Toronto's ombudsman has released a report into the fire that forced people from their apartments at 200 Wellesley St. E., two years ago, calling for major changes in how the city provides services in the aftermath of an emergency.

The fire broke out on Sept. 24, 2010, forcing 1,700 residents to flee the high-rise building.  They were kept out of their apartments for months.

In her report released Thursday, City of Toronto ombudsman Fiona Crean said her investigation "found that a lack of communication at all levels caused significant confusion in the provision of assistance."

Five children and three firefighters were among 17 people who were injured in the fire, which the Ontario Fire Marshal's Office believes was caused by a combination of careless smoking and the hoarding of paper in one apartment.

But Crean says the confusion surrounding the evacuation caused terrible harm to residents who — in many cases — are not able to look after themselves.

"These residents are among the most marginalized in our community," Crean said in a news release. "Many of them had nowhere else to go, were severely limited financially, and many had mental health or physical disabilities."

It was the city's Emergency Planning Unit that was responsible for providing temporary shelter, food and other services.

Crean says the EPU failed.

Among the problems, Crean says, were differences between EPU and Toronto Community Housing over who was in charge; some residents being told — incorrectly — that they would have to bathe and change their clothes before being allowed into a hotel; lack of medical care at an emergency overflow centre; and a decision by the city's Office of Emergency Management to decline to get involved during the early stages.

Crean makes 14 recommendations on how to prevent similar problems in the future, including better definition of the roles of EPU and OEM; that a single point person be placed in charge during emergency human services responses; and that evacuees be given timely, accurate information "to the extent possible."

The ombudsman said her investigation did not look into the provision of assistance to the 1,700 people but, she pointed out, "more than a year and a half after the fire, the city is still without a protocol for caring for vulnerable residents after an emergency. The need for such a protocol is among the most important of my recommendations coming out of this investigation."