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This is Lysyk's second review of home care this fall. Her first, released in September, revealed that nearly 40 per cent of the money the province spends on CCACs does not go to "face-to-face" treatment of patients. Her latest report shows that spending on home care has grown sharply in recent years, as have demands. Between 2008-09 and 2014-15, the Health Ministry increased home-care spending by 42 per cent, to $2.52 billion from $1.76 billion. Clients served increased 22 per cent, to 713,500 from 586,400.

In the meantime, 70 per cent of CCAC long-stay patients have complex care needs today, compared to fewer than 40 per cent five years ago. There are still no provincial standards for specifying the level of services clients with similar needs should get, a problem Lysyk highlighted in her 2010 report. Because of that, individuals with the same level of need may get five hours of personal support worker care weekly in one part of the province, eight hours in another and 10 hours in a third region. Even within the same region, service levels vary according to time of year. There were nine times more people on a wait list for home care at the end of the fiscal year 2014/15 compared with the beginning of the year in one CCAC, the report noted.

Health Minister Eric Hoskins has said that a major restructuring of the province's health system is on its way and has hinted that Ontario's 14 local health integration networks (LHINs) may take on some of the work now done by CCACs. But Lysyk's report also identifies problems with LHINs, which share the same geographic boundaries as CCACs, and are charged with planning and integrating health services and a local level and delivering provincial funding to them. It says LHINs' marching orders are not clear enough and that performance gaps are widening. For example, patients who no longer needed acute hospital care stayed in hospital more days in 2015 than 2007.

The government is committed to improving home-care wait times and to that end is increasing funding by $250 million this year and in each of the next two years, Hoskins said. Meantime, the report also found that a backlog of inspections of nursing homes, following complaints and critical incidents, is rapidly growing and placing residents at increasing risk.

We found the ministry often did not take timely action to ensure residents were safe and their rights protected," the 773-page report says in reference to those living in Ontario's 630 long-term care homes. It noted that the backlog of complaints and critical incidents had more than doubled - to about 2,800 in March 2015 from 1,300 in Dec. 2013. Critical incidents include neglect, abuse, unexpected or sudden death and misuse of residents' money. The auditor general found 40 per cent of complaints deemed high risk, which should prompt immediate inspections, took longer than three days to be inspected.

he auditor general notes the backlog of complaints and critical incidents regarding long-term care homes has more than doubled in recent years.

The Auditor General found wait times for long-term care that are extraordinary. Crisis clients are waiting more than three months for placement and wait times have tripled.

In Ontario’s privatized clinics (Independent Health Facilities) the Auditor found inadequate monitoring, poor inspections, a lack of financial oversight and inequitable access to care.

Apotex says it feels vindicated by the decision. "Apotex always has been and remains a most trusted partner in the global healthcare community. Apotex is fully dedicated to producing highest quality, safe, and efficacious medicines for all of our global consumers," said Apotex CEO and president Dr. Jeremy Desai in a company press release. Ambrose issued a short statement, but did not address the judge's comments.

In the court challenge, Apotex alleged Ambrose acted with "malice" toward the company and buckled under political pressure after a Star investigation that detailed U.S. regulatory findings of widespread problems in the company's Bangalore facilities. Agents from the U.S. Food and Drug Administration, in reports obtained by the Star, stated they found staff at the Indian plants discarding unfavourable lab results and retesting suspect samples until they yielded the desirable outcome. (The federal court ruling does not make any findings regarding the conditions of the Indian plants.) Pressure on Parliament Hill on the minister mounted after the articles last year, while critics lambasted Ambrose's department as "feeble, inadequate and incompetent."

Apotex, which has decried the costly ban as illegal, has always said its Indian-made products are safe and effective. The federal court ruling by Manson quashed the import ban, though Health Canada had already lifted it about a month ago, allowing the pharmaceutical giant to import its products under strict conditions. The regulator said in September that recent inspections of the two Indian facilities found "satisfactory progress" had been made to address its concerns about the company's data integrity. The ban had lasted 11 months. The court ruling does not say if the strict conditions are still in place. The judge ordered the government to pay at least part of Apotex's court costs, though the decision does not provide specifics. The decision also says that the order for Ambrose and Health Canada officials to retract their public statements related to the import ban shall be done "on terms to be agreed to by the parties."

In announcing the ban last year, Ambrose declared the trust between Apotex and the regulator was "broken." However, the judge ruled the minister's statements, intended to show the public she was taking strong action, were improperly fuelled by political expediency. "If the import ban was motivated by the purpose of protecting health and safety, it is curious that the minister and Health Canada would publicly assure that the banned drug products were safe and at no point issued any recall," Manson said in his decision. The judge found there was no evidence that there were serious health risks requiring the government to invoke an immediate ban without consulting the company.

The regulator had known about the problems at the plants for months and had been communicating with Apotex behind the scenes about what the company was doing to get its facilities up to acceptable standards, the decision said. Meanwhile, just days before the ban, a Health Canada official told Apotex that the regulator's own inspection had given one of the two facilities a passing grade.

For Wendy Armstrong, part of the citizen's group that pressed the auditor general in 2003 to investigate longterm care problems, said Tuesday's followup report was disappointing."There's a huge focus on whether process is being followed," said Armstrong, "and not much of a look at whether seniors are getting proper care on the front line."

Attending the meeting were representatives of two nursing home associations, representing private and not-for-profit homes, a seniors advocacy group and organizations for resident and family councils.

the task force will come up with strong recommendations for change within a few months

The Star stories examined the Health Ministry’s inspection reports and found that residents are routinely abused and neglected in many of the 627 Ontario-licensed nursing homes. The stories analyzed more than 1,500 inspection reports filed since the province rolled out a new system in July 2010, which itself was the result of a 2003 Star investigation into nursing home neglect. Serious problems were found in 900 cases. Of those, roughly 125 were abuse-related, 350 revealed neglect of a senior and the remainder found other types of poor care.

The Star also found that residents are limited to one diaper per eight-hour shift in some homes. That is “not acceptable care,” Matthews said.

After an hour inside a Ministry of Health boardroom, about 10 nursing home leaders left with a commitment to improve conditions inside the homes.

The fastest way to create change, Matthews said, is for families and staff to report every example of abuse or neglect to the ministry’s complaint line. The Star’s stories found many homes tried to cover up their problems by delaying or not reporting incidents to the ministry.

the association that represents Ontario’s 33,000 nurses sent a letter to its members on Friday saying they must report abuse

Grinspun said. “We are telling out members to report, report, report. We will stand by them in every instance where their voice is pushed to silence.”

For the frail elderly and chronically ill, known high-risk microbes

we should aim specifically at zero tolerance for ready-to-eat foods

this is the situation almost three years after the listeriosis outbreak in 2008, when at least 20 people died as a consequence of eating contaminated meats

we still depend on company insiders overseeing inspections with no uniform national standards or process benchmarks

Canadians are usually good at regulation.

Canada needs to adopt rigorous food safety standards that value food safety over profitability,6 and enforce them with higher-quality and more active surveillance and inspection measures that put more emphasis on higher-risk foods.4

Since the crisis, all the hospitals involved have stopped outsourcing gemcitabine and cyclophosphamide mixtures and brought it in-house, mixing their own medications.

Their trust would be further hit. Within two weeks, the Star reported that health-care companies are allowed to mix drugs for hospitals without federal or provincial oversight, prompting top health officials — Ontario health minister Deb Matthews and federal health minister Leona Aglukkaq — to scramble to close that regulatory grey area.

This week Jake Thiessen, the founding director of the University of Waterloo school of pharmacy, submitted a final report of his investigation into the issue. There has been no formal indication when it will be made public. Hospital administrators say they have been told it will be two to three weeks before they or the public see this report.

The Ontario College of Pharmacists has passed legislation that allows it to inspect any premises where a pharmacist works — not just licensed pharmacies.

All of the changes taken together would have seen Marchese Hospital Solutions still able to supply drugs as it did but subject to inspection by the college.

The federal government has new rules defining who can be a drug producer, adding that any facility supervised by a licensed pharmacist can do the job. The province has said that hospitals can only purchase drugs from accredited suppliers.

There is very little clinical evidence to indicate what might happen to a cancer patient who receives an underdose of chemotherapy.

At the same time, many of the more recent advances in chemotherapy have been in drugs that alleviate side effects like nausea.

In an oncology pharmacy, strange is not good. And on March 20, one week before Marley’s last cyclophosphamide treatment, Craig Woudsma, a 28-year-old pharmacy assistant, and a colleague at the Peterborough Regional Health Centre, had a bad feeling.

In this case, it was a shipment of new gemcitabine chemotherapy bags that required refrigeration, according to the label. Previous batches, from a different supplier, had not.

Woudsma noticed more differences. The bags from Marchese only had a total volume and concentration on the label — 4 grams of gemcitabine in 100 mL of saline — instead of the specific concentration, the amount of drug per single mL of saline, as the old bags indicated.

The new bag’s label did not contain enough information for him to accurately mix the patient’s dose. He needed to know the specific concentration.

When preparing the solution, staff at Marchese Hospital Solutions, in Mississauga, Ont., dissolved the medication into a pre-filled 100 mL bag of saline. These bags typically contain between 3 to 20 per cent more solution than 100 mL,

“I told the pharmacist in the area. And then it kind of went above me at that point ... They came to me saying, this is kind of a big deal; teleconferencing with the minister of health, that kind of stuff,” said recently, sitting on the front steps of his red-brick, semi-detached home in the village of Millbrook, Ont. “It’s kind of a foreign concept, to think that what we do, in our corner of the hospital, is going to get that kind of exposure.”

This means that the bag Woudsma was holding contained 4 grams of gemcitabine in more than 100 mL of solution. The concentration of the medication wasn’t what the label would have made him think. It was weaker than advertised.

People have asked Woudsma why he was able to catch a problem that went undetected at other hospitals for more than a year. Simple, he says. He had something to compare it to.

The company’s pharmacy workers did not remove the known overfill when mixing the medication because they thought each bag was going to a single patient

referred to in the industry as overfill, included to account for possible evaporation.

The hospital had switched that very day to a new supplier — Marchese Hospital Solutions. A bag of the old supply from Baxter CIVA was still on site.

Medbuy, a group purchasing company for hospitals, starting in 2008, had a contract with Baxter Central Intravenous Admixtures to provide drug-mixing services. The two drugs in question, cyclophosphamide and gemcitabine, were outsourced because they come in powder form and are tricky to mix. It takes about four hours to reconstitute them in liquid, and in that time they must be shaken every 20 minutes.

As that contract was about to expire, Medbuy issued a request for proposals for drug-mixing services: Baxter CIVA, which wanted its contract renewed, Quebec-based Gentes & Bolduc and Marchese all stepped forward.

The details of the new arrangement remain known only to Medbuy. It was founded in 1989 to get better deals for hospitals buying products like scalpels, bed pans and even some medications in bulk. The company’s 28 member hospital organizations in Ontario, New Brunswick and Prince Edward Island spent a combined $626-million on contract purchases in 2012.

Marita Zaffiro, president of Marchese, testified at Queen’s Park that the Medbuy contract did not indicate the hospitals wanted the labels on these drugs to cite a specific concentration. The reason she included it that way in the RFP was simply to show what could be done.

Sobel ran the calculations in his office. For a single patient to require a 4,000 mg dose of cyclophosphamide, on a common breast cancer treatment regime, that patient would need to be about 7 feet tall and weigh 2,200 lbs.

“The chance of 1,200 patients getting 4,000 mg exactly — it’s just impossible.”

Four Marchese pharmacists who played a role in the new contract work revealed to the Queen's Park committee in June that they had either limited or no background in oncology.

Marchese Hospital Solutions began as Marchese Pharmacy, a Hamilton-area community drugstore that expanded beginning in 1998 when Zaffiro became president. In 1999 the company obtained a contract to supply the Hamilton Niagara Haldimand Brant Community Care Access Centres, business they did until the contract expired in 2011, shortly before it was awarded the Medbuy contract.

It lost the CCAC contract in 2011, shortly before the Medbuy deal, and shed employees. Fifty-seven were either laid off or left the company during this troubled time, according to internal newsletters. But then things started looking up.

Zaffiro attempted to get accreditation for the site, according to her Queen’s Park testimony, approaching both the Ontario College of Pharmacists and Health Canada, neither of which took steps to regulate the fledgling business because each thought the other had jurisdiction.

Medbuy, Marchese and Jake Thiessen have maintained that cost was not a factor in the error. Marchese’s bid on the request for proposal came in at about a quarter of the cost of previous supplier Baxter Corporation. Bags from Marchese cost from $5.60 to $6.60; Baxter charged $21 to $34.

CEO David Musyj thinks about what went wrong. The problems, he says, go far beyond Marchese and Medbuy. “All of us are culpable,” he says. “We could have done some things internally that could have prevented this. We could have weighed the bags when they came in.”

The media is applauding Health Minister Dr. Eric Hoskins this week for promising greater transparency around private clinic inspections that had previously been kept secret by Toronto Public Health and The College of Physicians and Surgeons of Ontario (TCPSO).

They may have learned from the Ottawa Hospital’s ill-timed decision early in 2013 to divest 5,000 endoscopies to the private sector at the same time the TCPSO was making public the list of clinics that failed inspection public – including one Ottawa endoscopy clinic that may have exposed patients to HIV, hepatitis B and hepatitis C from equipment that may not have been properly sterilized.

"We will work to identify new tools that can help us continue to protect patient safety no matter where (patients) are receiving treatment. Ontarians have my commitment as minister that we will do whatever is necessary to protect the safety of patients," he said. TPH told the Star 11 patients contracted the liver-damaging virus during three outbreaks over the last three years; three were infected at the Downsview Endoscopy Clinic on Dec. 7, 2011, three at the North Scarborough Endoscopy Clinic on Oct. 17, 2012, and five at the Finch Ave. W. site of the Ontario Endoscopy Clinic on March 15, 2013. Nine of the 11 infected patients have gone on to develop chronic hepatitis C, meaning the virus has remained in their bodies, placing them at risk of serious, long-term problems, including cirrhosis of the liver and liver cancer. None of the clinics offered up anyone to be interviewed, but all three provided written statements. They all expressed concern for the health and recovery of the patients, said they co-operated fully with investigations and emphasized that they are committed to ensuring outbreaks never occur again. The Downsview Endoscopy Clinic also said it no longer uses multi-dose vials.

Mr. Jetleb blames politics for the problems arising from short staffing. “I think that this is a tragic consequence of bare-bones funding,” he said.

Staff members have complained that they are saddled with an increasing amount of government paperwork and have less time to monitor residents, Mr. Jetleb added.

Karl Rinas, 61, who was treated for a bleeding ulcer at a Leamington, Ont., hospital last February, says he ended up wiping down the bathroom himself after his complaints about the dried liquid waste he found on the floor and toilet seat failed to get a reaction, but he worried about older, less mobile patients.

Despite all her efforts, Martin says she has no doubt that the antibiotic-resistant superbug Clostridium difficile infection her mother contracted soon after surgery was related to the hospital's level of cleanliness.

"I know everybody nowadays has to work more with less, but to me, a hospital should be absolutely clean," she said.

Of the respondents who wrote into the fifth estate's survey about being harmed in hospital, most said the harm was a hospital-acquired infection such as MRSA and C. difficile.

Unlike in the food industry, there are no standardized inspections for cleanliness in hospitals.

A World Health Organization report that compared Canada's infection data with that of 12 other wealthy countries found that Canada had the second-highest prevalence (11.6 per cent) of hospital-acquired infections after New Zealand — much higher than that of Germany (3.6 per cent) or France (4.4 per cent).

Is outsourcing to blame?Those who work in hospitals have pointed to the increased outsourcing of housekeeping in recent years as one reason behind the decline in hospital cleanliness that patients and hospital workers have observed

The Canadian Nosocomial Infection Surveillance Program is the closest thing to a federal overview that Canada has, but it relies on voluntary reporting by only 54 hospitals in 10 provinces, most of them teaching facilities, which, according to infection control experts, generally have higher infection rates than other acute care hospitals because they tend to see more seriously ill patients.

But health authorities in other countries are moving away from private cleaning services. Four years ago, Scotland reversed its decision to allow outsourcing of cleaning and catering services because it felt private contractors were not doing a good enough job keeping the spread of infections in check.

Blamey says as long as housekeeping is done on a for-profit basis, employers will reduce the number of staff and cut corners on staff training and cleaning supplies.

"There's no question there's been an impact on the quality of cleaning, and you can see that throughout the years as various hospitals have struggled with very high-profile superbug outbreaks," said Margi Blamey, spokesperson for the Hospital Employees' Union (HEU), which represents 41,000 hospital cleaning and support staff in B.C.

Michael Gardam, who oversees infection prevention and control at the three hospitals that are part of Toronto's University Health Network, agrees that hospitals have fewer resources for housekeeping these days and have to concentrate cleaning on areas that are most likely to transmit bacteria — primarily the surfaces that multiple patients touch.

"I probably get more emails about dust bunnies in the stairwells than anything else in the hospital, and yet, we've done that for a reason. You're not going to catch anything from a stairwell, but you're going to catch it from your bed rails," Gardam said.

About two-thirds of hospital-acquired infections are preventable, Gardam said, but making a direct link between cleanliness and infection is not as straightforward as it might seem. Some hospital-acquired infections such as ventilator-associated pneumonia or central line-associated bloodstream infections have little to do with the hospital environment and can be controlled through proper protocols around equipment use. But a superbug like C. difficile is a lot trickier because it is hard to pinpoint its source.

Increasing cleaning staff on nights and weekends could also help. A typical medium-sized B.C. hospital that contracts out cleaning services has 24 cleaners by day but only four at night, says Blamey, and workers are often not backfilled when ill or on vacation.

"Bacteria don't care what time it is," said Gardam.

The infection expert says it doesn’t matter whether a private or public entity oversees cleaning; both have had problems with cleanliness. The bottom line is that hospitals generally undervalue the importance of cleaning staff, Gardam said.

"People don't really think of them as part of the team, but if you think about how infections are spread in hospitals, they're actually an incredibly important part of the team that goes far beyond just the cosmetic appearance of the room."

Tory Leader Tim Hudak said it is the role of the government to protect it citizens, not throw up their hands and blame someone else for the chemo drug not being effective.

The proposed changes were prompted by the recent discovery of under-dosing of chemotherapy drugs supplied by an independent company to four hospitals in Ontario and one hospital in New Brunswick.

“It does get a bit complex because under one roof with the operations, they actually have different areas that are doing different activities, and those different activities may actually be under different jurisdictions,” she said.

Marchese Hospital Solutions is technically not a pharmacy, which means it doesn’t fall under the oversight of the provincial government or the college.

“So it’s possible that we need to make sure that oversight and regulations are up to date.”

archese has a pharmacy in Hamilton, Ont., which was inspected by the college in January. Sharma said Health Canada had not visited any of Marchese’s businesses before the diluted drugs came to light, but paid a short visit after.

Outsourcing of medication preparation is a new trend and now’s the time to start looking at how it should be done in Canada, said Sylvia Hyland, chief operating officer of the Institute for Safe Medication Practices Canada.

However, the college is responsible for pharmacists and technicians, including those who may have been working independently for the company.

Marchese has said its products weren’t defective, and suggested that the problem wasn’t how the drugs were prepared but how they were administered at the hospitals.