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New Brunswick Child and Youth Advocate Norman Bosse releases a report in Fredericton on Jan. 28, 2019.Kevin Bissett/The Canadian Press

An investigation into the death of a 91-year-old man who was twice assaulted at a New Brunswick nursing home has uncovered a wide array of failures, including the home’s inability to protect residents from harm.

Norman Bosse, the province’s seniors advocate, issued a report Thursday that also revealed under-reporting of major incidents and a series of shortcomings in an investigation conducted by the adult protection branch of the province’s Social Development Department.

“The physical agony and emotional distress (he) endured during his final days should never be an ending to anyone’s story,” Bosse wrote in his report, which identified the victim only as George.

“Although 91 years of age, George was admitted to the nursing home in excellent physical condition. Two months later, George left the home on a stretcher, never to walk again.”

To protect the privacy of the victim and his family, the report does not reveal the identity of the victim or the nursing home, and there is no indication of when the man died.

But the report provides grim details about how George, a grandfather with dementia, had been assaulted at least twice by another male resident with dementia — incidents captured by surveillance cameras.

In the second incident, George was shoved to the floor by the other resident, identified as Tom, resulting in a broken hip. Complications arising from that injury led to George’s death shortly afterward, which the regional coroner ruled a homicide.

Bosse said the report is not about laying blame or finding fault, and he made of point of drawing attention to Tom in particular.

“We must stress that because of his dementia, this person was not in control of his actions and so cannot be blamed for the injuries he caused,” Bosse wrote.

Following both assaults, George’s family was wrongly told he had simply fallen, as was the case with an earlier incident that resulted in injury but was not properly reported because the surveillance tapes had been erased.

“During our investigation, we also discovered that, although no staff witnessed the first incident, George told the employee who discovered him on the floor, with Tom standing in close proximity, that ‘he pushed me to the ground,”’ the report says.

Following George’s death, the Social Development Department conducted an investigation that concluded there was no merit to allegations of neglect and abuse.

“What is troubling, however, is that the adult protection social worker only examined the final assault on George and did not factor in any of the other concerning incidents between his attacker and other residents,” the report says, noting that Tom had already been involved in nine other incidents with other residents.

“Moreover, the only people at the nursing home interviewed during that investigation were two members of the senior management team.”

Bosse concluded that the investigation had failed to review all of the relevant information.

As well, he found that staff at the home knew about the assaults, but management didn’t respond in a timely manner. “Many employees interviewed felt that their concerns and suggestions to management fell on deaf ears,” Bosse wrote.

“When we asked the nursing home’s management why interventions were not put in place early on to protect residents from Tom’s assaultive behaviour, they claimed ... staff were still getting accustomed to him.”

Bosse has submitted 13 recommendations to the government, including a call for legislative changes that would give the seniors advocate the mandate to conduct geriatric death and critical injury reviews arising from reports of abuse.

The report also recommends improvements to violence-reduction training, safety practices, care standards, annual inspections and the reporting of major incidents. As well, Bosse wants adult protection investigations to be improved and data on annual inspections compiled to identify residences in non-compliance.

Social Development Minister Bruce Fitch told a news conference Thursday that he couldn’t talk about specific incidents involving nursing home residents, but he was quick to argue that what happened to George, although troubling, was an isolated incident.

“I have no hesitation in stating today that we have full confidence in the commitment and ability of operators and staff to safeguard the well-being and safety of the 12,000 long-term-care residents in our province,” he said, reading a statement.

“The incident described is very serious .... However, this incident is not evident of a systematic problem within our network of long-term care facilities.”

Fitch said his department would review the report and consider making changes, and he confirmed that a review of adult protection policies was already underway.

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