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Maplehurst Correctional Complex December 2023 incident

Media release, "Ombudsman to investigate Ontario’s response to incident at Maplehurst Correctional Complex" (June 9, 2025) Investigation into the Ministry of the Solicitor General’s response to a December 2023 incident at Maplehurst Correctional Complex. Announced June 9, 2025. Case update …

Adults with developmental disabilities inappropriately housed in hospitals

Media release, "Ombudsman to investigate cases of people with developmental disabilities who are inappropriately housed in hospitals " (March 27, 2023) Investigation into the plight of adults with developmental disabilities who are inappropriately housed in hospital due to a lack of supports and …

Get me to the court on time

An inmate reached out to us to complain about a rapidly approaching court date. He was scheduled to appear in court in person, but the courthouse was a 15-hour drive away, and facility staff had not made travel arrangements to get him to court. Result: We made immediate inquiries with senior staff …
An inmate reached out to us to complain about a rapidly approaching court date.

A timely response

An individual who sent a complaint letter to the Special Investigations Unit (SIU) came to us for help, saying they had been told the SIU had no formal complaint process or timeline for receiving a response. As a fairness best practice, we generally recommend that public bodies establish a clear …
An individual who sent a complaint letter to the Special Investigations Unit (SIU) came to us for help, saying they had been told the SIU had no formal complaint process or timeline for receiving a response.

A history of violence

An inmate reached out to us after getting in a fight with another inmate. Both had previously been involved in physical altercations with each other, and should have been placed in separate units within the facility to prevent further ones. Result: Our Office spoke with senior staff at the …
An inmate reached out to us after getting in a fight with another inmate.

Urgency overlooked

An injured inmate sought our help with complications related to his eye socket, which had become seriously swollen. He told us he had raised this multiple times with health care staff, who had dismissed his concerns, suggesting it was just swelling and not a cause for alarm. Result: We immediately …
An injured inmate sought our help with complications related to his eye socket, which had become seriously swollen.

Language bridge

A Russian-speaking woman came to us for help in dealing with her daughter’s care through Ontario Health at Home. Since this matter falls under the mandate of the Patient Ombudsman, we referred her to them. However, she struggled to navigate the automated phone system and could not reach a live …
A Russian-speaking woman came to us for help in dealing with her daughter’s care through Ontario Health at Home.

Decades later

A man who was born in Portugal but has been a Canadian citizen for more than 50 years sought our help in renewing his health card. He did not have his original citizenship documents, and the Ontario Health Insurance Plan had extended his coverage to allow him time to get replacements. However, he …
A man who was born in Portugal but has been a Canadian citizen for more than 50 years sought our help in renewing his health card.

Fiscal fumble

A woman complained to us that the Trillium Drug Program made a mistake in calculating her out-of-pocket costs because they used an income tax return from the wrong year. Result: After speaking with program staff, we confirmed they were required to use information from the previous tax year, but …
A woman complained to us that the Trillium Drug Program made a mistake in calculating her out-of-pocket costs because they used an income tax return from the wrong year.

Traditional medicines

An Indigenous inmate told us he had not been able to smudge regularly at his facility, and he wasn’t allowed traditional medicines such as cedar, sage, sweetgrass and tobacco. RESULT: After we intervened, he met with a Native Inmate Liaison Officer and was provided with smudge spray, sage medicine, …
An Indigenous inmate told us he had not been able to smudge regularly at his facility, and he wasn’t allowed traditional medicines such as cedar, sage, sweetgrass and tobacco.

Indigenous healing lodge

An Indigenous inmate complained of repeated delays in response to her requests to see a social worker, so she could apply to an Indigenous healing lodge. RESULT: We spoke with facility officials, who said staffing shortages had resulted in delays. We kept in touch with the inmate, who confirmed she …
An Indigenous inmate complained of repeated delays in response to her requests to see a social worker, so she could apply to an Indigenous healing lodge.

Oversight 911

O N T A R I O n n O N TA R I O ’ S WATC H D O G OVERSIGHT 911 Investigation into how the Ministry of Health oversees patient complaints and incident reports about ambulance services OMBUDSMAN REPORT PAUL DUBÉ, OMBUDSMAN OF ONTARIO MAY 2021 911 1-800-263-1830 www.ombudsman.on.ca O N TA R I O ’ S …
Investigation into how the Ministry of Health oversees patient complaints and incident reports about ambulance services

Missed Messages

O N T A R I O REPORT OF THE FRENCH LANGUAGE SERVICES COMMISSIONER Carl Bouchard July 2024 Missed Messages Investigation into unilingual out-of-home government advertising regarding health services between April 1, 2020 and March 31, 2023 O N T A R I O Missed Messages DIRECTOR, FRENCH LANGUAGE …
During the COVID-19 pandemic, Ontarians turned to the provincial government for important information on protecting their health and that of their families and communities.

Service for a smile

A woman whose daughter had to have an emergency root canal procedure – at a cost of $700 – sought our help in obtaining coverage through Healthy Smiles Ontario, a provincial program that covers dental care for eligible children and youth who are 17 and under. The child’s dentist had not enrolled …
A woman whose daughter had to have an emergency root canal procedure – at a cost of $700 – sought our help in obtaining coverage through Healthy Smiles Ontario, a provincial program that covers dental care for eligible children and youth who are 17 and under.

Action reaction

A woman reached out to us after contacting the Ministry of Long-Term Care’s Action Line with concerns about her mother’s death in a long-term care home. She felt the Ministry had failed to respond to her concerns about the medical care given to her mother, who suffered an infection and dehydration …
A woman reached out to us after contacting the Ministry of Long-Term Care’s Action Line with concerns about her mother’s death in a long-term care home.

Report as required

We received complaints from two inmates at the same facility, alleging they had been sexually assaulted. One inmate complained that they were sexually assaulted by another inmate, and the other complained that they were sexually assaulted by staff. When we inquired with facility staff, we found …
We received complaints from two inmates at the same facility, alleging they had been sexually assaulted.

Privacy protections

We received complaints from a group of 10 inmates, all women, that they were strip searched by correctional officers in their unit, in view of one another. We flagged this case to senior staff at the facility. RESULT: After our intervention, the facility purchased privacy screens to prevent similar …
We received complaints from a group of 10 inmates, all women, that they were strip searched by correctional officers in their unit, in view of one another.

Mistaken identity

A transgender inmate contacted our Office after she was involved in an altercation with correctional officers. When we made inquiries, we learned that the facility’s computer system had not been updated with the correct information regarding the inmate’s gender identity, even though she had …
A transgender inmate contacted our Office after she was involved in an altercation with correctional officers.

Submission to the Ministry of the Solicitor General’s consultation regarding training for peace officers and use of force by police services

Submission to the Ministry of the Solicitor General’s consultation regarding training for peace officers and use of force by police services Paul Dubé Ombudsman of Ontario October 2023 1 Submission to the Ministry of the Solicitor General regarding training and use of force October 2023 Overview …
The Ministry of the Solicitor General has requested public and stakeholder input on various proposed regulations made under the Community Safety and Policing Act, 2019.

Positive test result

A pregnant woman who had tested positive for an infection contacted us when she received the results from Public Health Ontario and realized that the wrong follow-up test had been done. We made inquiries with staff at the Public Health Laboratory, who determined that the woman’s doctor hadn’t …
A pregnant woman who had tested positive for an infection contacted us when she received the results from Public Health Ontario and realized that the wrong follow-up test had been done.