“Totally unacceptable” is what Ontario Health Minister Christine Elliott had to say about a senior with COVID-19 being inadvertently left behind during the evacuation of the Rosslyn Retirement Residence.

Two more residents have died in the disastrous outbreak at the retirement home on King Street East, bringing the total to four. An 86-yr-old man and an 80-year-old man died in hospital Tuesday. Hamilton’s COVID-19 death toll now sits at 30.

During question period Wednesday, Elliott said it “certainly should not have happened” that the ill resident went without care for roughly 18 hours before being discovered at the evacuated home after family alerted St. Joseph’s Healthcare.

“That is not acceptable under any terms, not acceptable at all,” said Elliott in response to a question by NDP’s Sandy Shaw, MPP for Hamilton West-Ancaster-Dundas.

“We are working with our partners to review the protocols and understand why this could have happened, and to make sure that this never happens again,” said Elliott.

The Rosslyn evacuation was the first time in Ontario an entire seniors’ home had to be shut down during the pandemic, with every resident transferred to hospital because of the risk posed to those who lived there, said Winnie Doyle, executive vice-president of clinical operations at St. Joseph’s Healthcare.

In total 62 residents were sent to Hamilton General and St. Joseph’s while two seniors chose to make other arrangements. Paul Johnson, director of Hamilton’s Emergency Operations Centre, said he doesn’t know where they went.

Fewer than five of the Rosslyn residents sent to Hamilton General needed to go to the intensive care unit and none needed to go to that unit at St. Joseph’s. The rest are on the dedicated COVID units at the two hospitals.

“They had every resident evacuated to hospital because of a horrific COVID-19 outbreak, and unbelievably, one resident was left behind in the empty home, forgotten,” Shaw said during question period. “This is truly a nightmare.”

Elliott says the Retirement Homes Regulatory Authority is working with Hamilton public health and what used to be the Hamilton Niagara Haldimand Brant Local Health Integration Network (LHIN) “to understand what has been happening and to make sure that as people have been evacuated, they are going to be safe and healthy in their new home for the time being.”

Ontario’s Patient Ombudsman is also monitoring the situation closely. While the office doesn’t have oversight over retirement homes, its mandate does include hospitals and community care which were both involved with The Rosslyn during the outbreak and evacuation.

The Rosslyn’s outbreak started with one infected resident May 10. By May 12 it was flagged as being at risk, requiring aid from St. Joseph’s, LHIN home and community care, public health and Hamilton paramedics to be sent in to help with staffing, testing and infection prevention and control.

In addition, public health had issued orders — both before and during the outbreak — regarding concerns about infection prevention and control, ineffective monitoring of resident illness and a lack of personal protective equipment.

Despite all of these interventions, the virus spread within days to 63 of the 64 residents and 20 staff, including five who came from temporary agencies.

Elliott says the home was evacuated “due to concerns about the physical structure and to keep people safe and healthy.”

Doyle has described a chaotic situation during the evacuation May 15 where no Rosslyn staff were left at the home partly because so many had been infected. The last two retirement home staff had to leave that morning after testing positive themselves.

There was no master list of residents and no one on site who knew the seniors living there. There was confusion around which residents were among the nine sent to hospital before the official evacuation began at 4:45 p.m. Doyle says St. Joseph’s staff had a false report that the resident left behind was already at hospital.

Doyle said a search of the building was done including rooms, bathrooms and cupboards and “a mistake was made” to have missed the resident.

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