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At the time, patients and their caregivers reported that shipments of medical supplies were arriving late or, sometimes, not at all.

Doctors said that the shortages also affected pain-relief drugs and some medical-assistance-in-dying (MAID) kits, which were showing up incomplete.

While the ombudsman’s report recognizes that聽Ontario Health atHome should have been able to rely on the contracts signed with suppliers, it determined that the provincial agency is accountable for failing to ensure the care of patients during the supply-chain disruption.听

“The Patient Ombudsman observed a lack of focus on the potential impact on patients and their care,” the report read. “Patient Ombudsman did not observe significant engagement with patients or caregivers during the modernization process.”聽

The report also stated there was “significant lack of effective oversight” by Ontario Health and Ontario Health atHome when they revamped聽procurement and delivery systems in the province.

鈥淗ome care is a critical health service and when a disruption leads to patients not getting care, we all lose confidence in the health care system,” Patient Ombudsman Craig Thompson said in the report. “This investigation shines a light on how the disruption directly impacted the health and well-being of patients鈥� and created hardships for caregivers and providers.鈥�

The crisis culminated in the firing of former聽Ontario Health atHome CEO聽Cynthia Martineau in January.听

“Last fall’s supply delivery distribution was unacceptable,” Ema Popovic, spokesperson for Ontario’s Ministry of Health, said in an emailed statement to the Star. “Ontario Health atHome failed in its basic responsibility to patients, caregivers and families.”聽

Popovic said聽Minister聽Sylvia Jones took “immediate action”聽to direct the chair and former CEO of Ontario Health atHome to use “every resource” to resolve the issue while ensuring it doesn’t happen again.听

The access and distribution of medical supplies is now stabilized, she added.听

“Along with new leadership at聽Ontario Health atHome and additional mechanisms in place,”聽Popovic said, “Ontario Health atHome will continue to strengthen their delivery of connected home care services across the province.”聽

Ontario Health deferred questions to聽Ontario Health atHome.听

Ontario Health atHome did not respond to specific questions from the Star, but apologized for the disruptions in .听

“We deeply regret any distress or suffering endured by you, your loved ones, and your care providers who were unable to help you as they wanted to without the necessary supplies,”聽Anna Greenberg, interim CEO of聽Ontario Health atHome, wrote in a statement.听

“Ontario Health atHome remains fully committed to learning from this experience and to continually improving so that the patients we serve receive the high-quality home and community care they need and deserve.”聽

Greenberg said that, over the past year, the agency has conducted a comprehensive review of its medical equipment and supply processes and implemented key improvements.听

The Patient Ombudsman is requiring Ontario Health atHome to respond to the recommendations laid out in the report within the next 90 days, saying it will check with the agency every six months until the recommendations are fully implemented.听