, lack o inormation, and denial o access to children in care. In one case, amother alleged her child was sexally abused by an older oster sibling. Several peoplealso questioned the qualifcations o childrens aid society employees who operatewithout registration as social workers.

Unique in Canada, child welare services in Ontario are delivered by private agencies.Everywhere else, child protection is administered directly by government. Otherombudsmen have been able to assist amilies with concerns about child protection.For instance, in March 2013, the Manitoba Ombudsmans Ofce released a reportemphasizing the importance o risk assessment and case planning in the child welaresystem. In Quebec, in 2011-2012, ater a child was hospitalized with injuries allegedlycaused by his parents, the Ombudsmans intervention led to enhanced screening toidentiy neglect and abuse.

In Ontario, deenders o the status quo routinely reer to existing mechanisms toreview childrens aid societies, such as the Ministry o Children and Youth Services,the Provincial Advocate or Children and Youth, the Child and Family Services ReviewBoard, the courts, the Ofce o the Chie Coroner, and the Pediatric Death ReviewCommittee. However, none o these bodies has the Ontario Ombudsmans broadstatutory powers allowing or independent investigation o individual and systemicallegations o maladministration.


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While the Child and Family Services Review Board received authority to considercomplaints about childrens aid societies in 2006, only those seeking or receiving servicecan request its assistance, leaving many relatives and concerned community members

with no recourse. The Board is also restricted to considering procedural issues, suchas whether a childrens aid society provided reasons or its actions, listened to parentsconcerns about services, or responded to a complaint. It cannot investigate or considersystemic issues involving sta conduct or practices, or address substantive mattersrelating to child apprehension or ailure to investigate allegations o abuse. And itsremedies are limited to ordering that a childrens aid society respond or provide reasons.

In 2012-2013, we received 4 complaints about the Child and Family Services ReviewBoard, including concerns about its jurisdictional limitations.

[The Ombudsman] is a stellar investigator and has enormous integrity.His ofce is there or citizens as a mechanism to sort out problems

with governments. He does not invent such problems, but tries to

address them with recommendations. CAS oversight is long overdue,

in some cases it is a matter o lie and death.Anne Patterson, letter toLondon Free Press, March 23, 2013

Police

In 2012-2013, the Ombudsman received 365 complaints and inquiries about police,including allegations o assault, wrongul detention and arrest, harassment andthreats, inappropriate response to individuals suering rom mental illness, inadequate

investigation, and improper discharge o a Taser. We also heard complaints aboutcarding police keeping inormation about people who were stopped but not arrested.These were reerred to the Ministry o the Attorney Generals Ofce o the IndependentPolice Review Director (OIPRD) or the Special Investigations Unit (SIU), where appropriate.

Seven provinces allow or Ombudsman oversight o police services. For instance, in 2011,the Manitoba Ombudsman reported on police detaining intoxicated youths in jails.

This year, we received 43 complaints and inquiries about the OIPRD, raising concernsabout awed communications, investigations and decisions. Under the Police ServicesAct, this body does not all within our jurisdiction, even though the SIU does.


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Operations OverviewThe Ombudsmans Ofce received 19,726 complaints and inquiries in 2012-2013 a 6%increase rom the previous year. Most (54%) complaints were resolved within one week;66% were resolved within two weeks. The Case Summaries section o this report eaturesexamples o the many cases that were successully resolved, oten by our sta helpingpeople who elt they were stuck in endless bureaucratic lines.

The Operations section o the Ofce, which consists o Early Resolution Ofcers andInvestigators, ocuses on resolving individual cases. Cases that cannot be inormallyresolved are reerred or ormal investigation, while others are brought to the attention osenior government ofcials and successully addressed.

Both teams work closely with the Special Ombudsma Respose Team (SORT) toidentiy and resolve potential systemic problems wherever possible. Senior Ombudsmansta also meet regularly with top ofcials rom the most complained about ministries,organizations and programs to alert them to complaint trends and signifcant cases.


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Complaint Trends and Signifcant Cases in 2012-2013

Ministry o the Attorney General

Ofce o the Public Guardian and Trustee

Among its other responsibilities, the Ofce o the Public Guardian and Trustee (OPGT)is responsible or managing the fnancial aairs o people who are incapable o doing sothemselves. The Ombudsman received 162 complaints about the OPGT in 2012-2013,compared to 130 in 2011-2012. As in previous years, these complaints related primarilyto problems with the OPGTs communication with clients, delays and the quality oservice. Some complaints also involved OPGT decisions, such as reusals to provideclients with unds.

For example, OPGT sta inadvertently charged a man legal ees or its discussions with ourOfce about his complaint to us. They also attached an outdated ee schedule to the legalbill. When Ombudsman sta brought this to the attention o the OPGT, it ensured that theclient was not charged or the discussions with our Ofce and it sent the client a currentschedule or other ees.

Senior OPGT ofcials meet regularly with Ombudsman sta to discuss complaint trends,potential systemic issues and individual cases. The OPGT has continued to ocus its eortson improving customer service, an area the Ombudsman remains concerned about.

Ministry o Community Saety and Correctional Services

Correctional acilities Complaints rom inmates

Due to the consistently high number o complaints received rom correctional institutionsacross the province, the Ombudsmans strategy is to ocus resources on those involvingserious health and saety issues. In addition to agging complaints about excessive use oorce by correctional ofcers (the subject o the Ombudsmans latest systemic report seethe Special Ombudsma Respose Team section o this report), sta continue to monitorcomplaints about the handling o inmate-on-inmate assaults.

For example, we learned o two serious assaults at one institution, neither o which hadbeen investigated by the acilitys senior management. We brought these cases to theattention o senior ofcials at the Ministry, who ensured both assaults were investigated.The Assistant Deputy Minister also issued direction to the regions superintendents that alocal investigation should be conducted into any assault that results in serious injury.

We also continue to receive a high volume o complaints rom inmates about health-relatedissues, such as lack o access to medication, medical sta or treatment. Many complaintsinvolve health care sta not communicating with community physicians, institutionaldoctors reusing to prescribe medications, missed or delayed medication due to lockdowns,and medication being cut o without an alternative. We also received a large numbero complaints rom inmates with serious mental illnesses who aced long waits to see apsychiatrist, and about a lack o services or emale inmates with mental health issues.

In one case, a woman who was seven months pregnant had been in jail or more than threeweeks without seeing a doctor. Ater Ombudsman sta spoke to the health care manager atthe institution, arrangements were made or the woman to see a doctor and be transerredto the high-risk clinic in case she gave birth while in custody. In another case, an inmate who

has epilepsy complained that his identifcation card did not note his condition and he wasbeing made to sleep on an upper bunk; Ombudsman sta spoke with the relevant health caremanager and both his bunk and ID card were changed. In a third case, an inmate complainedthat a nurse had given him another inmates medication by mistake and he received amethadone overdose. Ombudsman sta ollowed up with the acilitys superintendent, whoconfrmed the mistake and ensured the inmates condition was monitored by a doctor. Thislatter case was also brought to the attention o senior Ministry ofcials.


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In January 2013, an inmate at a detention centre complained to the Ombudsman atermaking three requests to see a psychiatrist. Ombudsman sta discovered that the acilityhad used up its psychiatry budget or the fscal year and had reduced the psychiatrists

hours as a result, orcing sta to triage inmates requests so that those in crisis weregiven priority. Ater Ombudsman sta spoke to the regional director about the situation, aquarterly budget review was implemented to ensure even distribution o psychiatric hoursthroughout the fscal year. The regional director also directed all superintendents in theregion to consult with her about budgetary concerns, and committed to providing regularupdates to the Ombudsmans Ofce on this issue.

As we have done or several years now, senior Ombudsman sta meet with top Ministryofcials on a quarterly basis to discuss trends in complaints and emerging systemicissues. We also meet directly with those responsible or health care services in correctionalacilities to address issues and identiy areas or urther improvement.

Private Security and Investigative Services Branch

In recent years, Ombudsman sta have monitored complaints about the Ministrys PrivateSecurity and Investigative Services Branch, which is responsible or licensing privateinvestigators and security guards, as well as handling complaints made against them.

Last year, we reported that in response to concerns raised by Ombudsman sta, thebranch overhauled its complaint process. It has also cleared the backlog o 200 complaintsthat accumulated while the new process was being developed.

This year, Ombudsman sta identifed concerns to the Ministry about delays caused by thebranchs practice o returning incomplete licence applications and renewals to applicantsby mail without attempting to contact them to resolve problems. The Ministry made

improvements and as o April 2013, applications could be made and their status checkedby applicants online. The Ombudsman will continue to monitor complaints received aboutthe branch.

Ombudsman sta show employees o the Death Investigation Oversight Council elements o our complainthandling process, February 14, 2013.


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Death Investigation Oversight Council

The Death Investigation Oversight Council (DIOC) was established in December 2010to oversee the work o Ontarios coroners and orensic pathologists. It advises the ChieCoroner and Chie Forensic Pathologist on key issues, and can receive complaints aboutthese organizations work through its complaints committee.

Ater receiving complaints about the DIOCs customer service and conusion about its role,senior Ombudsman sta met with the chair to discuss ways to improve the transparencyand accessibility o the DIOCs complaint process. It was suggested that the DIOC shouldprovide clear, evidence-based reasons in its decision letters, improve communication withcomplainants, and ensure its role and mandate are clearly set out in its public materialsand website. The chair, who has worked proactively with our Ofce to address issues,agreed and changes were made to the website and DIOC correspondence. As well, theDIOC can now be contacted directly by phone.

Senior Ombudsman sta also provided an inormation session on the Ombudsmansmandate and operations to DIOC sta and shared some o our best practices orcomplaint handling.

Ontario Forensic Pathology Service Historically retained organs

The Ontario Forensic Pathology Service (OFPS) ofce works closely with the Ofce o theChie Coroner with regard to death investigations in the public interest. The Ombudsmanreceived 5 complaints ater the Ministry o Community Saety and Correctional Servicesissued a press release in June 2012 revealing that it had stored organs rom autopsiesconducted by the coroners ofce prior to 2010. The Ministry called on aected amilies toadvise how they wanted their loved ones remains to be dealt with. Many were upset that

this practice had never been public knowledge.

Our Ofce connected the amilies who complained with ofcials at the ofce o the ChieCoroner and at the OFPS who could provide inormation and answers. We have notreceived any urther complaints since August 2012.

The Chie Forensic Pathologist also met with the Ombudsman to explain why organshad been retained ater autopsies in the past, and to outline how aected amilies werebeing inormed. He noted that regulatory changes were made to ensure amilies wouldbe inormed about organ retention in uture. As o mid-April 2013, the Chie ForensicPathologists ofce advised us that it had been contacted by 2,500 amilies out o apotential 4,000 who could come orward. While the Ombudsman will continue to monitorthis issue, he advised the Minister that we have received positive eedback rom aectedamilies, and good co-operation rom the Chie Forensic Pathologist.

Ministry o Community and Social Services

Family Responsibility Ofce

The Family Responsibility Ofce (FRO) is responsible or the enorcement o court-orderedchild and spousal support in Ontario. Our Ofce received 794 complaints about the FROin 2012-2013, making it once again the most complained about Ontario governmentorganization. Complaints commonly involve inadequate or delayed enorcement o supportorders or insufcient communication with clients.

Similar complaint trends were observed this year, such as FRO sta ailing to reviewdocumentation, consider all available acts or ensure records are up to date beore takingenorcement action or unpaid support. Another requent complaint involved enorcementactions not in compliance with FRO policies and procedures.


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We received many complaints about wide variations in when and how FRO sta choseto take enorcement action. In one case, FRO sta repeatedly negotiated new paymentschedules with a man who had breached previous ones and owed more than $20,000 in

arrears. FRO policy requires aggressive enorcement (drivers licence suspension, garnishingwages, etc.) when such schedules are violated. It wasnt until Ombudsman sta contactedFRO management about the case that the man was told aggressive enorcement wouldbegin whereupon he began making support payments.

Poor record keeping and administrative errors are persistent problems or the FRO,sometimes resulting in serious fnancial impact on clients. For instance, it erroneously paidnearly $34,000 o a womans child support payments to a generic Ministry account rom1996 to 2007. The woman, who had been on social assistance in 1997 or 10 months, hadassigned her child support payments rom the FRO to the Ministry. However, the paymentswere never redirected to her when she came o social assistance, and she missed out onthem or 11 years. Ater Ombudsman sta intervened, the FRO reimbursed her or the

ull amount.Senior FRO managers meet regularly with our Ofce and have been very responsive tothe complaint trends and cases brought to their attention. The FRO implemented a newcase management computer system in April 2013 that will automate several o its manualprocesses and is expected to improve service. The Ombudsman remains optimistic aboutthe proactive measures and strategies implemented by the FRO to address problems, butcontinues to be concerned about the themes arising rom complaints.

Services or adults with developmental disabilities

In 2011-2012, the Ombudsman reported on serious, persistent complaints about theapparent lack o services to support young people with severe developmental disabilities

once they turn 18 and are no longer cared or through the Ministry o Children and YouthServices. Ombudsman sta worked closely with the Ministry o Community and SocialServices to resolve these cases one at a time, but complaints continued to mount. OnNovember 29, 2012, the Ombudsman announced a systemic investigation into provincialservices or adults with developmental disabilities who were in crisis situations. At thattime, our Ofce had received 64 such complaints, but several hundred more came in aterthe investigation was announced. More details on this ongoing investigation can be oundin the Special Ombudsma Respose Team section o this report.

While the systemic investigation was under way, a team o Ombudsman sta was assignedto deal with individual cases and help amilies fnd immediate solutions. This involvedollowing up where warranted with community agencies, Developmental Services Ontario

(DSO) ofces and Ministry sta.

In one such case, a young man with a developmental disability assaulted his widowedgrandmother at a hospital and was involuntarily committed to the psychiatric unit. Whenhis condition stabilized, the grandmother elt she could not take him home rom hospitalbecause she could not manage him. Ombudsman sta acilitated communication betweenthe Ministry (including senior ofcials), the hospital and the local DSO ofce. Ater sevenmonths, a temporary sae bed was ound or the man at a group home with thepossibility to become a permanent placement and his grandmother was very grateul orthe help she received.

In another case, we were contacted by a amily whose developmentally disabled 18-year-

old son had been suspended rom school or assaulting a teacher and several caregivers.He had also been violent at home and they had called the police or help. Ombudsmansta alerted the Ministry to the urgency o the case and it immediately arranged or homeservices or the amily and sought a residential placement or the man on an urgent basis.Two months later, his amily advised our Ofce that the Ministry had ound a suitableresidential placement or him in a group home and service providers had developed a planto stabilize his behaviour and have him return to school.


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Ombudsman sta continue to work to resolve the hundreds o individual complaints in thisarea as the investigation into the broader issues wraps up.

I am writing to acknowledge the excellent service recently receivedrom the Ofce o the Ombudsman o Ontario. Their ollow-through withDevelopmental Services Ontario resulted in an outcome that will mostcertainly enhance the quality o my [sons] lie throughout his adult yearsWe now have much greater peace o mind.Letter to Ombudsman rom mother o young man with developmental disabilities, February 2013

Thistletown Regional Centre

Thistletown Regional Centre is a Ministry-operated mental health centre that oers specializedservices and community supports to children, youth and amilies with complex special needsand developmental challenges. It also provides residential care or 13 adults, some o whomhave been living at the centre since early childhood or adolescence and are now middle-aged.

The Ombudsman was contacted by six amilies with adult relatives living at Thistletown.They were inormed by letter in March 2012 that the centre would be closed and theresidents relocated by March 31, 2013. They complained to the Ombudsman about thisdecision and the transition process.

Our review ocused on the transition process and the parents complaints that their callswere not returned or they were provided with inaccurate or inadequate inormation. Somesaid the profle setting out their loved ones needs did not reect the complex medical,behavioral or historical inormation in the recommendations made by the clinicians who hadworked closely with them. They also wanted to know i there were any contingency plans i

the new placement ailed.

Ombudsman sta also ound it difcult to obtain concrete inormation rom the Thistletowntransition team. Ater we expressed concerns to several senior Ministry ofcials, the Minsitrycommitted to improve communication with the amilies, and confrmed the residents wouldremain at Thistletown while new placements or them are ound. At the time o writing thisreport, Thistletown remains open and Ombudsman sta continue to monitor this process.

Ministry o Children and Youth Services

Services or children with special needs

In 2011-2012, the Ombudsman reported 47 complaints about services and treatment orchildren with special needs. This increased to 91 complaints in 2012-2013 representing anincrease o 94%. In the wake o the Ombudsmans investigation into services or adults withdevelopmental disabilities who are in crisis, we heard rom 60 amilies who were concernedabout the services available to children as well. Many also worried about what services wouldbe available when these children turned 18. Common complaints included a lack o serviceco-ordination (meaning amilies must deal with multiple applications and paperwork ordierent programs such as Special Services at Home and Assistance or Children with SevereDisabilities), and long waiting lists or services and programs such as respite or caregivers.

Ombudsman sta worked with community agencies and the relevant ministries to helpamilies connect with the appropriate service providers and to resolve these cases aseectively as possible.

Two o these cases echoed the issues raised in the Ombudsmans 2005 investigationand report, Between a Rock and a Hard Place, which revealed parents were being orcedto surrender custody o their children to childrens aid societies in order to place them inacilities that could care or them. Ombudsman sta resolved both o these cases. Moredetails can be ound in the Special Ombudsma Respose Team section o this report.


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Assistance or Children with Severe Disabilities beneft program

In 2010-2011, the Ombudsman reported on complaints rom amilies who were deniedthe Assistance or Children with Severe Disabilities (ACSD) beneft purely on the basis oincome. Our inquiries prompted the Ministry to review how its ofcials were applying theeligibility requirements or the beneft, particularly the extreme hardship clause. Thisclause allowed them discretion to approve ACSD benefts or amilies whose incomeexceeded the Ministrys ceiling i they had incurred extreme costs relating to a childsdisability. The Ministry ound that the criteria were not being applied consistently and tooksteps to clariy the rules or its sta. As a result, more amilies received the beneft underthe extreme hardship criteria.

The Ministry remained in contact with our Ofce on this matter and in 2012-2013, wereceived 5 complaints about such issues as delays in processing applications and ailureto give notifcation o the suspension o ACSD benefts.

In one case, the mother o a severely disabled boy who had been receiving ACSD orseveral years assumed that when he turned 18, he would be eligible or benefts under theOntario Disability Support Program (ODSP). She thought a letter rom her sons doctor tothe ACSD special agreements ofcer was all that was required, but when she later calledthe ODSP ofce or an update, she was told there was no record o an application on hersons behal. With the help o her MPP, she submitted an application, but her son died justdays beore it was approved. Ombudsman sta discussed the circumstances surroundingthe delayed application with senior sta at the Ministry o Community and Social Servicesand the Ministry o Children and Youth Services. The local ODSP ofce reviewed the caseand subsequently agreed to provide the mother with$2,273 in retroactive benefts. TheMinistry also put protocols in place requiring that inormation about ODSP be providedto the amily o any child receiving ACSD six months prior to the childs 18th birthday.

Applications rom ACSD clients or ODSP are now triaged and agged immediately andput through an expedited approval process.

Ministry o Energy

Hydro One

Hydro One complaints to our Ofce increased rom 232 in 2011-2012 to 328 in 2012-2013. The bulk o these were about disconnection notices and issues with so-calledsmart meters the newer devices that have been rolled out across the province inrecent years. In many cases, customers complained o receiving estimated usage billsthat did not accurately reect their power use, ollowed by large catch-up bills. Some

also complained that smart meters were installed or replaced without their knowledge.Ombudsman sta brought individual cases to the attention o Hydro One ofcials, whoagreed to provide explanations to customers and to make payment arrangements withthem as warranted. We are closely monitoring Hydro Ones progress in addressingthese issues.

The Ombudsman also continues to receive complaints about excessive or incorrect billingby Hydro One. Ombudsman sta work with Hydro One sta to resolve these issues, andto acilitate discussions with customers to explain charges and accounting. Examples oindividual case resolutions can be ound in the Case Summaries section o this report.


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Ministry o Health and Long-Term Care

Community Care Access Centre co-ordination

The Ombudsman was contacted by a lawyer on behal o a 37-year-old woman withan acquired brain injury who was unable to care or hersel. The woman was in arehabilitation hospital awaiting a residential placement in a long-term care acility,when she was arrested in connection with an altercation at the hospital and jailed.It was unclear which government or community agency was responsible or thewomans care and placement; Ombudsman sta made more than a dozen calls tovarious government organizations in order to obtain inormation about her history.

Ombudsman sta contacted two regional Community Care Access Centres(responsible or co-ordinating various home and community care services) aswell as several programs under the Ministry o Health and Long-Term Careand the Ofce o the Public Guardian and Trustee, in an eort to co-ordinate

inormation between the agencies that had lost touch with the woman when shewas incarcerated. Ater seven months in jail, she was released to a amily member,who registered her with another regional CCAC to fnd an appropriate residentialplacement or her. She has since been back in both jail and hospital, however,Ombudsman sta and ofcials at the Ministry o Health and Long-Term Care arekeeping a close eye on her case.

Out-o-country genetic testing

Two amilies contacted the Ombudsman when they were unable to obtain out-o-country unding or genetic testing on tissue rom deceased relatives even thoughthe testing had been recommended by specialists. In the frst case, a physician or

a 14-year-old boy who died suddenly while playing sports recommended genetictesting to see i his surviving siblings had the same undiagnosed connective tissuedisorder believed to have caused the boys death. The Ministry initially denied undingor the test because the boy was deceased and thereore not covered by OHIP.However, the Health Services Appeal and Review Board agreed to order the test onbehal o the mother, who was covered by OHIP.

In the second case, a widowed mother sought out-o-country unding to pay orgenetic testing o tissue rom her deceased husband, who also died o a connectivetissue disorder. The woman wanted the test to determine whether the couplesfve-year-old daughter had the same condition, but her doctor did not requestit because the Ministry had advised geneticists that it would not approve such

requests.

Ministry ofcials initially told Ombudsman sta they would review their policy onsuch testing in light o the frst appeal but that similar requests in the meantimewould be denied and would have to be appealed. When they provided no timelineor the review, we met with more senior representatives, ater which the Ministryconfrmed it would consult with the Chie Forensic Pathologist on the issue andthat new applications in the interim would be reviewed on a case-by-case basis. TheOmbudsman will continue to monitor the Ministrys progress in this area.


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Ministry o Government Services / Ministry o Health and Long-Term Care

Long-Term Care ACTION Line

The Long-Term Care ACTION Line was established or residents o long-term carehomes to report concerns about care and services provided by their residence orCommunity Care Access Centre. It is operated by ServiceOntario. Sta at the phone lineare to record inormation, ask questions, assess the problem and give the inormation tothe Ministry or the relevant Community Care Access Centre or ollow-up.

A long-term care home worker complained to the Ombudsman that she did not hear

back ater she reported a serious incident on the ACTION line. When Ombudsmansta asked Ministry ofcials about the call, it was discovered to be one o many thathad been dropped rom the computer system because the data had been enteredimproperly. The Ombudsmans inquiry revealed that this problem meant 260 calls werenot acted upon as required.

The Ministry agreed to look into the matter to determine whether any data rom the callscould be retrieved and to ollow up as warranted. It will also update the Ombudsman onhow it ensures calls to the ACTION line are properly handled and acted upon.


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Ministry o Natural Resources

Natural Heritage, Lands, and Protected Spaces Branch

OntariosAggregate Resources Actcontrols and regulates aggregate operations(aggregates are defned as gravel, sand, clay, earth, several types o stone, or anycombination o sand, gravel or stone). Aggregates are used primarily in constructionprojects. Under the Act, aggregate business operators in designated geographic areasare subject to a system o licensing, monitoring, inspection and enorcement, and annuallicensing ees and costs.

A licenced aggregate operator rom an area that was designated in 2007 complained tothe Ombudsman that it was unair not to subject all aggregate producers in the provinceto the same rules. He complained that operators in designated areas are at a competitivedisadvantage when bidding or contracts against unlicenced operators rom neighbouringnon-designated areas because the unlicenced operators are not subject to the same

licensing costs and requirements.

The Ministry advised the Ombudsman that it was developing options to address thisinequity. In March 2012, the Standing Committee on General Government was directedby the Legislature to review and develop recommendations to strengthen theAggregateResources Act, and the Ministrys aggregate policy initiatives were put on hold pending theoutcome o this review.

Ater the prorogation o the Legislative Assembly in October 2012, Ombudsman sta metwith senior Ministry ofcials on this matter. In January 2013, the Ministry said it wouldcontinue to seek direction rom the government to address this inequity.

Ministry o Training, Colleges and UniversitiesPrivate Career Colleges Branch

The Ministrys Private Career Colleges Branch is responsible or ensuring all private careercolleges are in compliance with legislation and taking enorcement action against thosethat are unregistered or otherwise break the rules.

In 2012-2013, the Ombudsman received 19 complaints about this branch, down rom 26in the previous year. Complaints involved inadequate communication, unair enorcementor delays in approving programs, renewing school registrations or responding to collegecompliance eorts.

One college director complained she waited several months or the Ministry to approvedistance education courses. When Ombudsman sta brought this concern to seniormanagers, we learned the branch had concerns about the quality o its own process orapproving such programs. It had stopped reviewing applications in October 2010. Wemonitored the branchs progress in developing a new policy ramework, and in November2012, the Ministry issued a new policy directive and resumed evaluating applications orsuch programs.

Ombudsman sta also spoke to the Deputy Minister about difculty in obtaininginormation and timely responses rom the Ministry on several cases. The Deputy Ministeragreed to review one case personally and supported our Ofces oer to meet with seniorMinistry sta on a quarterly basis to discuss progress on complaints and issues. One such

meeting had been held at the time o writing this report, to discuss complaint trends andwhat is expected when Ombudsman sta call the Ministry or inormation. Ministry stacommitted to making improvements, and we continue to monitor complaints aboutthis branch.


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Ministry o Transportation

Licensing Service Branch Ghost licences

In 2011-2012, the Ombudsman reported that a complaint rom a man convicted o drunkdriving led our sta to discover a disturbing issue with thousands o master licencerecords at the Ministry o Transportation. Master licence records are used by the Ministry

to store inormation provided by the police and courts about an oence or inormationrom a doctor about a drivers medical condition where no existing drivers licence or theperson can be ound or example, when someone without an Ontario licence is stoppedby the police or in an accident.

Once a master record is created, it is supposed to be matched with the driversofcial licence, i one exists. However, i the inormation received by the Ministry doesnot exactly match that on the existing drivers licence, this can result in more thanone licence record or the same person. In the case o the drunk driver, or example,because his surname was misspelled by one letter, his licence was not ound in thesystem and a master one was created. His conviction and prohibition rom drivingwere added to the master record, but his existing licence remained clear and so he

kept using it to drive.In releasing his report last year, the Ombudsman said he was very concerned about thenumber o ghost licences and their potential impact on public saety. He reported thatthe Ministry was improving its search tools to catch potential duplicate licences resultingrom misspelled names or addresses, but it had no plan to review all existing masterlicence records.


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Ombudsman sta worked closely with the Ministry on this issue. It was determinedmore than 1.1 millio master licence records had been created since 1966.Some 235,000 related to Ontario residents; the rest were created in order to enter

inormation about out-o-province drivers into the Ontario system.The Ministry has since taken specifc steps to identiy potential ghost licences.Its initial review identifed 13,866 potential duplicate records or Ontario residents 1,050 o which had been agged or suspension. These are being reviewed in stages,starting with those that involve Criminal Code suspensions because i these peopleare still driving, they pose the highest risk to public saety. At the time o writing thisreport, the Ministry had identifed 138 high-risk potential duplicate master licencerecords. O those, 100 were confrmed to be duplicates o drivers licences already inthe Ministrys database. The Ministry confrmed that 35 o the 100 duplicate licencesshould have been suspended but were not, and these drivers could still be on theroad. The Ministry is notiying them o their licence suspensions. Next, it will review

the 647 duplicate master licence records it identifed or people whose licences weresuspended or medical reasons.

The Ministry o Finances Internal Audit Division is also conducting an independentaudit o the licensing control system to assess the process and conditions that led tothe creation o master licences, the risk actors associated with them, and potentialshort- and long-term goals or the Ministry to monitor and reconcile duplicaterecords.

The Ministry has demonstrated that it takes the Ombudsmans concerns seriously.Senior Ministry ofcials have welcomed regular meetings with Ombudsman sta todiscuss their progress as monitoring o this issue continues.


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Training and ConsultationThe Ombudsmans Ofce shares its expertise in complaint resolution and systemicinvestigations with other agenci

Documents

Ontario Ombudsman 2012-13 annual report