1 2 3 4 SARS PUBLIC HEARINGS 5 6 7 8 ******************** 9 10 11 BEFORE: THE HONOURABLE MR. JUSTICE CAMPBELL, 12 COMMISSIONER 13 14 15 16 17 18 Held at: St. Lawrence Market 19 Toronto, Ontario 20 21 22 ******************** 23 24 25 November 17th, 2003

1 APPEARANCES 2 Doug Hunt )Commission Counsel 3 Jennifer Crawford ) 4 5 Ron Bain )Senior Investigator 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

1 TABLE OF CONTENTS 2 Page 3 Introduction by Mr. Justice Campbell 4 4 1) Ontario Nurses' Association and Ontario 5 Public Service Employees Union 7 6 2) Registered Nurses Association of Ontario 64 7 3) Service Employees International Union 78 8 4) Canadian Union of Public Employees 105 9 5) Ministry of Labour 125 10 6) Ontario Hospital Association 148 11 7) Occupational Health Management Services 165 12 8) Occupational Health Clinics for Ontario 13 Workers Inc. 189 14 9) Dr. Peter Strahlendorf 204 15 10) Bernadette Stringer 243 16 11) Lisa Karunakaran 260 17 12) Kathleen Valin 269 18 13) Linda Rumble 281 19 14) Christine Gibson 300 20 15) Jan Nichols 310 21 16) The Toronto Health Coalition and Families 22 Advocating for Reform of the Coroner's 23 Office 321 24 17) Susan Fraser 334 25 Certificate of Transcript 347

1 --- Upon Commencing at 9:00 a.m. 2 3 MR. JUSTICE CAMPBELL: As we begin this second 4 session of Public Hearings, it's important to us to remember 5 again the deaths from SARS of forty-four (44) members of our 6 community. Their deaths and the sacrifices made by the front 7 line workers, all of those who suffered from SARS and all of 8 those who fought it, continue to motivate the work of all of 9 us who are concerned about the outbreak and everyone who 10 investigates it in the search for the facts of what happened 11 and of the lessons we must learn. 12 Beginning in August of this year, a series of 13 newspaper ads and radio announcements invited public 14 submissions from anyone who wished to speak out in public 15 about SARS. From September 29th to October the 1st, we heard 16 thirty-seven (37) presentations and in the next three (3) 17 days, we will hear from the rest of those who asked to be 18 heard in public. 19 It's important to note that those who present 20 at these Hearings are not questioned or cross-examined 21 publicly. This investigation under the Health Protection and 22 Promotion Act is driven by confidential personal interviews. 23 There's no provision for adversary-type hearings and there's 24 no provision for cross-examination. During the course of 25 this investigation questioning, as in any other

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  1  investigation, takes place during the course of the
  2  confidential interviews.  We have followed up in the
  3  confidential interviews with a number of those who presented
  4  at the last sessions and we will continue to do so with those
  5  who presented then and those who present in these sessions.
  6                 We've interviewed about two hundred (200)
  7  people and hundreds of interviews and followup interviews
  8  remain to be conducted.  There is a great mass of documents
  9  to analyze.  
 10                 In order to present the public with a full
 11  account of what happened in the SARS outbreak, in order to
 12  make sensible recommendations for future change, a great deal
 13  of work remains to be done.  It will be approximately a year
 14  before I can be confident that the facts have been thoroughly
 15  enough investigated to support a final report that tells the
 16  public what happened and answers the questions that the
 17  public need to have answered.
 18                 In the meantime, other reports have been
 19  released to the public.  Dean Naylor's excellent report for
 20  the federal government, Learning from Sars: Renewal of Public
 21  Health in Canada, is extremely helpful, provides great
 22  insight and sheds a lot of light on many of the areas under
 23  investigation by this Commission.  Senator Michael Kirbey's
 24  Commission -- senate hearings have produced a similarly
 25  outstanding and very useful report on public health

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  1  infrastructure, after hearing from the wide range of public
  2  health people including some of those involved in the recent
  3  SARS outbreak.  
  4                 Dean David Walker's forthcoming report to the
  5  Provincial Ministry of Health is expected to explore in
  6  detail a number of a research areas with a focus on future
  7  recommendations in the nature of policy lessons learned from
  8  SARS and health systems approach to consider for the future. 
  9  One of our tasks is to integrate the results of all that work
 10  into our detailed investigations the findings and analysis of
 11  the introduction and spread of SARS in Ontario.
 12                 The next two (2) days of public hearings,
 13  tomorrow and Wednesday, and today, will accommodate the
 14  balance of those who asked to make public statements.  During
 15  the daytime session today, we're also having an evening
 16  session, but during the daytime session we'll hear from those
 17  invited by the Commission to explore a fundamental yet
 18  somewhat ignored issue of critical importance.
 19                 And that critical issue is workplace health
 20  and safety.  It is fundamental that we understand that
 21  hospitals are workplaces.  It's fundamental we understand
 22  that hospitals, like all workplaces, are subject to a system
 23  of legal obligations under the Occupational Health and Safety
 24  Act and regulations; that legal system is designed to protect
 25  the health and safety of hospital workers and other health

1 workers; that legal regime depends on the principle of 2 internal responsibility supported by a system of workplace 3 health and safety committees and enforced and supported by a 4 system of inspection and investigation through the Ontario 5 Ministry of Labour. 6 The application of workplace health and safety 7 principles in hospitals during the SARS outbreak will provide 8 a focus for most of the daytime presentations today. This 9 evening, we will continue with presentations by family 10 members and concerned citizens affected by SARS. 11 The first presenters this morning will be the 12 Ontario Nurses Association and the Ontario Public Service 13 Employees Union. 14 MS. LISA MCCASKELL: Good morning, yes, this 15 is on. Good morning, Justice Campbell. I'm Lisa McCaskell, 16 Health and Safety Officer at the Ontario Public Service 17 Employees Union known as OPSEU and with me today is Erna 18 Bujna, Health and Safety specialist for the Ontario Nurses 19 Association, ONA. 20 First of all, I'd like to thank you very much 21 for giving us the opportunity to speak and especially to 22 bring out some of the issues around occupational health and 23 safety which, as you said, have been somewhat overlooked 24 until now. 25 Workplace health and safety is important in

1 any workplace but in a healthcare environment it's doubly 2 important. If workers are not protected from health and 3 safety hazards patients and the public are not protected 4 either. It's that simple. 5 If workers are not told how to protect 6 themselves they cannot do so. If unions are left out of the 7 process, we cannot play a role in helping our members get the 8 information they need. Workers and their patients died as a 9 result of the SARS crisis. 10 We are pleased to be part of this Inquiry on 11 behalf of our members and hope that our testimony can avert 12 another such tragedy. OPSEU represents a hundred and 13 thirteen thousand (113,000) members including more than 14 twenty-eight thousand (28,000) healthcare workers. Of these, 15 approximately fifteen thousand (15,000) work in hospitals. 16 Most of them, members of regulated health 17 professions such as respiratory therapists, X-Ray 18 technologists, lab technologists, physiotherapists, 19 occupational therapists, diagnostic imaging technologists, -- 20 speech therapists and many others. 21 OPSEU members are also cleaners, office and 22 clerical workers and other non-regulated health workers. ONA 23 is the union that represents forty-eight thousand (48,000) 24 registered nurses and allied health professionals who work in 25 a variety of settings across Ontario.

1 ONA represents about twenty-one thousand, five 2 hundred (21,500) members in the regional municipalities of 3 Durham, York, Peel, Halton and the City of Toronto, the 4 regions most directly affected by SARS. 5 The Workplace Safety and Insurance Board says 6 it -- received one hundred and sixty (160) claims for 7 compensation from healthcare workers who actually exhibited 8 symptoms of SARS and another ninety-eight (98) from 9 healthcare workers who were exposed but did not develop 10 symptoms. 11 Both OPSEU and ONA had members who were either 12 directly or indirectly affected by SARS. Both unions had 13 many members who contracted SARS. Two (2) ONA members died 14 as a result of workplace SARS exposures. In our positions, 15 Erna and I educate and respond to health and safety concerns 16 from our members. During SARS our workload increased 17 significantly. We were inundated with calls for help from 18 our members. 19 We were asked to review the directives and to 20 provide advice and guidance. We did this in hazard alerts 21 and advice on the Union's website and in correspondence to 22 Union representatives. OPSEU and ONA both had 23 representatives who participated in bi-weekly teleconferences 24 with the Ontario Hospital Association, the Ministry of Health 25 and the Ministry of Labour.

1 During the crisis, we heard many frightening 2 stories from staff and from members who risked their own 3 safety and health in order to care for their patients. Many 4 of those workers believe that more could have been done to 5 protect them. 6 We're here to ensure our message is heard loud 7 and clear. SARS, along with other infectious diseases, is a 8 health and safety matter, one that we believe was handled 9 poorly by many employers, by the Ministry of Health and by 10 the Ministry of Labour. Every worker in this province has a 11 right to work in a safe workplace. 12 Although both workplace parties, that is 13 employers and workers, have an obligation to ensure that work 14 is done safely, employers have the greatest responsibility 15 under the Occupational Health and Safety Act. Section 25 of 16 the Act says employers must alert workers to workplace 17 hazards and that they must take all precautions reasonable in 18 the circumstances to protect workers from those hazards. 19 The Ministry of Labour enforces the Health and 20 Safety Act. Under Section 54 of the Act, the Ministry has 21 the power to enter any workplace at any time without warrant 22 or notice. If the Ministry's inspector finds that an 23 employer is violating the Health and Safety Act, the 24 inspector can issue orders for the protection of workers and 25 the employer can be prosecuted.

1 For years there have been reports about the 2 high rate of injury and illness among healthcare workers. 3 Despite these reports, we've witnessed a lack of enforcement 4 and the unwillingness of the Ministry of Labour to exercise 5 its powers under the Health and Safety Act to deal with 6 health and safety problems within the healthcare industry. 7 We believe that if a new workplace hazard has 8 suddenly threatened the lives and health of industrial 9 workers from any sector that the Ministry of Labour would 10 have responded much differently and more aggressively; 11 however, in our experience, for at least the last ten (10) 12 years the healthcare sector has been a low enforcement 13 priority of the Ministry. We have to ask why that is. 14 Perhaps it's because healthcare workers are 15 care givers. Their focus is on patient care; not on 16 protecting or caring for themselves. In the past they've 17 rarely refused unsafe work or even complained about unsafe 18 conditions. They work in a building, the hospital, which is 19 thought to be the safest place to take someone who is ill or 20 injured, so why wouldn't it also be a safe place to work? 21 It should be, but it isn't. In industry, for 22 example, construction workers know their work is dangerous. 23 Health and safety issues are real to them and are something 24 they know they must be concerned about. Why is it that in 25 healthcare, the industry with one of the highest rates of

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  1  injury and illness, that workers, employers and the public do
  2  not have the same awareness?  Why were hospitals a vector of
  3  contagion, not a haven of health?  
  4                 During SARS, healthcare workers realized that
  5  their work is really dangerous.  They realized, in many
  6  cases, that their hospitals wouldn't protect them.  It
  7  highlighted for ONA and OPSEU again how critical the
  8  Occupational Health and Safety Act is in providing a safe
  9  environment for our members.  
 10                 Our presentation today will focus on two (2)
 11  of three (3) main areas:  the directives and the Occupational
 12  Health and Safety Act, focusing on the roles of the Joint
 13  Health and Safety Committees and the Ministry of Labour.  The
 14  third area, infection control policies and procedures, which
 15  we only touch on, is addressed in greater detail in our
 16  written submissions to you and in private interviews.  
 17                 Our intent today is to highlight for you areas
 18  where the directives, poor health and safety practices, and
 19  lack of enforcement may have contributed to the spread of
 20  SARS.  Please note that our written submission contains more
 21  detail and examples than we've included in today's
 22  presentation.  Also, we have not included our preliminary
 23  recommendations today.  They are all included in the written
 24  submission that you have requested from us.
 25                 I'm first going to speak about the directives.

1 Erna then will speak abo -- speak to you about the 2 Occupational Health and Safety Act, the Ministry of Labour 3 and Joint Health and Safety Committees. 4 The first document to the medical community 5 about SARS that we have found is a March 18th letter to all 6 physicians in Ontario. This letter contained a warning about 7 the possibility of SARS coming to Canada. Most importantly, 8 the letter set out infection control measures and advice to 9 healthcare workers about how to protect themselves. 10 As far as we know, none of the information 11 about the protection of healthcare workers was communicated 12 to workers in any healthcare facility. Why would critical 13 information pertaining to the protection of healthcare 14 workers and infection control practices be sent only to 15 physicians? 16 Nine (9) days later on March 27, the first 17 hospital directive was issued to all acute care hospitals in 18 the province. The first directive required staff only in the 19 emergency departments of the GTA and Simcoe County Hospitals 20 to wear N-95 masks. We also call those respirators, so we 21 use them interchangeably, to wear N-95 masks and other 22 protective gear. 23 Workers in the rest of the hospital were not 24 required to take any special precautions to protect 25 themselves.

1 This distinction between what protection was 2 recommended for which groups of workers in the same 3 facilities arose again and again throughout the crisis. Both 4 Unions were constantly trying to establish which workers in 5 which areas were required to wear what personal protective 6 equipment and why. 7 Directives subsequent to the March 27th 8 document came fast and furious. Targeting acute care 9 facilities most often, but also giving direction to long term 10 care facilities, community care access centres, home care 11 workers and physicians' offices. 12 We've categorized the problems with the 13 directives into a number -- number of main areas. I'll first 14 address problems with transparency in the process of creating 15 the directives. 16 For convenience, we're treating the Provincial 17 Operation Centre, the POC, as a source of all of the 18 directives. Although it was never clear if final authority 19 for the directives lay with the POC or the Ministry of 20 Health. The occasional document was even issued directly by 21 the Ministry of Public Safety and Security. The directives 22 were always posted on the Ministry of Health website using 23 Ministry letterhead. But they were signed by the 24 Commissioner of Public Security as well as the Commissioner 25 of Public Health and Chief Medical Officer of Health.

1 The relationship between the Ministry of 2 Health and the POC was not made clear to us. In the early 3 days of the crisis, both Unions had difficulty getting access 4 to the directives at all. Although OPSEU and ONA were 5 involved in teleconferences discussing the directives, it was 6 not until April 7th, almost two (2) weeks after the first 7 directive was released that both Unions gained access to what 8 was called the Ministry of Health Dark Site. This is where 9 directives were posted. 10 Until then both Unions had relied on contacts 11 within the Ontario Hospital Association, the OHA for short, 12 or from Union members to provide them with the directives 13 that were governing the work and the safety needs of 14 healthcare workers. 15 Even when both Unions were issued the password 16 to access the Health Ministry's site, OPSEU and ONA were 17 warned in writing that, quote: 18 "The site is not intended for the general 19 public and is password protected to provide 20 access to healthcare providers associations 21 only." 22 To date, OPSEU and ONA are not sure who 23 exactly was working at the POC, how they were chosen, or what 24 their roles were. This question was raised numerous times at 25 the OHA teleconferences. To date, both Unions still do not

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  1  know.
  2                 Most importantly, ONA and OPSEU did not know
  3  the background and expertise of the people who were drafting
  4  the directives, that directed the daily work of healthcare
  5  workers.
  6                 The OHA teleconferences were often frustrating
  7  for Union representatives who did not obtain answers to
  8  health and safety questions in a timely fashion.
  9                 At the end of April teleconferences were
 10  reduced to once per week.  OPSEU and ONA continued to press
 11  the OHA's representative, Vice-President of Human Resources
 12  Management Services, and the Ministry of Health
 13  representatives to answer questions.
 14                 By the end of SARS-1, both Unions still had no
 15  answers to some of the basic questions such as an explanation
 16  of the POC process and never really knew if OPSEU and ONA's
 17  concerns were heard by the POC.  If a change was made to a
 18  directive, it appeared to address one of our concerns. 
 19  Unions learned of it only when reviewing the new directive.
 20                 Some time in June, the Ministry began to post
 21  the directives on its public site.  To date, ONA and OPSEU do
 22  not understand why the content of the directives was
 23  considered to be top secret and not a public document until
 24  June.  When the directives were changed, either strengthened
 25  or relaxed because there was no rationale offered and because

1 OPSEU and ONA did not know the process being used to 2 determine the changes. The Unions confidence in the 3 directives was diminished. 4 At the teleconference meetings, both Unions 5 repeatedly sought clarification and explanations for the 6 changes, especially when protected measures for workers were 7 reduced. Our Union representative requested that their 8 concerns be taken back to the POC for explanation. It was 9 OPSEU and ONA's position that the directives should always 10 err on the side of safety. 11 Neither Union received answers to questions 12 about relaxing the directives. For example, if workers 13 throughout a facility are required to wear certain personal 14 protective equipment one day and the next day only workers in 15 the Emergency Department are required to wear it, and there 16 is no explanation or rationale offered, it's difficult to be 17 confident that every precaution is being taken to protect the 18 health of our members. 19 This lack of transparency led many of the 20 members to speculate and raise concerns to both unions. 21 Whether the political interference because of the loss of 22 tourism or shortages of equipment had led to the changes or 23 whether, in fact, there were good epidemiological reasons to 24 explain decisions. 25 In summary, the two (2) unions were not privy

1 to the make up and processes of the Provincial Operations 2 Centre, the creation of the directives took place behind 3 closed doors and union input, questions, and suggestions 4 about the directives were seldom recognized. 5 Consequently, neither union could be confident 6 that the directives would adequately protect the health and 7 safety of our members. 8 The next section looks at the incomplete 9 nature of the directives. There were notable gaps in the 10 directives that, in the opinion of both unions and individual 11 workers, could lead to absurd and possibly dangerous results. 12 In some instances, the directives were just confusing. 13 Some workers who had been exposed to SARS were 14 put on what was termed 'working quarantine' and were allowed 15 to work, although they were confined to their homes during 16 time off. No official attempts to accommodate pregnant 17 workers were made and during the first month of the crisis, 18 directives offered remarkably little detail to assist 19 employers and workers to implement them. 20 Following are some examples of gaps in the 21 directives. There were transportation problems for 22 healthcare workers on working quarantine. Healthcare workers 23 on working quarantine were still using public transportation 24 during the crisis. 25 In order to prevent the possibility of further

1 exposure of the public, participants of the OHA 2 teleconferences asked that the Ministry of Health address 3 this in their directives. 4 Screeners, directives were not clear as to the 5 protective equipment that the screeners, those are the first 6 point of patient contact at the hospital, should wear in any 7 facility creating much confusion and anxiety. 8 Pregnant workers. There was no information in 9 any of the directives to address concerns raised by pregnant 10 workers about health effects of wearing the N-95 respirators 11 or about exposure to Ribavirin, one of the drugs being used 12 to treat SARS. 13 Workers, pregnant or not, agreed that wearing 14 the N-95 masks for any length of time caused increased 15 fatigue, probably because of decreased oxygen intake. The 16 mask restricts breathing and increased carbon dioxide levels, 17 the mask restricts successful exhalation because, as you 18 exhale, the air containing carbon dioxide is trapped in the 19 mask and then you breathe it in again. 20 For pregnant workers, breathing is already 21 affected by the pressure of the growing foetus on the 22 diaphragm. The interference in their breathing caused by the 23 mask led to extreme fatigue. The following examples were 24 communicated to OPSEU. 25 Pregnant workers in some cases asked to be

1 accommodated into work areas where they would not be required 2 to wear a respirator for an entire shift. Some employers may 3 have accommodated workers, some refused. In one (1) case, a 4 manager suggested that a pregnant worker, quote: 5 "Try a surgical mask and return to work." 6 In another case, pregnant lab workers were 7 told that they did not need to wear respirators if they had 8 no patient contact. This direction was later rescinded. The 9 other issue that worried pregnant workers was the use of the 10 drug Ribavirin which is known to cause birth defects and is 11 contra-indicated in pregnancy. 12 Workers were concerned that if they became ill 13 with SARS they would not be offered Ribavirin. They were 14 also worried about mixing and administering the drug. This 15 concern affected all healthcare workers who either were or 16 could become pregnant. 17 Next, I'm going to look at some of the 18 improvements to the directives. On April 20th, almost a 19 month into the crisis, detailed direction was given for the 20 first time on matters such as air supply to SARS Units and 21 patient rooms, procedures such as applying and removing 22 personal protective equipment, minimizing patient contact 23 during patient care activities and cleaning. 24 Four (4) days later, a revised directive was 25 released that contained even more detail. These directives

1 offered the first concrete evidence that the POC had begun to 2 recognize that employers, supervisors, and workers did not 3 understand how to implement previous directives. 4 A good example of the kind of detail finally 5 provided was the direction on housekeeping and cleaning 6 measures. Until these directives were issued, there'd been 7 no direction to ensure that adequate cleaning was being 8 performed to protect patients and workers from infection. 9 Some of the details in these directives 10 addressed what is not known about SARS, such as how long the 11 virus lives on hard surfaces. However, some details, are 12 standard cleaning routines that should have been applied when 13 dealing with any droplet-borne infectious illness. 14 Another example of a more detailed directive 15 was the first one for high-risk procedures. Between April 16 15th and 21st, nine (9) healthcare workers at Sunnybrook and 17 Women's Hospital were diagnosed with SARS following exposure 18 to a SARS patient during a long and complex medical 19 intervention. About a week later, the Provincial Operations 20 Centre released directives to address the exposures that may 21 take place during procedures that can produce airborne 22 respiratory secretions carrying SARS. 23 The US Centres for Disease Control published 24 its first SARS-related document concerning aerosol generating 25 procedures March 20th, more than one (1) month earlier. SARS

1 is primarily a respiratory infection, often requiring 2 procedures that generate airborne respiratory secretions. We 3 have to ask why did it take more than a month after the SARS 4 emergency was declared to issue these critical directives and 5 then only after nine (9) healthcare workers were infected 6 during such a procedure? 7 Another example of detail directives were 8 directions for respirator fit testing and respiratory 9 programs. The regulation for healthcare and residential 10 facilities that falls under the Health and Safety Act 11 mandates that a -- quote: 12 "A worker who is required by his or her 13 employer or by this regulation to wear or 14 use any protective clothing, equipment or 15 device shall be instructed and trained in 16 its care, use and limitations before 17 wearing or using it for the first time and 18 at regular intervals thereafter and the 19 workers shall participate in such 20 instruction and training." 21 The regulation also requires that: 22 "Personal protective equipment that is to 23 be provided, worn or used shall be a proper 24 fit." 25 This was the law in the healthcare sector for

1 ten (10) years before the SARS crisis. It appears that some 2 hospitals in Ontario did not apply this part of the law or 3 that some employers and supervisors simply did not know it 4 was the law. 5 We know of only one (1) hospital with a 6 respiratory protection program before SARS. And throughout 7 the SARS crisis, we've heard of many cases where hospitals 8 appeared either to ignore the directives on fit testing or to 9 be aware of them. 10 One example of the confusion about fit testing 11 is found in a June 2003 memo from the Director, Infection 12 Prevention and Control at the University Health Network in 13 Toronto which states, quote: 14 "Canadian regulations have never required 15 fit testing in the healthcare setting." 16 End quote. In the opinion of the unions, this 17 statement contradicts the requirement in the healthcare 18 regulation that requires employers to ensure that, and this 19 is the quote: 20 "Personal protective equipment that is to 21 be provided, worn or used shall be a proper 22 fit." 23 The Occupational Health and Safety Act 24 requires an employer, when appointing a supervisor, to 25 appoint a competent person for the purposes of the Act. This

1 -- this section of the memo just cited caused both unions to 2 question the state of institutional knowledge of and the 3 ability to apply the requirements of the Act in respect of 4 the appointment of competent supervisors. 5 The Ministry of Labour's role is to enforce 6 regulations under the Act. In the case of respirators, the 7 Ministry uses as its enforceable standard the 2002 Canadian 8 Standards Association document, Standards, Selection, Use and 9 Care of Respirators, which requires all Canadian workers to 10 pass a fit test before wearing a respirator. Until the SARS 11 crisis, neither union can find any evidence of the Ministry 12 of Labour attempts to pro-actively ensure compliance with 13 this regulation in the healthcare sector. 14 The lack of pre-existing respiratory programs 15 may have placed workers health at risk when the crisis hit. 16 Respirator programs provide guidance on issues such as who 17 assists with fit testing, where respirators are obtained, the 18 life of the masks, how to determine if they are soiled or 19 damaged, donning and doffing, maintenance and storage, and 20 what to do if a properly fitting mask cannot be found for 21 some workers. 22 MR. JUSTICE CAMPBELL: Just to help me again 23 with something you said at the beginning when you refer to 24 respirators again, masks and respirators mean the same thing? 25 LISA McCASKELL: Indeed, yes, we're using them

1 interchangeably. We think of them as masks but these -- 2 these masks that provide a higher quality of filtration -- 3 MR. JUSTICE CAMPBELL: Thank you. 4 LISA McCASKELL: --- they -- fall in then as, 5 that's -- they're actually defined as respirators. 6 The March 29th directive to acute care 7 hospitals noted the need for respirator fit testing, but 8 didn't say how to do it, who could assist, where respirators 9 were to be found, the life of the masks, how to determine if 10 they're soiled or damaged, how to store, how to put them on 11 and take them off, or what to do if a properly fitting mask 12 can't be found. 13 Directives two (2) days later to GTA long term 14 care facilities and community care access centres, repeated 15 the requirement for fit testing. This is the last mention of 16 fit testing that we can find until a May 22nd -- May 2nd 17 communique from the government that listed mask suppliers who 18 also provide fit testing services. 19 It did not emphasize fit testing nor 20 requirements in the Health Care Regulations or the CSA 21 Standard. 22 It simply said, quote: 23 "Studies document that proper fit testing 24 enhances the effectiveness of masks. 25 Through fit testing employees can learn

1 which type of mask best fits their facial 2 features". 3 Although the Health Ministry began to -- 4 stress fit testing in May, it was much later before 5 workplaces started to implement it. 6 Finally, fit testing began, sporadically due 7 to Union complaints and a nurse's June 6th work refusal. The 8 Ministry of Labour ordered that the nurse be fit tested 9 before being required to work in a workplace that required 10 respiratory protection. 11 Later in June, eight hundred and forty (840) 12 workers at Mt. Sinai were fit tested. Yet OPSEU workers at 13 Lakeridge were still being ordered into high risk areas in 14 June without being fit tested. Some staff were told they 15 could work in high risk areas without a fit test if they 16 didn't move their heads. 17 At Baycrest a June 12th memo to cost centre 18 managers said fit testing will begin in the near future. 19 Ridgepoint trained their fit testing trainers 20 on July 3rd and planned to complete phase one (1) of their 21 program by the end of July. 22 We'd just like you to remember two (2) things; 23 one (1), that this is happening at the end of June and yet 24 the first SARS crisis had erupted in March and also that 25 there had been a legal requirement to do that fit testing for

1 at least ten (10) years. 2 In the next section, I'm going to look at the 3 way that the directives didn't address workers other than 4 nurses and doctors. 5 While nurses reported that the directives were 6 vague, confusing, contradictory and non-specific, the 7 directives at least acknowledged their work. In contrast, 8 many other healthcare workers found nothing at all in the 9 directives to guide them in their specialized work. This was 10 especially true for staff doing critical diagnostic and 11 treatment functions and those in front line clerical jobs in 12 emergency, admitting and critical care. 13 Not until April 20th and 24th were detailed 14 directives released on how to safely enter and exit a SARS 15 patient's room. There was even direction on safely removing 16 specimens -- from a patient room then. These directives gave 17 clear direction on cleaning equipment inside patient rooms. 18 However, besides saying that every effort should be taken to 19 avoid sharing equipment and that disinfection protocols for 20 shared equipment had to be written by Infection Control. No 21 other guidance was given. 22 Consider for example, an x-ray technologist 23 required at times to perform x-rays with a portable machine 24 that is moved from one patient room to the next. Chest x- 25 ray's are one of the critical tools used to diagnose SARS.

1 Some patients had to have daily chest x-rays. Portable x- 2 rays were considered safer since suspect and probable SARS 3 patients would not have to be transported through the 4 hospital to the x-ray department. 5 But how were the technologists to ensure their 6 machines did not become contaminated and carry infections 7 from one (1) area to the next. The machine should be 8 disinfected after each use, but there was no directive to 9 explain how this should be done or if indeed portable chest 10 x-rays were safer at all. Nor was there any consideration 11 with cleaning protocols added to already heavy workloads, 12 what this meant for productivity and workers health. 13 On the other hand, if suspect and probably 14 SARS patients are brought to the x-ray department, how would 15 the -- department be kept uncontaminated and safe for other 16 patients and workers? 17 The cleaning protocols for patient rooms in 18 the April 24th directive are elaborate and time-consuming. 19 What is to be done in other areas of the hospital where 20 patients travel for tests? One assumes that all hard 21 surfaces that patients could touch or cough or breathe on 22 during their time in another department should be 23 disinfected, but, the directives were silent. 24 Another critical and much ignored area was 25 respiratory therapy. These workers, known as RTs, perform

1 diagnostic tests and treat patients with respiratory problems 2 throughout the hospital. Their work includes intubating, 3 which is inserting an airway, for patients who cannot breathe 4 for themselves, maintaining mechanical ventilation for these 5 patients, suctioning respiratory secretions, taking blood 6 samples and assisting with cardio-pulmonary resuscitation. 7 Only after nine (9) healthcare workers had 8 contracted SARS following prolonged attempts to intubate a 9 patient a Sunnybrook Hospital was a directive finally 10 released on May 1st that gave guidance for high risk 11 procedures in critical care areas during a SARS outbreak. 12 Lab workers were also ignored in the POC 13 directives. OPSEU could find no mention of any special 14 precautions recommended to laboratory technologists when 15 working with blood, sputum or other samples from probable or 16 suspect SARS cases. 17 Also invisible in the hospital directives were 18 clerical workers in Emergency and Admitting Departments 19 throughout the hospital. At least five (5) OPSEU clerical 20 workers contracted SARS in the workplace. One of the first 21 indications OPSEU had of this problem was -- this problem 22 with the directives was the April 1st directive to all acute 23 care hospitals which replaced two (2) previous directives. 24 On March 29th, all staff in any part of the 25 hospital in the GTA and Simcoe County acute care hospitals

1 were required to wear N-95 masks. However, the next day, on 2 April 1st, a new directive to all acute care hospitals in the 3 province required staff to wear N-95 masks only when caring 4 for or entering the room of a SARS patient and when in direct 5 contact with patients in intensive and critical areas or 6 Emergency Departments. 7 Direct contact was never defined. On first 8 glance, that would appear to remove the requirement for 9 clerical workers in critical care areas to wear respirators. 10 However, those workers are often a metre or closer to 11 patients as they take information and assist them in a 12 variety of ways. 13 This directive added to the confusion. 14 Another area that raised concerns for us was 15 when employers interpreted directives differently. 16 Throughout the healthcare sector employers interpreted the 17 directives and communicated to their employees how they were 18 to be implemented. 19 While this process is understandable, in many 20 cases that we became aware of, it was not acceptable as 21 sometimes both -- at both -- at times both unions had 22 concerns that certain interpretations of the directives may 23 have placed health and safety of our members at greater risk. 24 The POC was aware of these problems and issued 25 at least two (2) notices on June 3rd and 7th advising

1 hospitals that compliance with the directives is mandatory 2 and that they are not to be breached or modified. We are 3 unaware of any other action taken by the POC to address this 4 problem. 5 The following are examples of interpretations 6 placed on directives by individual facilities. Humber River 7 Regional Hospital, on Friday, March 28th, OPSEU issued a 8 hazard alert reflecting the March 27th POC directive to all 9 acute care hospitals. In it, OPSEU quoted the directive 10 stating, among other things, quote 11 "All staff in GTA and Simcoe County 12 Hospital Emergency Departments and clinics 13 to wear protective clothing, gloves, gowns, 14 eye protection and masks, N-95 or 15 equivalent." 16 Later that same day, OPSEU received a copy of 17 SARS update number 3 distributed by the Director, Employee 18 and Labour Relations at Humber River. It stated that quote 19 "Provincial officials have advised us that 20 the N-95 masks are now required only for 21 staff in positions involved in the care of 22 patients in isolation. For all others, 23 including clinics and Emergency 24 Departments, surgical masks are acceptable 25 protection."

1 When OPSEU followed this up with the Director 2 to find the source of the information that resulted in this 3 contradiction of the existing provincial directive, she said 4 the direction had come from a meeting of something called the 5 West Cluster Management Group, that was associated with the 6 Emergency Management Office. 7 It was unclear if this group was connected to 8 the POC or who the group members were. The Director could 9 provide no name or phone number. We assumed that the 10 hospital update was later changed to reflect the POC 11 directives although we received no formal notification of 12 that. 13 Another example is a June 5th, St. Michael's 14 Hospital e-mail that stated it was not necessary for any 15 staff and physicians other than those identified in the same 16 e-mail to be fit tested, despite the fact that the May 31st 17 POC directives indicated otherwise. 18 In another example, on June the 2nd and 3rd, 19 staff at Mount Sinai in labour and delivery asked management 20 to allow them to wear personal protective equipment as 21 indicated in the May 31st directive. Management told them 22 that there was minimal risk and, therefore, personal 23 protective equipment was not required. 24 Nurses who ignored management and persisted in 25 wearing their personal protective equipment as required by

1 the directives reported being laughed at. The day following 2 the request, a medical student on their unit went home 3 exhibiting classic SARS symptoms following an earlier 4 exposure. The labour and delivery nurses felt that they, 5 their families and the public were exposed unnecessarily to 6 SARS as a result of the hospital's direction. 7 The next area that I'm going to look at is the 8 way that the directives were confusing because they changed 9 rapidly and we weren't told about the changes. It was our 10 experience that the directives were often revised in 11 substantive ways with no explanation or warning. 12 The Ministry of Public Safety and Security 13 recognized this in an April 3rd letter to Ontario Health 14 Facilities which attempted to reassure the parties that the 15 changes were based on, what they called, "updated evolving 16 information". 17 Despite POC recognition that frequent changes 18 were of concern to the hospitals, there seemed to be no 19 attempt to broadcast to all stakeholders when new directives 20 were released. The changes to the directives made from one 21 day to the next were not highlighted or communicated in any 22 way, at least not to the unions representing healthcare 23 workers. 24 We were both forced to regularly check the MOH 25 Dark Site to see if new directives had been posted and then

1 to go over them in excruciating detail to try to understand 2 what changes had been made and to speculate why. 3 The following are a few examples of rapidly 4 changing directives. On March 29th the Ministry of Health 5 issued directives that clearly addressed precautions for all 6 hospital staff. It stated, among other things, for all staff 7 when in any part of the hospital use frequent hand washing 8 techniques, use N-95 or equivalent mask, ensure mask is fit 9 tested. 10 It also clearly outlined additional 11 precautions for staff who visit patient care units or staff 12 having direct patient contact, information about the re-use 13 of masks and gowns and when they must be disposed of and 14 replaced. It also provided direction about infection control 15 methods to follow after each patient contact. 16 On April 1st and 3rd, new directives were 17 issued. They reduced the precautions outlined in the March 18 29th directive. The new directive stated 19 "However, the routine use of gowns, gloves 20 and masks is not required provided the 21 patient is not in respiratory isolation." 22 This directive was released just after we 23 learned at the OHA meeting on April 1st that masks were in 24 short supply. ONA and OPSEU wondered whether employer 25 concerns about not being able to adequately supply masks to

1 all staff may have influenced the POC to change its 2 directives. 3 On May 13th, a new normal directive was 4 issued. It was confusing. The directive only briefly 5 referenced the Occupational Health and Safety Act and stated 6 that fit testing should be initiated immediately. However, 7 it appeared to identify only high-risk areas as needing to do 8 fit testing. 9 On May 31st, the POC released a directive that 10 appeared to offer better protection for workers. However, we 11 believe that the content of this directive should have been 12 issued immediately at the start of SARS II, a week earlier. 13 Both unions question why this important directive was not 14 issued earlier. 15 On June 16th, a new directive for acute care 16 facilities was released reducing the number of areas where 17 healthcare workers were required to wear personal protective 18 equipment. This followed the first ever SARS healthcare 19 worker work refusal. Both unions questioned whether the 20 relaxation of the May 31st directive was an attempt by the 21 POC to avoid further work refusals about personal protective 22 equipment. 23 At times, decisions that were made raised 24 questions that concerns other than worker health and safety 25 and public safety may have influenced the content of the

1 directives. 2 The following is one (1) example that raised 3 suspicions at OPSEU and ONA that the directives and 4 approaches to SARS were not always based entirely on 5 scientific and epidemiological evidence. More examples are 6 given in our written submission. 7 Sunnybrook and Women's Hospital, a June 4th e- 8 mail from the president and CEO stated that the hospital had 9 an issue with, quote: 10 "The appropriate use of full droplet 11 precautions where necessary as opposed to a 12 blanket application of this directive in 13 every area of the hospital." 14 The memo went on to say: 15 "We have consulted GTA teaching hospitals 16 and they agree that the directives need 17 further interpretation. To try and correct 18 this situation, we have sent our very own 19 doctors to work with the Ministry of Health 20 and other infection control practitioners 21 today to revise these directives. The 22 group should be finished their work either 23 today or tomorrow and we expect to have new 24 directives relatively soon." 25 Both unions wonder how Sunnybrook could expect

1 in advance that their input would result in a change to the 2 directives. Additionally, both unions query what scientific 3 evidence Sunnybrook had that they considered to be superior 4 to evidence previously relied on by the Provincial Operations 5 Centre scientists. 6 This ends my part of our presentation. As I 7 indicated, our preliminary recommendations on these issues 8 are contained in the written submissions provided at the 9 request of Justice Campbell. I'd like to point out, though, 10 that our recommendations are a result of the experience of 11 our members in dealing with this crisis and our combined 12 experience as health and safety specialists for our unions. 13 Again, I must emphasize that worker health and 14 safety is paramount. When the system puts healthcare workers 15 at risk, it also puts patients and the general public at 16 risk. We'll continue to make our voices heard to prevent a - 17 - prevent a similar tragedy from occurring. We urge 18 healthcare administrators and authorities to play -- pay 19 close attention to our findings and our recommendations. I'm 20 going to hand it over to Erna now. 21 22 (BRIEF PAUSE) 23 24 MS. ERNA BUJNA: Good morning, Justice 25 Campbell. My section of this presentation is on the

1 Occupational Health and Safety Act, focusing on the roles of 2 the Joint Health and Safety Committees and the Ministry of 3 Labour. During SARS, both ONA and OPSEU provided advice to 4 members about the Occupational Health and Safety Act. 5 The Act sets out the duties of employers and 6 supervisors and the rights and obligations of workers. It 7 also establishes the role of the Joint Health and Safety 8 Committee and the powers of the Ministry of Labour. In 9 addition, we gave advice about the regulation for healthcare 10 and residential facilities. That regulation governs workers 11 and employers dealing with hazards specific to the healthcare 12 sector. 13 For long periods in many workplaces, and for 14 the entire crisis period in others, it appeared to both 15 unions as if the Occupational Health and Safety Act did not 16 exist or at the very least, it was as if it did not apply 17 when the workplace hazard was an infectious illness. The 18 internal responsibility system, although never mentioned in 19 the Occupational Health and Safety Act, is a cornerstone of 20 the health and safety system contemplated by the Act. 21 In theory, all of the parties' rights, duties 22 and obligations combine to create a system that will allow 23 them to resolve health and safety concerns in the best 24 interest of all. Some believe the internal responsibility 25 system is based on the notion that the workplace parties have

1 equal rights and responsibilities and that most health and 2 safety problems can be successfully addressed because it is 3 in the interest of the employer and the workers to have a 4 safe and healthy workplace. 5 However, this approach seems to ignore the 6 reality that workers and the employer do not have equal power 7 and that it is the employer who controls the workplace. Both 8 ONA and OPSEU have a great deal of experience with workplaces 9 in the healthcare sector where the internal responsibility 10 system simply does not work. 11 During SARS, both unions were aware of many 12 instances where there appeared to be violations of the 13 Occupational Health and Safety Act and the healthcare 14 regulation. I want to give you some examples of possible 15 violations. Some employers and supervisors failed to provide 16 sufficient, proper or any personal protective equipment to 17 workers. Some supervisors did not appear to understand their 18 responsibilities to ensure that workers' health and safety 19 concerns were addressed. 20 Some employers gave little or no instruction 21 to affected healthcare workers, especially those whose 22 concerns were not addressed by the directives. Some 23 employers refused to allow joint health and safety committee 24 meetings to address the SARS crisis. 25 Both unions received reports that employers

1 had not reported critical injuries or occupational illnesses 2 to the Ministry of Labour, to the Joint Health and Safety 3 Committee and to the trade union. Neither union is aware 4 that any employer had introduced and implemented a 5 respiratory protection program prior to the SARS crisis as 6 required by legislation. 7 Both unions received reports of employers who 8 had not developed measures and procedures to ensure that the 9 health and safety of pregnant workers was protected. The 10 healthcare regulation requires them to develop special 11 measures to protect pregnant workers. 12 I'm now going to speak about the role of the 13 joint health and safety committees. It is the experience of 14 both ONA and OPSEU that prior to the SARS outbreak the health 15 and safety systems in many hospitals were weak and 16 ineffective. Both unions have received reports about the 17 following kinds of problems. 18 Joint Health and Safety Committees met 19 infrequently or not at all. Health and safety issues were 20 rarely resolved by the committees. Workplace inspections did 21 not take place. Legislated training was not up to date and 22 workplace injuries and illnesses were not reported to either 23 the Joint Health and Safety Committee or the Ministry of 24 Labour as required by the Occupational Health and Safety Act. 25 When the SARS crisis occurred members reported

1 that their employers took the position that there was no role 2 for the Joint Health and Safety Committee. ONA and OPSEU 3 quickly took the position that these committees should meet 4 on an emergency basis to address SARS-related health and 5 safety concerns. Although we regularly gave this advice to 6 local union leaders, very few of them were successful in 7 getting the committees to meet. 8 Even when the Joint Health and Safety 9 Committees did meet, these meetings were often ineffective. 10 Additionally, both unions raised the lack of Joint Health and 11 Safety Committee involvement at our OHA teleconference 12 meetings. Still very few committees met regularly. 13 The following are examples of these problems. 14 On March 26th an ONA labour relations officer for the 15 Scarborough Hospital reported that the union had requested 16 the employer to cooperate and hold emergency meetings of the 17 Joint Health and Safety Committee. 18 OPSEU's local president was making the same 19 request. It wasn't until April 1st that the Scarborough 20 Hospital finally agreed to hold a committee meeting. 21 However, the ONA labour relations officer reports that the 22 first full Joint Health and Safety Committee meeting did not 23 actually take place until April 16th. The hospital was 24 meeting daily with union leaders but did not want to involve 25 the committee.

1 When regular committee meetings finally began 2 in April, OPSEU members reported that a number of issues were 3 dealt with successfully. At North York General, workers 4 reported numerous health and safety concerns that indicated 5 the internal responsibility system was not working. 6 The ONA bargaining unit president called the 7 Ministry of Labour for assistance with various unresolved 8 health and safety issues and was told that these were 9 internal matters and not a violation of the Act. No help was 10 forthcoming from the Ministry. 11 At the Toronto Rehabilitation Institute, ONA 12 received a report that despite requests to meet, the employer 13 refused to acknowledge the need to have a Joint Health and 14 Safety Committee meeting. On June 10th, after a suspected 15 outbreak of SARS originating in the Lakeridge Dialysis Unit, 16 requests by OPSEU members for a Joint Health and Safety 17 Committee meeting were denied. 18 The employer said it did not think a committee 19 meeting was necessary although it did agree to meet with 20 local union presidents. When the union advised the employer 21 it would consult with the Ministry of Labour about this 22 issue, the employer relented and agreed to allow the 23 committee to meet. 24 Toronto Hospital Corporation, part of the 25 University Health Network, North York General, St. Michael's

1 Hospital and Sunnybrook and Women's College Health Sciences 2 Centre all had to be ordered by the Ministry of Labour to 3 consult with Joint Health and Safety Committees on the 4 employer's fit testing compliance plan. 5 At the University Health Network, known as 6 UHN, ONA learned that meetings with the Joint Health and 7 Safety Committee were problematic as the employer did not 8 even have an employer co-chair. ONA learned in April that 9 UHN had cancelled meetings of the committee. 10 At Princess Margaret Hospital where there was 11 a recommended moratorium on meetings, both co-chairs agreed 12 to cancel the April meeting of the Joint Health and Safety 13 Committee. Both unions believed that if the hospital sector 14 had had a properly functioning health and safety system with 15 safety conscious and responsive employers, supervisors who 16 were competent as required under the Occupational Health and 17 Safety Act and active Joint Health and Safety Committees made 18 up of well trained members, a number of problems could have 19 been avoided and perhaps fewer workers would have become ill 20 with SARS. 21 It is our position that as soon as the SARS 22 crisis was recognized, all employers should have active -- 23 acted aggressively to ensure that training, appropriate 24 equipment, and supervision was in place. Joint committees 25 should have been holding emergency meetings to discuss

1 existing infection control measures to protect workers and to 2 discuss and consider the directives coming from the POC. 3 It would have been useful for the joint 4 committees to meet collaboratively with those in charge of 5 infection control to ensure that the directives were being 6 interpreted in a manner that was appropriate for existing 7 conditions in their own facility. 8 Effective Joint Health and Safety Committees 9 would have been able to quickly assess whether -- where the 10 risks of exposure to SARS were greatest and would have worked 11 to ensure that workers understood the directives and could 12 implement them. Effective committees would have known or 13 could have assessed the existing knowledge base in different 14 groups of staff, taking into consideration previous training, 15 education, and languages spoken in order to ensure that the 16 measures in the directives were being communicated 17 appropriately and adequately to staff in every department. 18 Effective Joint Health and Safety Committees 19 could have increased their inspection frequency and 20 participated in ensuring that all workers were properly using 21 personal protective equipment and properly applying safe 22 measures and procedures in their units. 23 In most cases, this ideal scenario did not 24 take place. Much of the time of both unions was spent 25 offering basic education to members and Joint Health and

1 Safety Committee members about their rights under the 2 Occupational Health and Safety Act and the employer's 3 obligation to protect workers' health and safety. Both 4 unions were almost always just trying to get the Joint Health 5 and Safety Committee to meet. 6 I'd like to now speak about the role of the 7 Ministry of Labour. Both unions also had many issues about 8 the Ministry's involvement during the SARS crisis. It is the 9 role of the Ministry of Labour to enforce the Occupational 10 Health and Safety Act and its regulations. It appeared to 11 both unions that there was a deliberate attempt on the part 12 of the Ministry to curtail the enforcement activities of its 13 inspectors from the very beginning of the crisis. OPSEU 14 received a draft protocol dated March 26th that we believe 15 was finalized on April 2nd for all Ministry, district and 16 regional offices. It prohibited any Ministry staff from 17 attending at any SARS affected work site, even in the case of 18 a work refusal. 19 This memo, which we understand to have been 20 operative throughout the crisis instructs Ministry staff who 21 receive a formal worker complaint under the Occupational 22 Health and Safety Act to refer all such complaints to the 23 district manager. The memo stated that in unusual 24 circumstances, the district manager is to contact the 25 regional director.

1 The protocol advises that lawyers at legal 2 service -- services branch and Ministry physicians will be 3 available to provide assistance to the district manager. In 4 bold print, the protocol states: 5 "The district manager will handle all -- 6 SARS complaints personally and over the 7 phone. He or she will not attend the SARS 8 work site personally and will not send 9 another Ministry employee to the 10 workplace." 11 The protocol says workers should be advised of 12 the internal responsibility system or if technical advice is 13 required, the worker should call Tele-Health Ontario. It 14 also stated that work refusals are to be dealt with in a 15 similar manner. 16 ONA and OPSEU found this approach by the 17 Ministry to be one of the most frustrating and possibly 18 dangerous aspects of the SARS crisis. It is also the unions 19 position that a number of events and issues should have 20 triggered Ministry of Labour enforcement activities during 21 the SARS crisis. 22 Even before the crisis hit, there were serious 23 problems with enforcement of the Occupational Health and 24 Safety Act in the healthcare sector. 25 In January 2003, months before the crisis, I

1 and other Ontario Federation of Labour Health and Safety 2 Committee members met with the Director of the Workplace 3 Insurance Health and Safety Policy Branch in the Ministry of 4 Labour and a number of his colleagues to discuss various 5 outstanding health and safety issues. Ministry enforcement 6 was discussed, as was the need for inspectors to have a 7 heightened responsibility to respond when a worker's right to 8 refuse unsafe work is limited as it is in the healthcare 9 facilities. 10 Acknowledging that there were problems with 11 lack of enforcement, the Ministry agreed to arrange a meeting 12 between the Regional Directors and Labour to discuss issues 13 around enforcement. This meeting was held at the end of May 14 during SARS II. 15 The fact that were a large number of 16 healthcare workers who became ill with SARS as a result of 17 workplace exposures should have led the Ministry to 18 investigate. Both Unions believe that if that many 19 industrial workers suddenly developed a life-threatening 20 work-related illness, the Ministry would have launched 21 investigation immediately. The illnesses were constantly in 22 the media as were reports of shortages of equipment including 23 respirators. 24 The requirement for fit testing of the N.95 25 respirators in the March directive and then from May forward,

1 should have led the Ministry to enquire whether fit testing 2 was being done. The Ministry was, or should have been aware, 3 that hospitals may have had no previous experience with this 4 procedure despite requirements that had existed in the Health 5 Care Regulations since 1993. The Ministry of Labour was 6 involved with the production of the directives which should 7 have led to more active scrutiny of their implementation 8 where health and safety was affected. 9 There were repeated requests on the part of 10 OPSU and ONA staff for the Ministry to become involved as 11 both Unions learned that there were breaches of the 12 directives and contraventions of the Act and the Regulation. 13 Calls from healthcare workers to the Ministry about 14 unresolved health and safety concerns should have prompted 15 the Ministry to enforce its powers under Section 54 of the 16 Occupational Health and Safety Act. 17 Additionally, I reported to the OHA 18 teleconference meetings attending by Ministry officials that 19 critical entries were not being reported to the Ministry as 20 required by the Occupational Health and Safety Act. These 21 failures to report should have prompted an immediate Ministry 22 of Labour investigation. 23 I would like to now take you through a 24 chronology of events involving the Ministry of Labour. These 25 events demonstrated to us the Ministry of Labour's lack of

1 involvement throughout the crisis. 2 During the first round of SARS which emerged 3 mid March at the Grace site of the Scarborough Hospital, 4 approximately sixty-four (64) employees, paramedics, clerical 5 staff, nurses and doctors were diagnosed with SARS as a 6 result of workplace exposures. It was documented in various 7 media, popular and scientific, that healthcare workers were 8 contracting SARS. 9 On March 31st, a senior Ministry 10 representative spoke with me about various health and safety 11 issues. The representative was unable to answer questions 12 without first running them by the command centre as he had 13 not seen the directives. We questioned why a key Ministry 14 official had not yet seen the directives. I then sent him 15 the directives as he did not know when he would be receiving 16 them through Ministry channels. 17 On April 1st, I wrote on behalf of ONA to the 18 Ministry of Labour requesting guidance and clarification on a 19 number of SARS related issues; among them the specific health 20 and safety needs of pregnant workers. In its response the 21 Ministry cited the section of the Health Care Regulation 22 relating to reproductive hazards, but offered no guidance on 23 how the specific risk related to SARS were to be dealt with. 24 Early in May the same representative advised 25 me by telephone that the Ministry would not be issuing any

1 special guidance for pregnant workers. This was later 2 confirmed at the Ontario Hospital Association teleconference 3 where attendees were advised that neither the Labour of 4 Health Ministry -- that neither the Labour or Health 5 Ministries would issue a directive on the issue of pregnant 6 workers. As a result, worker anxiety and mistrust could only 7 increase. 8 In that same letter to the Ministry of Labour, 9 ONA also enquired about several other health and safety 10 issues. We asked whether the Ministry would employ a 11 heightened response to our members unresolved health and 12 safety concerns and complaints. Given their limited right to 13 refuse unsafe work under the Occupational Health and Safety 14 Act. 15 On April 15th, the Ministry replied stating 16 that they were responding to concerns, complaints and work 17 refusals. However, the Ministry did not respond specifically 18 to the query on the possibility of a heightened response. 19 On April 11th the bargaining unit president at 20 North York General Hospital reported to ONA that the Ministry 21 of Labour was advising workers that SARS was not a critical 22 injury under the Occupational Health and Safety Act. ONA 23 vigorously opposed this interpretation. 24 It was ONA's position that the Ministry's 25 refusal to recognize SARS as a critical injury under the Act

1 diminished the employer's responsibility to immediately 2 investigate with a view to preventing a recurrence. It also 3 removed a fundamental right under the Act for worker members 4 of the Joint Health and Safety Committee to investigate and 5 prevent further injuries. 6 It was the position of both unions that 7 suspect cases of SARS are an occupational illness under the 8 Occupational Health and Safety Act. It was also our position 9 that probable cases of SARS must be considered as critical 10 injuries under the Act. Employers have an obligation to 11 report critical injuries immediately, both to the Ministry of 12 Labour, to the Joint Health and Safety Committee and to the 13 Union. 14 These reports must also be produced in writing 15 within forty-eight (48) hours. These reports are intended to 16 trigger employer, Joint Health and Safety Committee, and 17 Ministry of Labour investigations with a view to preventing a 18 recurrence. 19 Employers also have an obligation to report 20 all occupational illnesses within four (4) days. The 21 Ministry of Labour had an obligation under its own policy to 22 investigate critical injuries to ensure that employers were 23 taking all precautions reasonable to protect workers. 24 Although the Act is silent on the Ministry's 25 obligation to investigate occupational illnesses, the

1 Ministry's own policy indicates that an inspector shall 2 respond to all reports of occupational illness and or 3 disease. 4 Both unions have been informed that the 5 Ministry of Labour is investigating the two (2) SARS-related 6 fatalities. However, to date, neither union has any 7 knowledge of the Ministry initiating any form of critical 8 injury or occupational illness investigation into what 9 factors contributed to so many workers contracting SARS. 10 And, Justice Campbell, as of two (2) weeks 11 ago, after questioning the Ministry of Labour, they still 12 could not tell us that they have gone in to investigate any 13 critical injuries. 14 At the joint, OHA, Ministry of Health, 15 Ministry of Labour teleconference meetings, ONA repeatedly 16 asked the Ministry of Labour for its position on SARS as a 17 critical injury. Several ministry representatives on -- 18 various dates promised a response, yet none fulfilled that 19 commitment. 20 On May 1st, a Ministry of Labour 21 representative finally informed ONA that the Ministry was 22 taking the position that SARS was not a critical injury. It 23 continued to be ONA's position that the Ministry's 24 interpretation of critical injury was further endangering 25 workers.

1 I asked that ONA's position be taken back for 2 further consideration. She agreed. Later that same day the 3 Ministry's representative contacted me. The only question 4 that had come back from her superiors was, and I quote: 5 "Why do you care?" 6 I explained that among many reasons, the 7 definition of an injury as critical triggers investigations 8 which then should lead to better prevention. Shortly 9 thereafter the Ministry of Labour's provincial physician 10 advised ONA that the Ministry had accepted that probable SARS 11 was, in fact, a critical injury and that it would be calling 12 all healthcare employers to advise them of their reporting 13 obligations under the Act. 14 Between April 15th and 21st, nine (9) 15 healthcare workers at Sunnybrook Hospital were diagnosed with 16 SARS following exposure to a SARS patient during a complex 17 and prolonged medical intervention. These exposures and 18 subsequent illnesses were well-documented in the popular 19 media and shortly afterward in -- scientific journals. 20 In one scientific journal article, the authors 21 speculate on the various reasons that there were so many 22 exposures and illnesses among healthcare workers. All were 23 related to lack of training on how to minimize -- exposures 24 during high risk procedures. 25 One (1) worker was documented as wearing a

1 beard while he had his respirator on. No one had advised him 2 to shave it. There had been no fit testing of respirators. 3 To date, neither union is aware of any Ministry of Labour 4 investigation into events at Sunnybrook that contributed to 5 this volume of occupational illnesses. 6 On May 22nd and 23rd, news of a new SARS 7 outbreak, SARS II, emerged at St. John's Rehabilitation 8 Hospital and North York General Hospital. It quickly emerged 9 that a number of patients who had SARS had been transferred 10 to other Toronto hospitals. 11 In addition, it was discovered that a large 12 number of healthcare workers had contracted SARS during the 13 time that the initial outbreak appeared to be waning. This 14 news was in the media by the time union representatives met 15 with the Ministry of Labour managers on May 27th. To the 16 knowledge of both unions, the Ministry took no action as news 17 of this situation was revealed. 18 ONA also received verbal reports that 19 healthcare workers at North York General had been reporting 20 the unusual patient illnesses to their supervisor. Workers 21 reported that they were cautioned that they were overreacting 22 and no action was necessary. 23 This indicated to both unions that the 24 infection control system and the internal responsibility 25 system were inadequate to protect workers as workers reported

1 that their complaints about a hazard to their own health was 2 disc -- were discounted. A total of forty-two (42) workers 3 from North York General were diagnosed with SARS by early 4 June. 5 On May 27th, a number of union representatives 6 met with the director of the Ministry of Labour's 7 Occupational Health and Safety Branch Operations Division and 8 the Ministry's regional directors. Union representatives 9 raised a number of enforcement issues at this meeting. OPSEU 10 and ONA specifically raised the SARS issues again and advised 11 the Ministry that they believed it was not fulfilling its 12 role. 13 Both unions pointed to the number of 14 occupational illnesses, contradictions in the Operations 15 Centre directives, confusion regarding personal protective 16 equipment within the hospital sector, lack of fit testing and 17 lack of training. Both unions strongly advised the Ministry 18 that if it need -- that it needed to get involved more 19 proactively and that it should not rely on POC directives and 20 internal hospital infection control practitioners to ensure 21 workers' health and safety during the SARS outbreak. This 22 meeting had no apparent effect. 23 By June 6th, ONA had received numerous 24 inquiries from individuals seeking answers to their health 25 and safety questions.

1 During SARS II it became apparent to OPSEU and 2 ONA that many employers were not responding to healthcare 3 workers' concerns about their health and safety. Calls from 4 workers about masks not fitting and their fears of exposure 5 lead three (3) of ONA's representatives to call the Ministry 6 of Labour themselves on June 6th, requesting the Ministry to 7 go into North York General and St. Michael's Hospital to 8 issue orders at least around fit testing and supervisor 9 competency under the Occupational Health and Safety Act. 10 On June 6th, an RN who is a member of the 11 Ontario Nurses Association initiated a work refusal because 12 her N-95 mask did not fit her properly. For the first time 13 to OPSEU and ONA's knowledge, the Ministry of Labour became 14 directly involved in the issue of respirators and fit 15 testing. 16 The Ministry inspector determined that the 17 worker refuser -- refusal was valid under the Occupational 18 Health and Safety Act. At the investigation meeting on June 19 9th, the inspector issued orders to the employer with almost 20 immediate compliance dates. The orders required the employer 21 to implement a respirator program for all workers with direct 22 ca -- patient care in the SARS unit, the ICU, the Emergency 23 Department, all employee and patient screeners, and cleaning 24 staff who were entering the rooms of SARS patients. 25 At this meeting it appeared to ONA that the

1 employer's focus was on fit testing and training of nurses 2 and doctors. It was ONA who had to remind the employer that 3 fit testing must include all workers who enter SARS patient 4 rooms. Similar orders were also issued to St. Michael's 5 Hospital. 6 Shortly after this, the Ministry advised ONA 7 that it was going to start targeting all Toronto hospitals 8 regarding the fit testing and training issues, starting with 9 category 3 and 2 facilities. This was almost three (3) 10 months into the outbreak. 11 During all this time it had been reported 12 repeatedly that healthcare workers were one of the groups at 13 highest risk of contracting SARS. Over one hundred (100) 14 healthcare workers at this point had contracted SARS as a 15 result of workplace exposures and two (2) nurses and a 16 physician died. Many more were quarantined as a result of 17 workplace exposures and countless people's lives were 18 disrupted. The emotional and physical toll is yet to be 19 accounted for. 20 In this same week, ONA reported to the 21 Ministry of Labour that we had received complaints that Mt. 22 Sinai was refusing to fit test. ONA requested that the 23 Ministry include Mt. Sinai in the first round of its 24 investigations. On June 11th, I was advised by the Ministry 25 of Labour that they would visit Mt. Sinai either on Friday,

1 June 13th or June 16th. June 13th was later confirmed. 2 On June 10th I wrote to the director of the 3 Ministry of Labour's Occupational Health and Safety Branch 4 Operations Division to follow up on the numerous health and 5 safety issues that had been raised with the Ministry of 6 Labour at the January and May meetings with the Ministry and 7 the Ontario Federation of Labour. To date, ONA has not 8 received a response. 9 On June 12th and 13th, Barb Wahl, ONA 10 President, wrote to the same director asking for more 11 Ministry resources to facilitate the proactive -- 12 investigation. She also wrote regarding the disclosure of 13 information under the Occupational Health and Safety Act 14 about ONA members who contracted SARS and requested the 15 Ministry to investigate forthwith any and all critical 16 injuries. To date, no response has been received. 17 On June 13th, the Ministry of Labour's 18 provincial physician advised ONA that the Ministry would not 19 be doing any more proactive investigations. Despite my 20 questions, the representative would not disclose who, in the 21 Ministry, had made this decision or what had influenced it. 22 It is the position of both unions that 23 critical decisions like these should be a matter of public 24 record. Although the Ministry later resumed some proactive 25 investigations, to all our knowledge, the Ministry never

1 visited Mount Sinai. 2 On June 17th, North York General sent the 3 Ministry an updated list advising them of all occupational 4 illnesses. The unions are not aware of any critical injury 5 investigations initiated by the Ministry at North York 6 General to date, despite this notice having been received. 7 On June 18th, ONA President, Barb Wahl, wrote 8 to the then Premier regarding her concern for member and 9 public safety due to the Ministry of Labour's decision to 10 scale back the proactive inspections and the Ministry of 11 Health's decision to reduce protection to healthcare workers 12 in its June 16th directives. 13 The Premier did respond. However, ONA was not 14 satisfied with the response as it did not, in the union's -- 15 opinion, adequately explain the Ministry of Labour's actions 16 or the Ministry of Health's rationale. 17 On June 28th, one (1) healthcare worker, 18 registered nurse Nelia Larosa, died from SARS following a 19 workplace exposure at North York General Hospital during the 20 second SARS outbreak. The second outbreak was identified May 21 23rd, approximately two (2) months after the first outbreak. 22 The Ministry of Labour has initiated an 23 investigation into this fatality but ONA has not seen a 24 fatality report at this time. While it may be that no one 25 (1) factor will be identified as responsible for this

1 worker's death, both unions must act -- ask, what 2 responsibility the Ministry of Labour may have in this case 3 given its reluctance to investigate previous occupational 4 illnesses, complaints from workers and knowledge of possible 5 violations of the Occupational Health and Safety Act and the 6 Healthcare Regulations. 7 Both unions believe it was ONA's formal 8 complaints in June that finally triggered the issuing of 9 orders in some of the facilities. Both unions believe that 10 if a similar situation had emerged in an industrial setting 11 that the Ministry would have acted swiftly and proactively to 12 ensure that all reasonable precautions were being taken to 13 protect workers from further illnesses. 14 On July 19th, a second registered nurse, Tecla 15 Lin, died of SARS. She had been exposed early in the first 16 outbreak when she had volunteered to work on the SARS Unit of 17 her hospital, Westpark Healthcare Centre. 18 Although little was known about SARS when 19 Westpark opened it's interim SARS Unit, the illness was known 20 to be highly communicable, either by droplet or respiratory 21 transmission. Westpark has a state of the art respiratory 22 unit open in February 2000 featuring negative pressure 23 isolation rooms for highly infectious clients and specific 24 procedures such as protective respirators for staff. 25 The unit is designed to care for patients with

1 complex and multi-drug resistant tuberculosis. Neither union 2 knows if the SARS Unit was housed within that special 3 respiratory unit, however, even if it was not, one would have 4 assumed that Westpark would be one of the safest hospitals in 5 the province in which to care for highly infectious 6 respiratory illnesses given their reputation and their 7 expertise. 8 The unions await the fatality report from the 9 Ministry of Labour which may explain what went wrong. 10 MR. JUSTICE CAMPBELL: I note that you're 11 moving to another topic and I should note that we have 12 another group scheduled to start at ten (10) past 10:00. 13 MS. ERNA BIJNA: I think I've got one (1) 14 more page then I'll be finished. 15 MR. JUSTICE CAMPBELL: So take whatever time 16 you need to wrap it up. 17 MS. ERNA BIJNA: Thank you. OPSEU and ONA 18 have provided you today with many examples of a health and 19 safety system that failed. Our preliminary recommendations 20 can be found in the speaking notes that we have provided to 21 you. 22 Justice Campbell, it is clear to both ONA and 23 OPSEU that if the culture of worker health and safety is to 24 ever improve in the healthcare sector, the culture of health 25 and safety must be changed by this government and its

1 ministries. The Ministry of Health and Long-Term Care, when 2 developing directives -- directives must incorporate health 3 and safety law directly into the directives. 4 The government must also ensure that the 5 Ministry of Labour will enforce the Occupational Health and 6 Safety Act and that they will have the means to do so. The 7 Ministry must ensure that all employers in this province are 8 complying with this most superior legislation. 9 For ten (10) years Ontario's Health Care 10 Regulation has required employers fit test workers before 11 having to don their equipment and despite Section 54 of the 12 Occupational Health and Safety Act which gives the Ministry 13 of Labour the power to enter into any workplace at any time 14 without warrant or notice, we are unaware of any instance 15 prior to June 6th when the Ministry exercised that power and 16 ordered employers to fit test and develop respirator 17 protection programs. 18 In this instance alone it appears that it has 19 taken the Ministry over ten (10) years to finally realize 20 that many employers in healthcare were not complying with 21 this Section of the Regulation under the Occupational Health 22 and Safety Act. 23 Justice Campbell we must ask ourselves, how 24 many other possible violations are not addressed by the 25 Ministry of Labour when enforcement of the Occupational

1 Health and Safety Act in the healthcare sector is not made a 2 priority? How many other workers can be spared the trauma 3 that healthcare workers endured and how many lives could be 4 saved if only the health and safety of workers were 5 everyone's top priority? 6 Justice Campbell, your recommendations can 7 sculpt health and safety into a culture where worker health 8 and safety must be everyone's top priority. When our members 9 safety is protected then the public will also be protected. 10 Thank you. 11 MR. JUSTICE CAMPBELL: Thank you for your 12 presentation. Your presentation reflects a great deal of 13 work and it's easy for anyone to say that there are problems, 14 it's much more difficult to do what you have done in your 15 details and comprehensive analysis supported by some concrete 16 evidence and real examples that illustrate your concerns and 17 the problems they reflect. 18 Your work reflects a significant contribution 19 to this investigation. I thank you for it. Unfortunately, 20 there wasn't time for you to cover all of the material, 21 there's another section in your brief on infection control 22 which is very important as well. 23 The presentation in its entirety will be 24 posted on our website and if it's not up right now, it should 25 be up by the end of the day or shortly thereafter.

1 Thank you again. 2 Next presenter is the Registered Nurses 3 Association of Ontario. 4 5 (BRIEF PAUSE) 6 7 MS. ADELINE FALK RAFAEL: Good morning. My 8 name is Adeline Falk Rafael and I'm the President of the 9 Registered Nurses Association of Ontario. 10 I would like to thank the independent 11 Commission to investigate the introduction and spread of SARS 12 for inviting RNAO to present on the issue of occupational 13 health and safety. 14 SARS was an experience our profession will 15 never forget. Indeed we must never forget. 16 The findings in today's presentation are based 17 on what we heard during and after the SARS outbreak. RNAO 18 supported and advised hundreds of nurses during this period. 19 These findings were enriched by fifteen (15) focus groups and 20 fifty-one (51) additional personal interviews. They reflect 21 a comprehensive view of nursing perspectives from students to 22 direct patient care providers to administrators and educators 23 across all sectors. 24 Our presentation acknowledges that this crisis 25 was unlike any we had experienced before. We, the

1 government, health organizations and healthcare professionals 2 were ill prepared to tackle SARS. Not only did we need to 3 manage an infectious disease whose origin and transmission 4 were initially unknown, but we had to do this from within a 5 depleted healthcare system. 6 We focus today on four (4) themes as they 7 pertain to Occupational Health and Safety: Material 8 resources, human resources, communication and system inter- 9 connectedness and surge capacity. 10 First, material resources. Nurses pointed to 11 major health and safety concerns exacerbated by limited 12 occupational health and infection control resources. During 13 the outbreak, nurses expressed serious concerns regarding the 14 access to and effectiveness of protective gear. They also 15 described the extreme comfort -- discomfort caused by the 16 extended use of face masks. We heard numerous concerns about 17 the quality and timeliness of mask fit testing. We'll begin 18 with the availability of protective gear. 19 Nurses reported diverse experiences in the 20 availability of supplies and equipment to meet the emerging 21 new standards for personal protection and patient safety. In 22 some instances, nurses always had the right equipment, 23 screening processes and assessment clinics were set up, HEPA 24 filters were readily available and SARS units were well 25 equipped. Some hospitals even provided designated dressing

1 rooms and scrubs were provided so staff did not have to take 2 their uniforms home. 3 Other nurses reported significant problems in 4 acquiring much-needed supplies. In the early stages of the 5 crisis and in some occasions, also during the second 6 outbreak, some nurses were expected to re-use masks. Some 7 would break protocol if supplies were lacking and some 8 actually used the same gown more than once. Some units 9 hoarded supplies and many nurses reported inconsistencies in 10 the availability of supplies within their facility. 11 Nurses told us they equated the lack of 12 available supplies with a lack of support. The availability 13 of protective gear was of even greater concern for support 14 staff. Some perceived a pecking order, whereby orderlies or 15 cleaning staff were last on the list and when we raised these 16 issues with employers, the response was that the organization 17 was strictly following provincial directives. 18 Let's move to the mask fit testing. During 19 the second phase of SARS, mandatory mask fit testing began 20 posing additional challenges. The process required 21 industrial specialists to perform precise tests taking thirty 22 (30) to forty-five (45) minutes per nurse and a variety of 23 masks were needed to meet individual safety needs. 24 Consistently, nurses expressed concern about practicing 25 through Phase I of SARS without properly fitted masks. As

1 one acute care staff nurse said, it is disappointing that 2 after twenty-two (22) years of infection control precautions, 3 fit testing has never been considered in hospitals. 4 There was considerable diversity in how the 5 fit testing process was conducted. Some nurses reported that 6 if an appropriately fitting mask was not available, the nurse 7 could not and would not safely work in that clinical setting. 8 Other nurses reported confusion over the fact that employers 9 expected them to work despite failing the mask fit testing. 10 On several occasions, the fit testing process was abandoned 11 because of too many, quote, "failures." 12 And what about the impact of extended use of 13 masks? Nurses were expected to wear masks for entire shifts 14 during the many weeks of the crisis. Despite several 15 requests from RNAO and the SARS Nursing Advisory Committee 16 for hourly breaks so masks could be temporarily removed, most 17 nurses did not have this opportunity and some reported that 18 they worked entire shifts without any break because of 19 staffing shortages. 20 Nurses complained about a constant burning 21 irritation of the throat, tightness in the upper chest, 22 headaches, allergic skin reactions, swollen lips and tongue, 23 dizziness, lethargy, sleep disorders and the exacerbation of 24 other health problems such as asthma. Some nurses reported 25 that they could taste and feel the fibers from the mask and

1 were concerned about long-term implications of prolonged mask 2 use. 3 Indeed, some of these experiences were so 4 acute that we fear some nurses may have experienced oxygen 5 desaturation. The Ontario Ministry of Health and Long Term 6 Care was quick to respond to our concerns and provide -- 7 provided funding for RNAO to work with researchers at the 8 University of Toronto to evaluate the effects, if any, on O2 9 levels resulting from extended use of masks and we know that 10 other important research projects to evaluate the effects of 11 using protective gear are also underway. 12 The second theme we want to talk about today 13 is human resources. We'll begin with the link between 14 staffing shortages and Occupational Health and Safety 15 practices. 16 Staffing needs were barely met even before the 17 SARS outbreak. Some critical care units had increased staff 18 levels following months of concerted effort but most reported 19 continued shortages. 20 Nurses told us that on some shifts agency 21 nurses comprised nearly 50 percent of the overall staffing 22 compliment. Nurses described the pressure they felt to come 23 to work sick and to work double shifts as sick time would not 24 or could not be replaced. 25 Astonishingly, a few nurses told us they were

1 called to come to work even though they reported to their 2 employer that they had a cold a or flu-like symptoms and some 3 of these nurses were later diagnosed with SARS. 4 Pressure from employers was compounded by 5 nurses' personal commitment to care. As one (1) nurse said 6 to us, people were sick and worn down but we all hesitated to 7 phone in sick. We knew we were needed. And a senior nurse 8 administrator added, we were already dealing with a tired 9 staff, resources were tissue paper thin. 10 In long-term care facilities, funding and thus 11 staffing levels is based on the previous year's activity. 12 Thus, staffing shortages were a major issue with any added 13 costs for one (1) area leading to cuts in another. Senior 14 administrative staff from the long-term sector told us that 15 nursing staff responded magnificently to the crisis but 16 warned that this intensity of response could not be 17 sustained. 18 Indeed, SARS only magnified staffing 19 difficulties. As one (1) nurse said, nurse patient ratios 20 are poor at best and this doesn't allow for good infection 21 control. 22 The creation of designated SARS units 23 increased the demand for nurses, met, in most cases, by 24 redeployment from other areas. Hundreds of public health 25 nurses were redeployed to the communicable disease team

1 leaving their regular work unattended. 2 Exhausted nurses became ill, some with SARS, 3 others were quarantined. In one (1) instance, a single case 4 of SARS resulted in the quarantine of a hundred and eighty 5 (180) staff for ten (10) days. SARS also cast a spotlight on 6 the number of nurses working for multiple employers. 7 The great majority of them forced to because 8 of lack of full-time employment. In Toronto, for example, 46 9 percent of casual nurses work for two (2), three (3) or four 10 (4) employers. For home health nurses, the added time needed 11 to pick up personal protective equipment, to review new 12 directives and to spend more time with clients increased the 13 impact of staff shortages. 14 We'll now move to staffing in occupational 15 heath departments. Prior to the SARS outbreak, occupational 16 health and infection control departments were inadequately 17 staffed, juggled competing priorities and encountered 18 difficulties in managing the responsibilities and the roles. 19 Nurses practicing in infection control roles 20 told us that sound infection control practices could not be 21 consistently applied by nursing staff largely due to the 22 nursing workload. These difficulties were magnified during 23 the SARS crisis. 24 The lack of trained and expert infection 25 control practitioners became the most prominent issue as the

1 crisis unfolded. Nurses from other clinical roles became 2 deputized infection control practitioners. 3 How do workloads affect occupational health 4 and safety? Nurses described workloads as heavy with staff 5 working at maximum capacity even before SARS. Nurses cited 6 more patients and greater complexity of care needs as key 7 factors influencing their increased workload. 8 Well before SARS, long-term care facilities 9 witnessed significant increases in resident acuity and public 10 health and home care nurses also reported excessive 11 workloads. All participants agreed that workloads -- 12 workload increased dramatically with SARS. 13 The protective equipment, added fatigue, 14 frequently changing directives, increased anxiety of patient 15 and family members and the added burden of having to carry 16 out non-nursing tasks, all contributed to the horrendous 17 workload. 18 In long-term care facilities, the restriction 19 of visitors also the meant the loss of assistance for 20 residents during meals. Nurses in all sectors continued to 21 work despite extreme fatigue and feeling ill. One (1) nurse 22 noted that the team could not have continued much longer due 23 to exhaustion. 24 Holidays were desperately needed and some were 25 provided but there were no back up resources. In the home

1 care sector, the regular work of case managers was left 2 unattended. Concerns were also raised about the potential 3 for error that occurs when people are exhausted. 4 Nurses were the largest group of healthcare 5 professionals to acquire SARS in the course of providing 6 patient care. The workers' -- Workers' Safety Insurance 7 Board reported that seventy-nine (79) nurses missed work for 8 more than fifteen (15) days due to SARS. 9 As the crisis continued, a few of the nurses 10 shared that sometimes the fear was paralyzing. Of particular 11 concern was the fear of exposure to SARS while carrying out 12 invasive care. Nurses also expressed fear that the 13 protection available to them was inadequate, particularly 14 during prolonged and often emergency procedures such as 15 intubations. This leads us to wonder if the level of 16 exhaustion experienced by nurses contributed to the resulting 17 high level of exposure and contamination. 18 We now move to our third theme, Communication. 19 We heard and experienced the chaos of communication during 20 the first sear -- phase of SARS and witnessed significant 21 system improvements in the second phase. We also heard 22 repeatedly about nurses concerns not being heeded by senior 23 physicians and others in positions of authority, especially 24 but not only during the second phase of SARS. One nurse 25 said:

1 "Nurses were ignored and suppressed by 2 administration and medical staff. They 3 were discounted and considered not to have 4 any knowledge of medical issues. What 5 possible motivation could there have been 6 for not listening to the nurses?" 7 End quote. And a nurse manager asked: 8 "How many nurses raise red flags and are 9 not listened to?" 10 Many nurses still feel that nursing paid the 11 highest price among healthcare workers as a result of being 12 ignored. Breakdowns in communication within and between 13 organizations compromised the health and safety of nurses and 14 others. 15 Moving now to Transparency versus Secrecy. 16 Nurses in all sectors expected open and honest communication 17 during the SARS crisis. The majority of nurses cited 18 significant and serious problems in the quality and content 19 of communication. One (1) frequently cited problem was the 20 provincial directives changed frequently and unexpectedly. 21 Directives would be announced on a Friday in the late 22 afternoon with fewer staff or resources available to 23 operationalize them. 24 Concerns were also expressed that the input 25 from providers was absent in the design of directives, a

1 factor that made implementation more difficult. 2 Many nurses, particularly direct care 3 providers, expressed concern about, quote: 4 "Too many secrets." 5 They reported that the seriousness of some 6 situations was not openly conveyed to everyone. In one 7 example, nurses who assisted with a bronchoscopy procedure on 8 a patient diagnosed with a viral illness, subsequently, found 9 out that the procedure was done to rule in or out the 10 diagnosis of SARS. 11 In some settings nurses were told they could 12 not know how many patients and staff had acquired SARS due to 13 confidentiality reasons, while other organizations provided 14 the data readily without compromising patient 15 confidentiality. 16 Several nurses expressed concern, reporting 17 that they could no longer trust their employers or some 18 members of administration to tell them what was going on. 19 Managers reported being well informed of issues and changes; 20 however, being over-extended with two (2), three (3) and 21 sometimes four (4) units, they barely had time to communicate 22 with their entire staff, let alone take the time to provide 23 individualized support. Some told us how exhausting it was 24 to continually communicate verbally on an individual basis to 25 large numbers of staff.

75
  1                 Finally, system inter-connectedness and surge
  2  capacity.  System-wide we heard about problems in
  3  coordinating decision making and directives between and
  4  within sectors.  The result was considerable confusion, as
  5  all sectors moved to contend with SARS.  Other programs and
  6  patients and residents who rely on those programs were
  7  neglected.  
  8                 Nurses described how the restrictions imposed
  9  during SARS significantly affected the quality of the care
 10  they were able to provide.  Over all, nurses described a
 11  system stretched beyond its capacity as it struggled to deal
 12  with SARS, a system significantly lacking necessary surge
 13  capacity.  
 14                 Public Health Nurses expressed concern over
 15  how SARS influenced their ability to maintain the health
 16  promotion and illness prevention aspects of their practices. 
 17                 They commented that SARS was the latest in a
 18  growing list of public health threats that have erupted in
 19  Ontario in recent years.  Others include contaminated water,
 20  increased incidence of TB, West Nile virus and the overall
 21  reduction of public health services and funding since the
 22  early 1990s.  
 23                 These urgent problems direct attention and
 24  resources away from essential promotion and prevention
 25  programs.  Thus the standard or level of services to sustain

1 health are significantly compromised in an environment that 2 too often undervalues health promotion. 3 This crisis was unlike any we had experienced 4 before. We, government, health organizations and healthcare 5 professionals and associations, were ill-prepared to tackle 6 SARS from within a healthcare system weakened from years of 7 funding cuts and a work force exhausted by a decade of 8 relentless structuring -- restructuring. 9 In closing, SARS was an experience that the 10 nursing profession will never forget. The response to SARS 11 exhausted individual nurses and tested the very limits of 12 their professional commitment. As always, nurses rose to the 13 occasion to best serve the public. 14 However, if we want to preserve and enhance 15 this essential profession, and we must, then nurses need 16 reassurances in return. RNAO's complete list of 17 recommendations, seventeen (17) in total, was presented to 18 the Commission on September 29th. 19 At this time, we would like to highlight for 20 you some key reforms that will improve our preparedness for 21 future emergencies and restore the public's and the 22 profession's confidence in our healthcare system. 23 On behalf of the profession and the patients 24 we serve, nurses ask to be listened to and their knowledge 25 acted upon. To be protected through better emergency

1 preparedness, infection control and health and safety 2 practices. 3 Urgently, to improve system capacity, 4 connectedness and communication and immediately to increase 5 full-time employment opportunities and decrease the overtime 6 -- over-reliance on part-time and casual work. 7 In turn, nurses will continue with their 8 unwavering commitment to serve the public in a knowledgeable 9 and caring manner. RNAO is committed to working towards 10 system improvements to ensure nurses and patients are well- 11 protected. 12 Indeed, the Association took a leadership role 13 throughout the SARS outbreak by supporting nurses in all 14 roles and sectors, advocating to their employers for better 15 protection and immediately launching the SARS Nursing 16 Advisory Committee which has now been formalized by 17 government as one (1) of the reference groups. 18 Another example of this Association's 19 leadership is VIANurse, an on-line system funded by 20 government allowing nurses to be immediately redeployed on a 21 voluntary basis to organizations designated emergency status 22 by the Ministry of Health and Long-Term Care. 23 There are many other initiatives that RNAO is 24 leading and we look forward to working with nurses, employers 25 and government, to build a better and stronger healthcare

1 system for all Ontarions. A system that will function well 2 in good times and during emergencies. Thank you. 3 MR. JUSTICE CAMPBELL: Thank you for your 4 presentation. There are a number of details we'd like to 5 follow up with you on later on and are you content that we 6 put your submission up on your website as well. 7 MS. ADELINE FALK RAFEEL: Sure. 8 MR. JUSTICE CAMPBELL: Thank you very much. 9 MS. ADELINE FALK RAFEEL: Thank you. 10 MR. JUSTICE CAMPBELL: We'll take a break now 11 until eleven o'clock. 12 13 --- Upon recessing at 10:41 a.m. 14 --- Upon Resuming at 11:00 a.m. 15 16 MR. JUSTICE CAMPBELL: The -- the next group 17 to present in this section on Occupational Health and Safety 18 is the Service Employees International Union. 19 MS. SHARLEEN STEWART: Good morning, Justice 20 Campbell. My name's Sharleen Stewart. I am the 21 international Canadian vice president of the Service 22 Employees International Union and with me this morning are 23 Rose Ann Clark from North York General Hospital and John Van 24 Beek from SEIU. 25 I want to first thank you, Justice Campbell,

1 for providing SEIU with an opportunity to elaborate on SEIU 2 Canada's concerns about Occupational Health and Safety 3 policies, regulations and enforcement compliance in Ontario's 4 hospital sector. In our first report, we spoke about the 5 importance of due diligence for health and safety procedures. 6 To date this due diligence is still not evident in many of 7 the institutions. 8 I want to again, for the record, state whom 9 SEIU represents; it is critical to understanding our 10 concerns. SEIU Canada represents ninety-thousand (90,000) 11 members across Canada. We are part of Service Employees 12 International Union which has 1.6 million members in 13 healthcare and related industries across North America. 14 In Toronto SEIU represents hospital workers at 15 Sunnybrook Women's College, St. Michael's, Mt. Sinai, 16 Princess Margaret, North York General, Toronto East General, 17 Humber River Regional Hospital, William Osler, Toronto 18 General, Baycrest, Runnymede Chronic Care Hospital and West 19 Park Hospital. In addition, our members also work in nursing 20 homes, retirement homes, home care, and community living 21 settings. 22 As Registered Practical Nurses, environmental 23 and housekeeping staff, clerical workers, dietary personnel, 24 porters, technicians and skilled trade workers, we are too 25 often the forgotten healthcare workers. The critical work

1 our members do in preventing the spread of disease and 2 infection in the hospital environment is often overlooked or 3 undervalued, often characterized as auxiliary services. 4 There is little acknowledgment of the 5 essential roles, both direct and indirect roles, that our 6 members play in providing patient care. The role that our 7 members play on the front lines of the healthcare system is 8 most powerfully underscored by the fact that at least ten 9 (10) SEIU members were diagnosed with and treated for SARS. 10 Hundreds of others were in work quarantine or home 11 quarantine. 12