A year into waiting for the Social Development Department to move her to a new home, a woman with worsening dementia wandered out of her special care home for the 12th time.

She died after being found unresponsive, having spent all night outside.

It’s an outcome the New Brunswick seniors advocate, Kelly Lamrock, says was preventable,

“I wish I could say that no one saw it coming. But many people saw it coming,” Lamrock wrote in a report issued Wednesday on long-term care.

“There were some, on the front lines, who worried and warned and pleaded for help.”

A year earlier, Social Development acknowledged the woman, identified in the report only as Alice, could not remain at the special care home she was placed in.

WATCH | System failing to respond ‘in a human way,’ advocate says:

Senior wandered off from special care home a dozen times before she died, report says

Seniors advocate Kelly Lamrock’s latest report tells the story of Alice, who died after wandering away from her home. She had been waiting for a spot in a more suitable facility for a year.

Despite that, Alice remained there until her death — with no additional resources or intervention from the department to keep her safe in the meantime.

Lamrock said Alice’s story shows the department is failing to act with urgency when seniors are living in unsafe circumstances.

“I don’t know where the tipping point will be,” he said.

“I know that a woman died. I know that she didn’t have to … I know that it will happen again, unless we change.”

‘Died cold and alone’

Alice had lived in the special care home, which is not identified in the report, for two and a half years before wandering away for the first time.

She was found “disoriented but safe by a highway,” the report said.

After that incident, a physician advised that she needed a higher level protection than what the special care home could offer.

The home asked Social Development to give Alice a new assessment — the department’s process to determine whether someone should go on the nursing home waitlist.

But the advocate found the department never acted on that request.

Five months later, Alice was found on a road after leaving the home again.

The special care home made a second incident report to the department, the report said, prompting the start of an assessment.

It took another month for that process to determine Alice should be relocated — the same recommendation Alice’s doctor made six months earlier.

She was placed on the nursing home waitlist, Lamrock said, but was left to wait in the same home — without any added resources to keep her safe.

In the year before her death, she wandered away 10 times, and seven incident reports were filed to Social Development.

Despite those reports, the advocate found the department did not intervene or offer the home additional support.

The final time Alice left the home, she spent all night outside while police searched for her.

“She largely died cold and alone,” Lamrock said.

“Really, the opposite of the promise we want to make to seniors in our long-term-care system.”

Woman was ‘loved,’ association says

An adult protection investigation found an “allegation of lack of supervision” against the home was not substantiated.

Jan Seely, the New Brunswick Special Care Home Association CEO, said the situation was heartbreaking for everyone at the home.

“My heart goes out to the family, and the people that loved this lady — that also extends to the staff in the home, the residents, the families that would have become close with her,” Seely said in an interview Wednesday.

“People live like a family in our homes, they’re not generally very large.”

Depending on the location, Seely said, delays with assessments happen regularly — even when cases require more urgent action.

“If I have a person that lives in a home and, and they are missing, God forbid, they wander off,” Seely said. “There’s a phone call made to the social worker. There’s … an incident report that is filed, you know, and then you wait.

“Right now, the wait time is far too long. And, as this report has highlighted in this case, you know, 7, 10, 12 incidents [and] still waiting a year. I mean, that’s unacceptable.”

Minister of Seniors Lyne Chantal Boudreau didn’t have an answer for why the department failed to intervene before Alice’s death.

“It was in 2022 … at this time, we want to make sure that it will not happen again,” Boudreau said to reporters in Fredericton.

“It’s hard to understand of course. It’s hard for me to understand also.”

Boudreau noted a survey about security sent to nursing homes in the last month, but she didn’t say whether the department would do anything else in response to the report.

Opposition parties said Alice’s story is not the only case where a person relying on Social Development fell through cracks in the system.

“We’ve got to stop filing reports, and … fix the darn problem,” Progressive Conservative MLA Margaret Johnson said.

“Talk to the people [who are] boots on the ground. People working within these facilities can tell you, ‘If we did this, then this wouldn’t happen.'”

Green Party MLA Megan Mitton said more accountability is needed within the department for failures to protect seniors.

“Some of the recommendations that have actually been made in the past …I see the advocate making again,” Mitton said.

“There’s not a way for people to escalate things, and push back if they’re worried.”