New Brunswick’s Advocate Releases Report into Preventable Death of New Brunswick Senior, Calls for Urgent Reform

New Brunswick Seniors Advocate Kelly Lamrock today released a report examining the circumstances surrounding the death of an older adult, identified as "Alice," who wandered away from a special care home and later died after not being found in time.

The report concludes that Alice’s death was preventable and highlights significant administrative and governance failures within the long-term care system and the Department of Social Development.

“This introduction would be easier to write if this was wildly unusual. If someone didn’t do their job, or if something got lost, or if something got missed, then I would pinpoint that failure and believe that the system would work to make sure it didn’t happen again. But what do I say when the system follows its own rules perfectly, and yet someone dies a preventable death?”

The report details how Alice, a woman living with dementia, repeatedly wandered away from a special care home that staff and medical professionals had warned could no longer safely meet her needs. Despite repeated requests for reassessment, incident reports, and medical advice indicating she required a higher level of care, she remained in the same placement for more than a year after being assessed as needing significantly more support.

“I wish I could say that no one saw it coming. But many people saw it coming. There were some, on the front lines, who worried and warned and pleaded for help. And there were others who could have seen it coming but just kept moving the file along the bureaucratic conveyor belt, so numbed by the insulating routine of compliance that they couldn’t see the vulnerable person in danger until it was too late.”

According to the report, Alice wandered away from her care home on eleven separate occasions. Seven incident reports were submitted to the Department of Social Development after her reassessment determined she required a higher level of care. No expedited action was taken, and no interim measures were implemented to reduce the risk to her safety.

“The system got eleven warnings from eleven incidents. There would be no twelfth warning. The twelfth incident turned into a preventable death.”

Lamrock said the case reflects broader systemic problems identified in his previous reports, What We All Want and How It All Broke, including a culture that prioritizes compliance with procedures over outcomes for vulnerable citizens.

“In reports like How It All Broke, I’ve warned that our system values compliance over results. People are given steps to follow and processes to adhere to. There is no room to convey urgency. There is no incentive for being the one who warns that people are suffering.”

The report examines delays in reassessment, failures to provide interim supports, shortcomings in departmental oversight, and the inability of existing review mechanisms to identify or address systemic problems.

“Everyone got what they needed from the system. Except Alice. Alice was found alone, and unconscious, and then Alice died.”

The report makes five recommendations to the Department of Social Development, including:

• Creating results-based accountability measures for regional offices and senior leadership;

• Establishing mandatory timelines for reassessment requests;• Requiring consideration and documentation of interim safety measures when vulnerable individuals are waiting for higher levels of care;

• Creating escalation mechanisms for repeated high-risk incidents; and

• Expanding Adult Protection investigations to examine departmental decision-making and oversight, not only the actions of care facilities.

Lamrock said the report is ultimately a call for cultural change throughout government.

“I think it’s possible to create processes that require people to escalate files when the status quo is not good enough. I think it’s possible to change cultures to empower people to speak up when they fill out the forms and can see we are going to fail people. At some point, it takes someone in charge to tell people that the urgency of compassion has to come before the comfort of compliance.”

Lamrock concluded the report by warning that without meaningful reform, similar tragedies will occur again.

“I know that a woman died. I know that she didn’t have to. I know that she died, and the system ran exactly as it was designed to run. I know that it will happen again unless we change. My job is to make sure that they can’t say they did not know.”

Read the Report