The 1,204-page report submitted by Justice Archie Campbell of the Ontario Superior Court of Justice – SARS commissioner and author of the report – was released to the public Jan.9, and is the last of three previously published reports that dissect the beginning-to-end issues of the outbreak. The first report in April 2004 addressed the problems of Ontario's public health infrastructure, while a second report a year later addressed deficiencies in health protection and emergency response laws.
The final report accuses the government of being completely unprepared to respond to the outbreak of SARS (severe acute respiratory syndrome) – which killed 44 people in the Toronto area. It also points to a failure to protect the health care workers who were on the front lines when the SARS outbreak occurred.
"The lack of preparation against infectious disease, the decline of public health, the failure of systems that should protect nurses and paramedics and others from infection at work – all these declines and failures went on through three successive governments of different political stripes," Campbell wrote.
Systemic problems alleged in the report include:
- Poor internal and external communications;
- Problems with preparation and planning for an outbreak of a virulent disease;
- Accountability issues (who is in charge and who does what);
- Problems with worker and patient safety;
- Infection control, surveillance and lack of independent safety inspections;
- Resource problems including people, money, laboratories and infrastructure; and
- A lack of the application of the precautionary principle that action to reduce risk should not wait for scientific certainty.
Health Care Workers – "Heroes of SARS"
According to the report, 45 percent of Ontario's 375 SARS cases were among health care workers, and two nurses and one doctor died from the disease. Campbell applauded the nurses and doctors and everyone else involved in helping contain the outbreak, calling them "the heroes of SARS."
Campbell called for the ministry to take more of a lead role in the event of future infectious diseases and to include occupational health experts to help contain the outbreaks. Comparing hospitals to mines and factories, Campbell urged the government to institute workplace safety programs in hospitals just as it would in any other hazardous workplace environment.
He also emphasized that recommendations from the previous two reports were not meant to be taken lightly, as the government has implemented only five of the commission's 25 recommendations.
Nurses Pleased with Report Findings
The Ontario Nurses Association hailed the report as "significant and groundbreaking," and one that offers the government the opportunity to dramatically improve the safety of Ontario's hospital workers.
The Ontario government said in a statement that it plans to use the final SARS report "to help further strengthen public health and better protect Ontarians and health care workers."
"The contributions of countless health professionals who helped us cope with SARS will never be forgotten," Health and Long-Term Care Minister George Smitherman said. "It is our job as government to learn from the experience and ensure we will be able to respond rapidly and effectively to any health emergencies. … Ontario's nurses can be assured that their safety is a priority for this government."
To access the report, click here.