TorontoOntario’s patient ombudsman says in a new report that medical supply shortages last fall for palliative and home-care patients were triggered by one vendor, but the actions and inactions of a government agency contributed.Ontario Health atHome ‘failed in its basic responsibility to patients, caregivers’: health ministerAllison Jones · The Canadian Press · Posted: Sep 24, 2025 2:43 PM EDT | Last Updated: 38 minutes agoThe patient ombudsman says the issues lessened by December but has given the agency four recommendations to improve, including better oversight and giving patients advance notice of significant service changes. (Carl Court/Getty Images)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, ombudsman Craig Thompson said.As part of the investigation into the Ontario Health atHome supply issues, Thompson’s 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. 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.”‘Delayed deliveries leave patients unserved: reportAnother 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.WATCH | Ontario Liberals ask auditor to look into shortage of medical supplies: Ontario Liberals ask auditor general to probe home care supply problemsThe Ontario Liberals are demanding the province’s auditor general investigate a critical shortage of medical supplies. CBC Toronto reported last week that home care patients across Ontario have been facing shortages of crucial equipment for about a month. But the problem still isn’t fixed. Lorenda Reddekopp has the latest.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.Interim CEO offers apologyThe 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.
Lack of planning, oversight led to Ontario home care supply shortages: ombudsman
