TORONTO — A grim portrait of Ontario’s health care system was painted by the provincial auditor general on Wednesday, who released a report detailing physicians performing death investigations on their own patients, foreign objects left in bodies after surgery, and nearly six of every 100 patients in Ontario since 2015 experiencing harm while in hospital.

Across Canada, only Nova Scotia has worse hospital patient harm numbers than Ontario. According to auditor general Bonnie Lysyk’s review, public concern around health care safety has been increasing in recent years due to growing research about the impact of medical errors and other hospital-acquired harm on patients, as well as on the health care system.

Lysyk was at a loss for answers on why Ontario fared so poorly compared to other provinces and territories, urging the ministry to explore the issue.

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Each year, Lysyk’s office found, out of the more than 1 million patients discharged from an Ontario hospital, some 67,000 had been harmed in some way during their stay. And right now, Ontario’s hospitals are not required to report “never-events” to the Ministry of Health — instances that should never happen and could cause serious harm or death, like foreign objects being left inside surgery patients or, more frequently, patients developing pressure ulcers from not being moved in their beds. The report documents 214 such incidents occurring since 2015, at six of the 13 hospitals they reviewed. None of the hospitals set any targets in their plans for improvement to stop the events from repeating.

Ontario Health Minister Christine Elliott denied any patients were harmed due to understaffing — an issue NDP leader Andrea Horwath pointed to on Wednesday, saying that hospitals “can’t do more with less.”

“Some of the issues relate to personnel,” Elliott said, noting that they needed to work with the College of Nurses to ensure they were appropriately keeping track of concerning incidents in nurses’ pasts, lending more assuredness to hiring hospitals. Elliott noted that many hospitals were now reporting their “never-events” to the ministry. “But we need to make sure, and we will continue to work to ensure that all hospitals do report these types of incidents,” she said.

Several human resource matters were broached in Wednesday’s report. Nurses who were repeatedly terminated or banned from hospitals, for lacking competence or practice issues, were found by Lysyk’s team to have been rehired by other hospitals and agencies. “Hospitals may not share relevant information about a nurse’s complete and truthful employment and performance history, with other potential employers,” Lysyk wrote.

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Disciplining physicians was meanwhile found to be costing hospitals handsomely, and at times taking years. One particular physician’s disciplinary case that Lysyk detailed took around four years, and cost the hospital more than $560,000. An ongoing disciplinary process for the very same physician — at a second and third hospital, where they are currently practicing — has already cost the two hospitals more than $1 million.

“Physicians’ legal costs in such cases are effectively paid by taxpayers because the government reimburses physicians for their malpractice insurance fees. This means physicians can potentially draw out disciplinary cases for years at little cost to them personally,” the report notes.

A glimpse at Ontario’s funding for chronic kidney disease services and addictions treatment flagged a number of issues. Around $40 million of the $134 million spent on the province’s opioid strategy since August 2017 was found to have been distributed equally among regions, instead of according to need. Ontario’s base funding for kidney transplants has not changed since 1988, Lysyk noted — currently, it stands at about $25,000 for a deceased-donor kidney transplant, though the average current cost is now $40,000.

When asked about the addictions funding, Elliott told reporters they were “very concerned about the equity of services” delivered across the province. She then pitched the mental health and addictions centre the government is currently trying to establish through a bill, saying that team would be able to focus on service equity issues if the legislation passed. Green party leader Mike Schreiner later accused the government of “fiddl(ing) with bureaucracy” while front line issues persisted, which he attributed to “chronic” overcrowding.

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The report also noted unethical behaviour by some of Ontario’s coroners — as some physicians were found to have performed death investigations on their own patients. Supervising coroners, who are meant to ensure quality in such investigations, were missing “significant errors” in 18 per cent of death investigation reports, Lysyk noted. And the Office of the Chief Coroner and Ontario Forensic Pathology Service had no policy on when to suspend or terminate coroners, she found — despite their audit identifying multiple coroners who had been sanctioned by the College of Physicians and Surgeons.

Coroners are not required to document their reasons for refusing to investigate a death, and the office does not publicly report on the status of recommendations made by inquests or review committees, “leaving the public in the dark about whether issues involving safety have been addressed.”

Solicitor General Sylvia Jones told reporters on Wednesday that Ontario’s head coroner and forensic pathologist had accepted the auditor general’s recommendations for changes, and would be moving forward on them. “I was surprised,” she conceded, when asked by a reporter specifically about the report of coroners performing death investigations on their own patients.

And in other healthcare-related facilities, worrisome details emerged. Three of five long-term care homes reviewed in detail by the audit team prepared meals using food beyond its best-before date, including a case where residents were served “liquid whole eggs” that were three months expired.

While Lysyk told reporters that such incidents were surely upsetting for her team to see, she gave credit to Ontario’s two long-term care associations for sitting down with her team to review the recommendations they’d made.

“I think once we get to the grassroots, I think everyone wants to do the right thing, but sometimes you just get caught up in the day to day job,” Lysyk told reporters. “I don’t think there was any intent in a lot of these things.”

Still, Elliott told reporters she was surprised and concerned by the details offered in Lysyk’s report — asked specifically about the portion referencing the long-expired eggs. “We are going to work with the long term care homes, as well as the inspectors, specifically focused on food safety issues,” she pledged.