Regina nursing home didn't follow rules in death of Margaret Warholm: Ombudsman

The long-awaited report by the Saskatchewan Ombudsman into Margaret Warholm's care has found that neither health ministry guidelines nor the policies of a Regina care facility were fully followed in her case.

Family blamed Santa Maria home after 74-year-old died last year

The report into Margaret Warholm's treatment was released today by the Saskatchewan Ombudsman. (Submitted by the family of Margaret Warholm)

The long-awaited report by the Saskatchewan Ombudsman into Margaret Warholm's care has found that neither health ministry guidelines nor the policies of a Regina care facility were fully followed in her case.

An investigation into the woman's treatment at Santa Maria Senior Citizen's Home was launched late last year. Warholm suffered a fall in August while being prepared for a bath.

Her health deteriorated and she was taken to hospital where she died three days later, on Oct. 6, at age 74.

Ombudsman Mary McFadyen got involved after concerns were raised by Warholm's family, who said neglect at the home caused Warholm's death.

McFadyen found several instances where the care Warholm received did not meet the Ministry of Health's program guidelines for special care homes nor Santa Maria's own policies and procedures.

"These instances included the way her bedsores were managed, ensuring she had adequate nutrition and hydration, following up on changes in her weight, ensuring safe lifts and transfers, and managing her pain," a news release from the Ombudsman's office said.

The 64-page report makes 19 recommendations to ensure what happened to Warholm doesn't happen again. The investigation has prompted close to 90 similar complaints from families with loved ones in care.

Neither the Ministry of Health nor the Regina Qu'Appelle Health Region is making sure that the Ministry's standards are being met and applied consistently across the region and in facilities throughout the province, the report says.

Santa Maria responds

The Santa Maria facility issued a news release saying it has made 25 changes to improve the health and safety of residents.

"The event that precipitated this report is troubling to all of us at Santa Maria," officials said. "As devastating as this incident has been for us, we know that our concerns pale in comparison to the pain caused to Margaret Warholm and her family. Every one of our residents deserves compassionate, respectful care in a community that puts their safety first."

Santa Maria accepts the Ombudsman's recommendations, it said.

"We know that there are weaknesses in our operations that need to be addressed. We also know that more needs to be done to build a culture that promotes compassion, critical thinking, and personal accountability at every level within our organization."

Health Minister responds

Saskatchewan's Minister of Health, Dustin Duncan, said the recommendations in the report appear to be worthy of follow up.

"Certainly on the face of it there's no recommendations that, on the initial view of them, that we would reject," Duncan said. "We accept the recommendations and we will look to implement them."

Family supports recommendations

Family members of Warholm said the report's recommendations should be followed.

"If the recommendations are carried out then a lot of families are going to maybe rest a little bit easier that their family member won't have to go through what our mom did," Leanna MacFarlane said.

She also advised other families with elderly people in care to be vigilant.

"Just protect your loved ones," she said. "They were there for you, you should be there for them."


To encourage thoughtful and respectful conversations, first and last names will appear with each submission to CBC/Radio-Canada's online communities (except in children and youth-oriented communities). Pseudonyms will no longer be permitted.

By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Please note that CBC does not endorse the opinions expressed in comments. Comments on this story are moderated according to our Submission Guidelines. Comments are welcome while open. We reserve the right to close comments at any time.

Become a CBC Member

Join the conversation  Create account

Already have an account?