(Updated) Lack of planning, oversight led to Ontario home care supply shortages: ombudsman

Medical supply shortages last fall for palliative and home care patients were triggered by one vendor, but a lack of planning and oversight at a government agency contributed, Ontario's patient ombudsman concluded in a report Wednesday.

Affected patients included a person with three forms of Stage 4 cancer whose delivery of supplies to ease their end-of-life pain and nausea was delayed, not arriving until 10 minutes before they died, the ombudsman said.

For patient ombudsman Craig Thompson's investigation into the Ontario Health atHome supply issues, his team spoke to affected patients and caregivers who filed complaints, nurses and staff at the government agency. 

The report highlights the experiences of several patients, including the Stage 4 cancer patient, who also did not receive supplies — including those needed to change a catheter — for three weeks in the month before their death. Then the symptom-relief kit that is meant to arrive very quickly once ordered by a doctor did not come until 14 hours later, the report said.

"The care co-ordinator disclosed that the incident was traumatizing for the family and morally distressing for everyone involved," the ombudsman wrote. 

"They also shared a comment made by the doctor following the patient’s passing: '[the patient] died choking and in pain and … the [kit] was delayed.' The caregiver indicated that 'there was no reason for [the patient] to die in pain.'"

Another patient with a serious infection in their arm requiring regular antibiotics through IV at home had missed deliveries, forcing them to go to hospital for the medication, the ombudsman wrote. Doctors had said the patient was at risk of needing an amputation if the infection didn't improve.

A patient described in the report as frail and elderly, who required catheterization three times a day, had delayed deliveries of their supplies. When packages arrived they were delivered to the front door of the apartment building instead of their unit, where previous deliveries had been sent, and contained catheters for children and inadequate lubricant, the ombudsman wrote. The patient got urinary tract infections as a result.

Ontario Health atHome had new supply contracts that took effect Sept. 24, but at that time the providers had insufficient medical supplies to fill all the orders based on inaccurate forecasts, the ombudsman wrote.

"Various witnesses reported and documents confirmed that concerns about the accuracy of the...forecast data had been communicated to Ontario Health and Ontario Health atHome well before the go-live date," the report said. 

By mid-October, Ontario Health atHome had started offering to reimburse patients and families for supplies they bought out of pocket due to issues with their deliveries. As of Feb. 11, there were 932 reimbursement claims paid out totalling $590,125, the ombudsman wrote.

The actions and inactions of one vendor, who the report does not name, set in motion the supply shortages, but a lack of planning and oversight by Ontario Health atHome was also at play, the ombudsman wrote.

"In our view, a more active governance structure focused on identifying and addressing risks, more time for implementation, and transparent collaboration and communication among participants ahead of the go-live date would have prevented it or at minimum mitigated the impact of any disruption," the report said.

The issues lessened by December, the ombudsman said, but he gave the agency four recommendations to improve, including better oversight and giving patients advance notice of significant service changes.

The organization's CEO at the time was let go, and in a letter Wednesday the interim CEO said they are fully committed to learning from the experience and improving, and are offering an apology to patients, families and caregivers.

"We deeply regret any distress or suffering endured by you, your loved ones, and your care providers who were unable to help you as they wanted to without the necessary supplies," interim CEO Anna Greenberg and board chair Carol Annett jointly wrote. 

"Patient care remains at the heart of Ontario Health atHome’s mission, and the safety, well-being and dignity of the patients we serve is always our top priority. In this circumstance, we did not meet our commitment to high quality patient care."

Thompson wrote in the report that Ontario Health atHome displayed an "attitude of complacency" about the major procurement project and did not focus on the potential impacts on patients.

"Patient Ombudsman observed a lack of focus on potential impact on patients and their care," the report said. "During the implementation, there was an active decision against patient engagement and communication."

In addition to delivery issues, patients reported significant quality issues after September, including leaking catheter bags and wound dressings that were not absorbent enough.

Health Minister Sylvia Jones said in a statement that Ontario Health atHome "failed in its basic responsibility to patients, caregivers and families."

"Along with new leadership at OHaH and additional mechanisms in place, OHaH will continue to strengthen their delivery of connected home care services across the province," she wrote.

This report by The Canadian Press was first published Sept. 24, 2025.