Inside the Halifax high-rise at the centre of a Canadian COVID-19 tragedy

Gerald Jackson spent his final days with COVID-19 lying just centimetres from another man's bed, separated by a curtain in an eighth-floor room. A third man lay about three metres away.

It was not what Darlene Metzler had pictured for her father, the 21-year navy veteran who loved dancing the jive, singing and travelling on cruise ships.

But Jackson, 84, had been diagnosed with dementia and his medical needs were beyond what home care or assisted living could provide. In May 2019, he moved to a triple-bed room inside the Centre building at the Northwood long-term care facility in Halifax.

In mid-April Metzler got a call: one of her father's two roommates had tested positive for COVID-19. The staffer on the phone told Metzler the COVID unit was full; there was no way to separate Jackson from the others.

"There was only one way to feel, and that was to prepare for the phone call that said my dad is positive," she said.

Metzler and her siblings didn't know that triple rooms existed at Northwood until they learned their father would be placed in one. Now, they place the blame for his death on April 28 on the configuration of the 44-year-old building.

"This was like a hospital room," Metzler said in an interview. "I challenge somebody to walk in that room and tell me that doesn't look like institutional living where seniors are being warehoused."

It is one of many difficult lessons learned at Northwood, where the virus has claimed the lives of 53 residents, making it one of the deadliest COVID-19 outbreaks in the country and accounting for the bulk of the 60 victims in Nova Scotia.

Some families have called for a public inquiry or a class-action lawsuit to examine the facility's decisions, particularly around shared rooms.

For its part, Northwood said it's long been concerned about the issue. For three years, it's had a plan before the province to make all rooms private — a proposal that continues to sit with Department of Health.

Those tight quarters, combined with a crucial misunderstanding by health officials early on of how the virus could spread asymptomatically, proved fatal.

Northwood bills itself as the largest not-for-profit continuing care organization in Atlantic Canada. It dates back to 1962 and a social movement created to help seniors living in poverty. It cares for some of the most frail and vulnerable people in the province.

Its Halifax facility, located off Gottingen Street near the Macdonald Bridge, is made up of three buildings — the Tower, the Manor and the Centre. Their original purpose was not to warehouse seniors, but standards for such residences were different when they were built.

Today, single rooms with ensuite washrooms, grouped around a central living room or kitchen area are preferred — not a possibility in most of Northwood's downtown campus.

Of the three buildings, the Centre is the youngest, dating from June 1976. It's also the building where COVID-19 has raged longest and hardest. It has 297 beds in total. More than half are in double or triple rooms. There are another 188 long-term care beds in the Manor, in both shared and private rooms.

But right now the old arrangements are moot. By late May, Northwood had been able to separate all but 25 of its 485 beds. Some residents have been moved to a hotel.

Space has also opened up for another reason — many who lived at Northwood are now dead.

Northwood has dealt with communicable diseases like influenza and gastroenteritis before, and early in March the facility started taking the same sort of infection control steps for COVID-19. They included cleaning door knobs, handrails and elevator buttons more often, and tracking flu-like symptoms in residents.

On March 12, it restricted visits from families and volunteers who had recently travelled outside Canada. Two days later, it applied the same rule to staff who had travelled internationally and told them to self-isolate. All workers were screened daily for fever and cough.

Then, late in the morning of Sunday, March 15, the province announced its first three cases of COVID-19 and immediately closed long-term care facilities to all visitors. The move was so sudden that some families who had visited Northwood that morning were told not to return later in the day.

At the time, public health officials recommended against healthy people wearing masks. The position was that the virus was only spread by those who were symptomatic, a belief that turned out to be wrong.

In hindsight, Northwood now knows the virus had started spreading and incubating among staff and residents shortly after the no-visitor order was issued.

Northwood CEO Janet Simm said contact tracing later determined an asymptomatic person could have been in the facility as early as mid-March.

It's even possible they were there before the province declared a state of emergency that closed many businesses and limited social gatherings to no more than five people.

At the time, there were outbreaks in the communities of Enfield and Elmsdale, and in the Prestons-Lake Echo-Lawrencetown area. Simm said contact tracing has shown it's "very clear" that's how staff members first became infected.

It is also certain that a significant number — more than 10 — were unaware they had COVID-19 as they worked in different areas of the building.

"It was very, very early on. The symptoms that we're now screening for are very different than what we were screening for way back in early April," said Simm. "So those poor staff had no idea that they were putting residents or co-workers at risk."

On April 5, the first staff person inside Northwood tested positive. The next day, all staff were told to don masks through their shifts — a move that came before the Public Health Agency of Canada issued long-term care guidelines that called for similar measures.

A day later, five residents tested positive, yet only one had any contact with the staff person. It was becoming clear the virus was spreading asymptomatically.

Two wards set aside for COVID-19 patients filled up. Staff soon decided not to shuffle roommates, even if they tested negative. The decision drew sharp criticism from many families but is defended by Simm, who said they quickly learned that even if a roommate of a positive resident had tested negative, chances were they had already caught the virus.

On April 17 and 18, the first three residents died of COVID-19. Dozens of other residents and staff were sick. The facility was no longer able to cope on its own.

The worst weekend

From Toronto, Michele Heath could tell something was wrong. At the beginning of the pandemic the Northwood staff had time every day to set up a video call so Heath and her siblings in Dartmouth, N.S., could chat with their mother, Ruth, a resident of the nursing home.

But that changed as time went on.

It culminated on the evening of April 18, a Saturday, when Heath called the nursing station every quarter of an hour, letting the phone ring until it stopped. No one answered.

"My family and I found that very disconcerting and a clear message that the staff must be run off their feet and just going full out just to try to respond to the needs of the residents," Heath said.

She does not blame staff and believes they took good care of her mother. But two days later the siblings decided to remove her from Northwood, even though it meant taking on an exhausting schedule of 24-7 care.

By that weekend, so many Northwood workers were sick or self-isolating that staffing at times sunk to just "a couple of people" per 33-bed floor, according to Northwood executive director Josie Ryan. The care workers could not keep up.

But the picture changed dramatically that Monday, when reinforcements from the Nova Scotia Health Authority and other nursing homes began to deploy at Northwood.

Ryan explained that day, the tone of relief clear in her voice, that Northwood now had four staff on every floor, plus an occupational therapy and physical therapy team making sure residents were hydrated and had some social time.

"They may not get a shower but their personal hygiene needs are being met," Ryan said.

"So it's been a good day so far this morning."

With the help of more than 40 extra people, the staffing situation stabilized. That weekend, the first resident had been moved to a 29-bed "recovery unit" set up by the province at a nearby hotel.

Regular swabbing of residents and staff in order to test for the virus continued, with the expectation that more cases would be found. By the end of May, Northwood had recorded 345 cases of COVID-19, nearly 30 per cent of them among staff.

Metzler, the daughter of COVID-19 victim Gerald Jackson, is concerned the province has said little so far about whether Northwood will be able to maintain the new arrangement where most residents have single rooms.

"I think we need to keep the momentum going so that people hear that this isn't acceptable, that change is required," she said of shared rooms. "It's not good for infection control measures. It's not good for privacy.

"I don't think it's good for the staff either. My heart goes out to those wonderful caregivers that work there, that are doing the best they can every day with what they have."

Heath, whose family made the decision to move their mother out of Northwood on April 20, said her mother was in a "very small" shared room with one other person.

"I think that's one of the key elements that needs to be examined here," she said. "What should the physical structures look like? How should they be designed to best ensure, certainly, infection control and prevention, but also to create a home-like environment for individuals? Because really that's what I think everybody would like to have for their loved ones."

Heath's family would like to see a public inquiry examining all of the lessons learned during the pandemic: the size and configuration of rooms, the decisions on testing and communications on when to issue personal protective equipment to staff, the compensation for care workers, and how the virus managed to spread so widely in this one particular facility.

Northwood had a full house in the weeks leading up to the outbreak: 17 people were admitted in March, including 11 transferred from the hospital system and six from the community. There were 16 vacant beds, but none in the most in-demand long-term care.

The facility has been worried about the effects of crowding for years. In 2017, it sought $13 million from the Department of Health to add three floors to the Centre building, a change that would allow all residents a single room.

The board of directors of Northwood had concerns about infection control, and was so worried it considered converting some of its affordable seniors housing units into long-term care beds.

The province did not approve the funding proposal in 2017, nor in 2018 or 2019, when Northwood submitted it again.

At the time, influenza was considered the main problem, but the experience with COVID has put those concerns in a new light.

"Influenza is a really huge issue — not necessarily something that the public is aware of, but in long-term care influenza [and] other types of infections in vulnerable populations is something that we deal with every day," Simm said.

Weeks before the first Nova Scotians tested positive for COVID-19, the local NDP MLA, Lisa Roberts, questioned Health Minister Randy Delorey in the legislature about the proposal.

"I know staff continue their discussions with the facility provider as to opportunities," Delorey told the House on Feb. 28. "It would be inaccurate to suggest that the submission was not considered; they continue to have discussions with the provider about their proposal."

Those discussions continue to this day.

Simm said the Department of Health has been "very supportive" of Northwood moving to single rooms, but ultimately the decision on whether residents can keep the private rooms they now have rests with the province.

Both Delorey and Premier Stephen McNeil have said questions about shared rooms will be reviewed once the outbreak is over.

"The work for decisions about the future of what long-term care infrastructure facilities are going to look like, that hasn't, as part of our review, taken place yet. Our focus has been on our response and the care for individuals," Delorey said in an interview.

The 29 Northwood residents who have been living in a hotel for weeks must eventually be placed somewhere. There is not enough space at Northwood to give each a single room, so some will be returning to roommates.

If Northwood returns to its previous configuration, it won't be hard to find people to occupy those shared rooms. According to the health minister, the wait-list for long-term care has grown since the pandemic began from about 1,300 people to 1,400 or more.

Delorey also pointed out that Northwood is not the only facility in the province with multiple-occupancy rooms. It's a feature of many older nursing homes.

The province announced last year the construction or conversion of 162 new long-term care beds, most of them in Cape Breton, and last week said another 23 were coming to the Halifax area. New construction will be to modern standards, but not one of those facilities is ready yet.

Metzler said she worries about a resurgence of the virus, and that flu season is also not far off. She said Northwood residents should not be placed back in shared rooms.

"I get the impact of it backing up the hospital system, for instance, there's probably patients in a hospital waiting for long-term care beds. So then that's backing up the hospitals and so on and so forth. I don't have the answers, but I know what needs to be done."

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