A high-end Oakville nursing home neglected the bedsores on an elderly woman for so long that a rotting ulcer ate deep into her leg, exposing her shinbone through blackened flesh.

After nearly three months of lax care at The Waterford, Dorothy Benson grew increasingly sick from the infection in her decaying skin and died in hospital from problems related to sepsis and dehydration, according to an Ontario Ministry of Health report. She died on August 24, 2013, at age 93.

The Waterford’s “neglect” and “inaction,” as the ministry inspector described it, meant Benson’s life ended in agony. She had an ulcer eight centimetres wide on her left shin, a gaping hole on her heel and a smaller sore on her foot. (The inspection report was later altered, with black ink covering the line that stated the home’s inaction “contributed” to her death. It was replaced by handwritten notes saying inaction “jeopardized the well-being of the resident.”)

For Ontario’s aging boomers, Benson’s death is a cautionary tale with a dire warning: nursing homes are rarely penalized for neglect. In The Waterford case, no police charges were laid. No inquest was called.

“If a kid had died in foster care from that kind of wound, do you think we would have seen police charges? Very likely,” said Jane Meadus, of the Advocacy Centre for the Elderly.

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Meadus, a lawyer, said details in the publicly available ministry report on Benson’s death, dated Feb. 11, 2014, show that police could have considered the Criminal Code charge of failing to provide the necessities of life. That charge has been used in other cases in which vulnerable people were neglected by relatives in the family home.

A Halton Regional Police spokesperson told the Star its detectives were called off by the regional supervising coroner.

Sgt. Chantal Corner said detectives were advised by the coroner that there was “no criminal aspect” to the investigation. “We have had no further involvement as it was deemed a coroner’s investigation,” she said.

The coroner’s office, however, has since told the Star it will not hold an inquest: a public hearing that examines the circumstances of a death to prevent others from the same fate.

The lack of accountability infuriates Benson’s son, Sheldon.

“It’s totally outrageous how the coroner can ignore this and a police officer can turn a blind eye,” Sheldon said. “It seems that seniors are expendable. I do not accept this.”

The Waterford’s only repercussions came from “compliance orders” in the 2014 Health Ministry report into Benson’s death. The investigation was launched after Benson died and Sheldon filed a complaint related to inadequate care from the doctor, nurses and frontline staff.

That inspection resulted in ministry orders to fix inadequate skin and wound care practices (the bedsore category.) The ministry inspector found two other residents also suffering from problematic wound care.

Chartwell, the real estate investment trust that owns The Waterford, didn’t dispute the ministry’s findings.

“I want to say how much we regret the situation that the ministry’s report chronicled,” said Karen Sullivan, chief operating officer for Chartwell, which operates 179 long-term care and retirement homes across Canada. “I would also say to you that the ministry actually did us a favour with this report.”

In a detailed report, the ministry inspector concluded there was a link between the home’s neglect of Benson’s bedsores, starting in May 2013, the ensuing sepsis and dehydration, and her rapid decline in the Oakville Trafalgar Memorial Hospital.

“This inaction contributed to the resident’s death while in hospital,” it said.

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The report said the home didn’t do the following: check Benson’s wounds weekly, prevent dehydration, use proper wound assessment tools, reposition Benson so she wasn’t lying on the sores, revise plans when wounds didn’t heal and ensure frontline staff had proper training.

Sullivan said Chartwell took the inspection report seriously and made major changes in training and practices. A new administrator has since been hired to run the home.

The Waterford’s subsequent annual inspection, in December 2014, found no violations for bedsores or dehydration. In its 2015 annual inspection, the ministry cited the home for hydration problems related to one resident and delayed repositioning of another.

Benson’s wasn’t The Waterford’s first case of inadequate bedsore care. Ministry inspection reports from 2011 and 2012 detail similar problems with pressure ulcers — the painful wounds that can result from poor nutrition, dehydration or being left in one position for too many hours.

Despite a “compliance order” in 2011 and voluntary plans for change in 2012, the report into Benson’s death concluded the home made “no specific changes or improvements.”

In a lawsuit filed against Chartwell earlier this month, Sheldon Benson said the neglect of his mother’s “growing gruesome pressure ulcers” amounted to a “high-handed, flagrant and calculated disregard” for her rights. Chartwell said it won’t comment on legal matters.

Sheldon told the Star that he asked Dr. Roger Skinner, the regional supervising coroner, to conduct an inquest into the neglect of his mother while in the care of a provincially licensed long-term care home.

“No human being should be permitted to ‘rot’ as she did ...,” he wrote in a letter to the coroner.

In a written response dated June 11, 2014, Skinner said Benson’s death would be examined in the September 2014 meeting of the coroner’s “Geriatric and Long-Term Care Review Committee.”

Skinner said he’d provide that decision in writing. Sheldon said that the coroner’s office sent a letter in late spring, saying there would be no inquest because his mother died from natural causes related to sepsis.

“It’s not right that the system just ignores neglect in nursing homes. More than anything, I wish the police would revisit this.”

According to Chartwell’s Sullivan, there was no followup from authorities.

“We have no information on record that we participated in a coroner’s report or police investigation regarding this matter.”

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