BC’s Ombudsperson – the pot calling the kettle black?

Ombudsperson takes 4 years to respond to complaint, says ‘no investigation’

BC’s Ombudsperson Kim Carter and her entourage were out in the Lower Mainland communities of Abbotsford, Chilliwack, Richmond and Surrey last week, urging people to tell her and her “team” all about their complaints and concerns.

Kim Carter calls these sojourns into the British Columbia hinterland,“mobile intakes”.

At the end of the week, Ms. Carter took time to do a few media interviews. During these interviews, Kim Carter revealed that the most common complaints her Office receives about government agencies and other organizations her Office oversees are:

  • “Unreasonable delay” by public agencies and organizations in responding to complaints, and
  • “No good, clear explanation” for the concerns brought forth in complaints.

CBC-BC Radio morning show hosts in Vancouver and Victoria, Rick Cluff and Gregor Craigie, both asked Kim Carter about the recent appointment of a Seniors’ Advocate for British Columbia. The BC government decided to make the Seniors’ Advocate office part of the Ministry of Health, and stipulated that the Seniors’ Advocate would not investigate individual cases.

Kim Carter commented that since the new Seniors’ Advocate would not be permitted to investigate individual cases, “…there will still be a very active role for our Office (to take seniors’ care complaints) and we’ll be very much involved with seniors issues because we do have that power.” [interview starts at the 8:30 mark of the podcast]. In other words, her Office is the only place complaints about seniors’ health care in BC can be brought for investigation, once the complainant has exhausted the avenues available within the organization or agency alleged of wrong doing.

But “active” role is not what comes to many complainants’ minds when they think of BC’s Ombudsperson Office.

In fact, Seniors at Risk has learned that the BC’s Ombudsperson Office has a reputation far worse than many of the agencies it oversees, and particularly when it comes to:

  • unreasonable delays
  • no good, clear explanation
  • failure to investigate cases

Here’s one of several examples of Ombudsperson Office neglect that has been brought to Seniors of Risk’s attention recently.

Unreasonable Delays 

In August 2008, Rita McDonnell of Surrey, BC submitted a complaint to the Ombudsperson regarding the care received by her 68-year-old father, Gary Davis while in hospital.

She received a response from the Ombudsperson Office on December 21, 2012. Yes – more than four years later.

In the meantime, Gary Davis had died in a publicly funded long-term-care facility in July 2009 after developing severe bedsores and hospital-acquired infections from inadequate care that necessitated amputation of his legs, and enduring rough treatment by nursing staff.

Failure to Investigate

The letter from the Ombudsperson’s Manager of System Review, Carly Hyman, said, “… we did not investigate your complaint”.

Instead, they “chose” to keep the complaint file “open” to “help inform our systemic investigation into senior’s (sic) care,” referring to the Ombudsperson’s report entitled, “The Best of Care: Getting it Right  for Seniors in British Columbia”. That report was released over a year ago, in February 2012.

In other words, the Ombudsperson’s Office did nothing at all about Gary Davis’ horrific two years of neglect and rough care at the hands of publicly funded hospital and long-term-care facilities and staff.

Why did it take the Ombudsperson four long years to respond to a complaint – a complaint that was not even investigated? Why, if the complaint was used to “inform” the writing of her report, did it take another year for Carter’s Office to send Ms. McDonnell a reply?

Ms. Hyman, says in her letter, “I apologize for the length of time taken to respond.” How about an explanation about why it took so long?

One thing we know, this is no surprise to those who’ve tried to get assistance from this “watchdog” agency. This dog is dozing.

Seniors at Risk has received information from other families who, similarly, are still waiting for the results of an investigation into their cases of serious institutional elder abuse and neglect, or even just an update into the status of their cases.

Not only did the Ombudsperson fail to investigate Gary Davis’ case, Ms. Hyman’s December 21, 2012 letter contains basic errors of fact. For example, Ms. Hyman incorrectly states that Ms. McDonnell’s complaint was made in 2009, when her complaint was actually made in 2008.  Was this merely sloppiness, or was the Ombudsperson’s Office trying to hide the actual length of time it took them to respond?

The Ombudsperson’s letter also incorrectly states that Ms. Hyman’s “colleague, Harry Vogt informed you in June 2010, while we did not investigate your complaint we chose to keep our file regarding your complaint open to help inform our systemic investigation into senior’s (sic) care.”

Rita McDonnell disagrees. She says that when she last spoke with Harry Vogt in 2010, she was given to understand that the Ombudsperson’s Office was doing an investigation into her father’s case, not just using it to “inform” their systemic report. If the Ombudsperson’s Office had indeed made a decision not to conduct an investigation into her complaint, why would they not have sent Ms. McDonnell anything in writing to that effect, at that time? Why would they wait two and a half years to officially inform her?

It’s not as if these Ombudsperson Officers are poorly paid front-line clerks with minimal education and experience. An Ombudsperson Officer position pays as much as $77,000.00 plus the usual gold-plated government perks and pensions, according to a current job posting.

Ironically, says Rita McDonnell, she originally went to the Attorney-General to request that they investigate and lay criminal charges against the two hospitals, Royal Columbian and Langley Memorial and its adjacent long-term-care facility, Cedar Hill. The Attorney-General’s office told her that if she wanted an investigation, she should go to the Ombudsperson’s Office, and so she did. If these injuries were found on a elderly person being cared for by their family at home, criminal charges would be laid, according to the recently passed amendment to the federal Criminal Code, Bill C-36 as documented in a recent Seniors at Risk story, “Institutions ‘named and shamed’ for elder abuse”.

Is the system deliberately set up to force people to go in circles, only to come out at the same place they started, years later, without being any further ahead? It certainly seems that way. And, is this incompetence, disinterest, or something more sinister, a deliberate effort to thwart the public when they seek assistance and accountability?

No good, clear explanation

The Ombudsperson says that many of the complaints received about the government ministries and agencies that her Office investigates are that these organizations provide no good, clear explanations for concerns raised by the public.

But, the sum total of the Ombudsperson’s response to Ms. McDonnell’s complaint is a reference to the Ombudsperson’s “Best of Care” report, saying “Some of the recommendations [in that report] may be of particular interest to you.

OK, like what, exactly?

“For example, we recommended that the Ministry of Health, after consultation with stakeholders, establish specific and objectively measurable regulatory standards that apply to key aspect of care in all residential care facilities, including bathing frequency, help with going to the bathroom and call-bell response times.”

Set standards for bathing times? Standards for “help with going to the bathroom”?? Gary Davis suffered serious, life-threatening skin ulcerations so deep they went clear to the bone, caused his legs to be amputated, and likely brought about his early demise. These are not injuries caused by lack of call-bell response time standards, this is systemic institutional elder abuse.

Here’s a “clear” explanation of what Gary Davis endured.

Despite doctors’ orders, staff did not turn Mr. Davis or get him out of bed often enough. The hospital and nursing home did not inform the family of these injuries for several months after they occurred, and only after Rita McDonnell started asking questions, “I wanted to know why he smelled so bad.”

“McDonnell said she was horrified when staff removed his bandages and she saw the large, open, festering wound on her father’s lower back for the first time.

It was awful, unbelievable,’ she said.

‘It was black. He was rotting.’ “

CBC Go Public, March 23, 2010 “Senior loses legs to hospital infections, bedsores”

Fraser Health spokesperson, Heather Cook, [callously] blamed the family, insisting a “lack of communication with the family was the biggest problem.”

Take the challenge – dare to look at Gary Davis’ wounds caused by the utter indifference of nursing care staff at our publicly funded health “care” institutions. The photographs are difficult to look at, but it’s much harder to imagine how this man endured the pain these deep, untreated open wounds caused.

These injuries did not happen because there weren’t standards and regulations. They occurred because paid staff neglected Mr. Davis, apparently with zero accountability.

Even though most hospital and nursing home staff these days are care aides or practical nurses (LPNs), not RNs (Registered Nurses), staff are trained in basic bedsore care of invalids. Why is the Ombudsperson making recommendations for regulations, standards and training that already exist, but which staff and hospital administrators simply ignore?

“When she then complained her father wasn’t being moved enough, McDonnell said, ‘One of the nurses told me, ‘Care aides don’t get paid enough, you couldn’t pay me enough to do that job.’ ”

Carly Hyman’s letter continues, “We also made observations about the difficulty of enforcing and monitoring the current standards, and have included recommendations to help ensure that standards of care are effectively enforced…”  

Was it too much trouble or work for Ms. Hyman to mention one or two of the report’s recommendations, ones that actually relate to Gary Davis’ case, specifically?

Finally, Ms. Hyman states that the Ombudsperson’s 2012 report recommended that all residential care facilities be required to:

  • “investigate all complaints they receive
  • complete investigations within 10 business days
  • inform complainants in writing of the outcome…”

Ahhh, the pot calling the kettle black. If only the Ombudsperson had ‘walked their talk’ for Rita McDonnell and her father.

Is Kim Carter contravening the Ombudsperson Act?

Most surprising of all, is that Kim Carter is apparently not even abiding by the Ombudsperson Act (9), the legislation that governs her Office.

Section 22 (1) states:

“If the Ombudsperson decides

(a)  not to investigate or further investigate a complaint…

the Ombudsperson must

(c)   record the decision in writing, and

(d)  as soon as is reasonable, notify both the complainant and the authority of the decision and the reasons for it.”

Is four years “reasonable”? Rita McDonnell’s complaint about the outrageous neglect her father suffered was made while he was still alive, and with his blessing. This how the Ombudsperson handles urgent, life and death cases?

Kim Carter was re-appointed to another six-year term in May 2012 when Rita McDonnell was still waiting for a response from her Office. Did Kim Carter’s performance in Gary Davis’ case warrant her reappointment as BC’s Ombudsperson? The government Liberals and opposition NDP apparently think so. “During her first term, Ms. Carter has shown a strong commitment to good governance in British Columbia,” said committee chair [and MLA and Parliamentary Secretary to the Premier, Christy Clark] John Les.

When one considers that John Doyle was not appointed to another term as BC’s Auditor General (despite being widely lauded within and far beyond BC’s borders), one wonders why it was that the government gave Kim Carter such a warm and resounding seal of approval. She’s supposed to be a watchdog, not a lapdog. Was her contract renewed because she is so adept at appearing to do a good job, as opposed to actually doing a good job? Our seniors deserve better.

So, what was Ombudsperson Kim Carter doing in the Lower Mainland last week? Getting desperate people’s hopes up. And, perpetrating the myth that the BC Ombudsperson might actually help resolve their concerns and hold to account those responsible for misconduct.

“I thought that they were going to do an investigation, but they did nothing. Nothing,” says Rita McDonnell.

Receiving the Ombudsperson’s letter in late December 2012 put a pall on the McDonnell family’s Christmas, ripping open old wounds that had barely begun to heal.

In response to the letter from the Ombudsperson Office, Rita and Mark McDonnell’s 18-year-old daughter Sara conceived and produced a music video as a tribute to her grandfather and the song they both enjoyed so much, “When I’m Sixty-Four” by Sir Paul McCartney, who Sara had the pleasure of seeing perform live a few months before Christmas.

The making of this music video is Sara’s response to the Ombudsperson’s callous disregard for her grandfather’s unimaginable suffering.

Now… for your listening pleasure, a touching musical tribute to Sara McDonnell’s grandfather, Gary Davis entitled:


For Grandparents – Breaking the Silence… of Institutional Elder Abuse

Sara McDonnell, vocals and guitar
Alexa Tarrayo, video coordinator
Sir Paul McCartney (Lennon-McCartney), lyrics and music

Knowledge. Compassion. Courage. Action.

Take a stand against institutional elder abuse.

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  1. OMBUDSPERSON – POT CALLING KETTLE… I feel for this family. The ombudsperson, and staff should be ashamed of themselves! Why did you take so long to get back and did nothing for this family? Daughter Sara’s video was powerful message as was the article. Good job keeping us informed! Why can’t the Ombudsperson ( REALLY ) care for the seniors!

    Comment by Too long — March 13, 2013 @ 7:05 pm

  2. OMBUDSPERSON – POT CALLING KETTLE… Excellent article, well written and heart stopping. My God, my God,my God….how many times does this have to happen before there is enough public outrage to stop it?

    Comment by Jacquie — March 13, 2013 @ 7:24 pm

  3. OMBUDSPERSON – POT CALLING KETTLE… I saw the images of that poor man’s body and was completely disgusted! Although I am not a senior, I too am dealing with medical negligence so I completely understand. Someone had made a comment that they don’t understand the lack of public outcry and I think it’s because they have not had that experience yet. But I think young and old alike need to band together and continue to speak out. We all pay for healthcare but we shouldn’t be paying for this!

    Comment by In pain — March 13, 2013 @ 9:02 pm

  4. OMBUDSPERSON – POT CALLING KETTLE… “Dr Mendelsohn said: “Do not waste your time going to Ombudsman.” They are just there to placate the harmed patient, while they side with the doctors.” Seen on Facebook.

    Comment by JayG — March 14, 2013 @ 11:12 am

  5. OMBUDSPERSON – POT CALLING KETTLE… Our experiences with the Ombudsman’s office are not regarding senior’s issues; we have had a long battle with the actions perpetrated by our municipality that have escalated over the years due to the fact that there is nothing to stop the preposterous mismanagement. Our original complaints were filed in November of 2006; many phone calls and updates, to our files, have been made since. And what has been done to rectify the problems? Nothing. Nada. Over the six + years we have heard many, many reasons why the O’s office hasn’t done anything but that doesn’t mitigate the damages that keep piling up. It is time for this office to just come clean and admit that they have no power or authority and save the taxpayer a few dimes, and maybe allow for a REAL advocacy office to be opened. As long as we have this pseudo-authority the public will be fooled into thinking we have avenues to register complaints and see them taken seriously. Maclean’s magazine understands what the O’s office can’t seem to; they’ve already recognized our city twice for it’s dubious management. Number one in Canada in infamy. How wonderful.

    Comment by Klaus — March 14, 2013 @ 12:13 pm

  6. OMBUDSPERSON – POT CALLING KETTLE… I am not surprised that the Ombudsperson used the “case” for reporting purposes, if they did. I am currently involved with this Office. It seems the pattern is to accept cases and wait! They want your personal information, they are made aware that time is of the essence, and yet, they wait. Apparently, they are waiting for more information…perhaps to add to their statistics? The reason for appealing to the Ombudsperson in the first place is because there is a problem in need of resolution, now. Everything is time sensitive, everything is in chaos, the unsuspecting citizen is led to believe that the Ombudsperson will help to resolve the chaos. Instead, they wait. And, truth be told, the first communication I had from this Office let me know that I would be very lucky to even get my chaos taken on by this Office. It would seem that the only cases they want are the most severe, and even then they don’t do anything. But, no matter what, no action has been taken with the exception of the demand for more data. If I had depended on this Office for help, I would still be in the same chaos I brought into the scrutiny of the Ombudsperson. I am horrified about the salary levels in this organization. To be highly paid to wait is criminal. Put the money back into whatever is going to get proper care for BC citizens.

    Comment by fedupBC — March 14, 2013 @ 5:20 pm

  7. OMBUDSPERSON – POT CALLING KETTLE… Thank you so much.
    We applaud your work

    Comment by Ruth — March 15, 2013 @ 12:46 pm

  8. OMBUDSPERSON – POT CALLING KETTLE… Waiting for best but getting it wrong! it’s so sad that Ombudsperson and staff are getting paid while this family has suffered so much. Lack of caring keeps on happening. Please we need somebody that can stand up to this horrible treatment to seniors and their families no more talking about it really do something that matters. Amazing article thanks for keeping us in touch with what’s rally going on which is (a whole lot of nothing!! )

    Comment by Broken in BC — March 15, 2013 @ 10:22 pm

  9. OMBUDSPERSON – POT CALLING KETTLE… Great piece. Thanks for exposing the truth!
    I think there needs to be an investigation on the relevance of the Ombudspersons office. Have they ever actually helped anyone or are they just another drain on our tax dollars and just another useless Government appendage! Someone must seriously look into this.
    They have also had our case for going on four years – with no conclusion. It has been passed along through four different case workers.
    People go to them in hope of saving their loved ones from horrendously abusive situations only to have their hopes dashed. They give people false hope.

    Comment by Doreen — April 18, 2013 @ 8:01 am

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