A 91-year-old froze to death outside her retirement home. 2 years on, her family still doesn't know why
It’s not the first incident of its kind in Canada
On a snowy February night in 2022, the temperature was hovering around -8 C when 91-year-old Vera Wilson slipped outside through an unalarmed service door at her retirement home. The door locked behind her.
Staff didn't realize she was missing until 2 a.m., almost four hours later. By the time she was found — steps from the door, curled partly under a bush in a fetal position and covered in snow — it was too late.
Two years later, her son, Brian Wilson, is seeking answers as to how his mother could have frozen to death at a place he thought would keep her safe.
"How can this happen? How could she leave the building and not be detected?" said Brian.
In February 2021, Vera's family moved her from an Ottawa retirement home into a Seasons Retirement Communities home in Brantford, Ont., so she could be closer to them, just 20 minutes away.
"Part of it was the perception of the level of the care that they were able to provide," said Brian about choosing Seasons. "It felt very friendly. It felt very welcoming."
Over the course of the year, Vera would lose track of time, he said, but no one at the retirement homes where she lived ever told family that she was at risk of wandering.
"She was never, ever reported as being a wanderer. Or, I guess you could say, even a flight risk. Like, none of that was ever reported to me by any retirement home," said Brian.
Canada has seen a number of wandering incidents leading to death in recent years, CBC News has found. Some experts warn that these incidents could increase along with the country's aging population and a lack of options for proper care.
A timeline of the events
Vera was last seen by staff at 9:23 p.m. when they gave her medication, according to the Brantford Police Service report, a copy of which CBC News obtained. Surveillance footage reviewed only afterwards would reveal that she had left the building at 10:23 p.m., through a staff hallway.
At 2 a.m., Seasons staff went to assist Vera with a routine bathroom visit and noticed she had gone missing, the report states. Just two staff members were working that night, instead of the typical three.
The staff called their managers, who searched the building and surrounding areas several times. They then reviewed video surveillance, which showed she had left the building.
According to the report, the video also showed Vera walking, crawling and sitting, while not being able to get back into the building.
A Geriatric and Long-Term Care Death Review Committee report obtained by CBC News highlights the same details.
Police were dispatched around 4 a.m. A staff member found Vera dead, with her hands covering her face, roughly 20 minutes later. She wasn't wearing any outerwear.
The coroner determined the cause of death was hypothermia, and ruled it an accident.
Brian was shovelling snow in his driveway that morning around 8:33 a.m. when two police officers walked up to deliver the news.
His immediate response was "absolute shock."
His mother had always complained about how horribly cold the Saskatchewan winters had been when she was a kid living on a farm, he said. She vowed to never go back to Saskatchewan in the winter.
Her being outside that night "was totally uncharacteristic of her."
The committee's report states Vera suffered from vascular dementia, which resulted in her wandering from the home. Brian says he was aware of his mother's dementia, but the risk of wandering was never brought to his attention.
Brian is currently pursuing legal action against Seasons Retirement Communities, filing a civil suit at the Ontario Superior Court of Justice earlier this month, seeking $4.1 million.
"It seems there was no discussion with the family on moving the decedent to a safer environment," the report states. "Wandering risk was not mentioned in the six-month assessment."
In general, the report claims there's a gap between the type of care advertised by homes in the province and the level of care actually being provided.
It's also not the first case from Ontario that the committee reviewed of a retirement-home resident with dementia who died after exiting a building.
Residents at risk of wandering should be living in an environment appropriate for their needs, the report states, and if they aren't, facilities should work with the residents' families to move them to a setting that is.
Seasons declined multiple interview requests from CBC News, and didn't answer questions about whether it had implemented the committee's recommendations. The company operates 22 locations across Ontario and Alberta.
"Due to the ongoing litigation, we cannot comment further at this time," it said in a statement.
"Seasons Retirement Communities are retirement homes that offer supportive services to residents. Independent residents can come and go on their own. Seasons has in place various technologies and safety measures in our homes as the safety and well-being of our residents remain our top priority."
Different types of care
Jane Meadus, a Toronto lawyer at the Advocacy Centre for the Elderly, says it is important for families to remember retirement homes are different from long-term care and nursing homes.
"Retirement homes are tenancies. People do have the freedom to come and go," she said.
However, in this case, "one of the problems is that they didn't have alarms on all the doors."
An alarm could have alerted staff, who could have advised her not to leave.
Meadus said the long waiting lists for long-term care can result in some homes "trying to cover the gaps and offer care that they may not actually be able to provide legally."
The review made several recommendations for the Seasons home.
Facilities caring for vulnerable people at risk of wandering should have an auditory alarm and review "code yellow" (meaning a missing resident) procedures to include immediate viewing of video surveillance available, especially in the winter, the committee said. Police should be notified as soon as possible of a missing person who may have left the building, and video surveillance should be used on all entry and exit doors.
Facilities should also ensure that, as a patient's dementia progresses, their needs and care environment are regularly re-assessed by a health-care professional.
No condolences
Brian says he was disappointed by the lack of communication from Seasons after his mother's death.
"We received no other communication, from the retirement home, by the senior administration, in reference to the incident at all, even a 'sorry for your loss' comment."
Meadus says Seasons legally could have done so.
"There's actually a law that allows people to say that, to say that they're sorry without having any kind of legal liability on that."
'This is going to happen more and more with time'
CBC News reached out to coroners in every province and territory to find out how often Canadian seniors wandered from either a long-term care, nursing or retirement home and died of hypothermia between 2019 to present. B.C. and Nunavut did not respond.
Deaths reported:
- Ontario
- Quebec
Does not track this specific type of data:
- Newfoundland and Labrador
- Saskatchewan (Does not track specific cities or towns)
- Alberta (Does not track deaths from wandering)
- Northwest Territories
No deaths reported:
- Prince Edward Island
- Nova Scotia
- New Brunswick
- Manitoba
- Yukon
A CBC News review of 53 coroner reports provided by the Quebec government found 11 cases involving seniors with some form of cognitive impairment who froze to death after wandering from their long-term care or retirement home.
Those reports found some of the same issues with unalarmed doors and a need for increased care resources.
These types of incidents may increase as the general population ages, said Dr. Samir Sinha, director of geriatrics at Sinai Health in Toronto.
There are currently more than 650,000 people living with dementia in Canada, according to the Alzheimer Society of Canada. By 2030, it's estimated that a million Canadians will be living with it — and of them, 60 per cent will experience some level of wandering.
"That's a huge number of people who potentially could be in a situation like this. So I'm not being alarmist," he said.
He said long-term care and retirement homes must have preventive measures for vulnerable seniors so they don't go missing, and robust protocols for if they do.
"If a person wanders off," he said, "especially in inclement weather, the minutes count. We're not talking hours. We're talking minutes count, especially in a Canadian winter or a hot summer."
In fact, a similar incident did occur in 2016 at another Seasons in Owen Sound, Ont., when an elderly man fell a few steps from the door and spent hours outside, frozen, until a teenage passerby found him in time.
Seasons declined to comment on whether there had been any policy changes since that incident.
Although coming forward with details of his mother's death will not bring her back, Brian is hoping it may bring awareness to this issue.
"I don't want this to happen to anybody else," he said.
"I don't want another person, another family member, to have a police officer come and say, 'Your mother or your father died because they froze to death because they left the building.'"
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