New Brunswick Advocate Kelly Lamrock's stinging report on the province's long-term care system tells the story of 'Alice,' a woman in her 70s living with dementia in a provincial care home.Fred Lum/the Globe and Mail
“I know what to say when the system fails,” New Brunswick Advocate Kelly Lamrock says in the foreword to his latest report. “But what do I say when the system follows its own rules perfectly, and yet someone dies a preventable death?”
The answer to that question comes in the form of a stinging 17-page indictment of the province’s long-term care system, one that seems to have lost sight of that fact that its job is to protect and care for some of society’s most vulnerable.
Even the title is a gut punch: “Death by System: How an Older Adult Died a Preventable Death While Government Followed the Rules.”
In the report, Mr. Lamrock, whose role is to protect the interests of vulnerable populations, tells the story of “Alice,” a woman in her 70s living with dementia in a provincial care home.
Alice lived in the home – which is not named – for 2½ years without incident but, one day, she wandered and was found “disoriented but safe by the side of the highway.”
A physician who examined Alice said she needed to be moved to a more secure home and asked for an assessment that would allow her to get on a wait list. The Social Development department didn’t act on the recommendation.
Five months later, Alice wandered anew, and again escaped unharmed. That triggered an assessment and a recommendation to relocate her – exactly what the doctor said six months earlier.
Long story short, Alice wandered away from the home 10 more times in the last year of her life. The final time, she “died cold and alone,” Mr. Lamrock wrote.
Appallingly, despite Alice’s dementia-related wandering, no additional measures were taken to watch over her, and no efforts were made to relocate her. She festered on a wait list until her horrific death.
“I wish I could say no one saw it coming. But many people saw it coming,” Mr. Lamrock wrote.
But no one did anything, especially the obvious, which was to immediately get Alice out of a care home incapable of caring for her safely. (She was in a level 2 special care home but needed to be in a level 3B long-term care home.)
The rules were followed to the letter, and Alice moved ever so slowly along the bureaucratic conveyor belt, with no one daring to do the sensible thing and move her to the top of the wait list.
After Alice’s death, there was an investigation, which essentially concluded that everyone had done their job to the letter, so no one was to blame.
The infamously ironic phrase springs to mind: “The operation was a success, but the patient died.”
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Mr. Lamrock called that investigation a “rubber stamp procedural necessity instead of a mechanism for accountability and improvement,” a textbook example of what happens when systems care more about procedures than outcomes.
“If a system cannot use common sense and compassion when somebody’s life is in danger, the system is broken,” Mr. Lamrock said.
And broken it is. Not just in New Brunswick, but across the country.
No one knows this better than Mr. Lamrock, who, in his role as New Brunswick Advocate, has produced some astonishingly insightful reports that should be mandatory reading for senior policy-makers and politicians across Canada.
In 2024, he published “What We All Want,” a damning look at the state of long-term care, and “How It All Broke,” a broader look at why health and social welfare systems are struggling.
In the latter report, Mr. Lamrock blames our repeated public policy failures on five governance issues, which can be distilled down to the chapter headings: the lack of effective human resources planning; the curious detachment of the budgeting process from reality; following rules instead of getting results; little data, little analysis, no follow-up; and funding the crisis, starving the solutions.
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In short, systems fail to invest in people and programs that will prevent problems, which invariably leads to endless series of costly crises, big and small.
Every one of those governance failures is clearly visible in Alice’s story. She was a victim of a quagmired culture that values compliance over compassion, inertia over action, and leaves no room for innovation and reform.
“I know that a woman died. I know she didn’t have to,” Mr. Lamrock wrote in his stern analysis of Alice’s death. “I know it will happen again, unless we change.”
But the most chilling words in the “Death by System” report are the first sentence: “It could have been any of us.”