WINNIPEG -- A review of Manitoba’s largest and deadliest long-term care home outbreak has found more could’ve been done to prepare and respond to COVID-19.

The highly anticipated report went public Thursday as Maples care home continues to face scrutiny.

External reviewer Lynn Stevenson’s 74-page report found the care at Maples to be more than reasonable prior to the pandemic.

In early November, it went into crisis mode.

“It is a little bit like a bush fire,” said Stevenson. “Once it starts going, it really grabs hold.”

The report found a lack of urgency by Revera, the company that runs the place, to call for reinforcements.

It also identified gaps in pandemic planning at multiple levels.

“The pandemic plans, while they were very robust and comprehensive, did not take into consideration what happened at Maples which was the precipitous and significant loss of staff over a very short window of time,” said Stevenson.

An outbreak declared Oct. 20, 2020, lasted until Jan. 12, 2021.

During that time 74 staff, and 157 residents tested positive for COVID-19. Fifty-six residents died after contracting the virus.

“This was a tragedy for the residents, their families and for the staff caring for them,” said Health Minister Heather Stefanson.

The provincially commissioned review was prompted by a paramedic’s anonymous Reddit post, flagging what they described as nightmare conditions.

On Nov.6 multiple ambulances were dispatched to the care home to treat 12 patients. Eight seniors died in a matter of 48 hours.

The report said it was only at that time that the Winnipeg Regional Health Authority, which oversees long-term care homes in the city, became aware of the magnitude of the crisis.

The report makes 17 recommendations ranging from revised pandemic planning to more funding for long-term care.

Critics and some family members of those who died say the findings don’t go far enough.

For Larry Baillie, the external report into the outbreak at Maples care home falls short.

His dad Glen is one of the residents who died after contracting COVID-19.

“Why did this facility have 56 deaths?” Baillie said. “This didn’t answer it.”

Opposition politicians said the report fails to address why the provincial government didn’t act faster.

“How can the government release a document saying they were only aware of staffing problems on Nov. 6 and yet at the same time give us documents clearly showing in black and white that they knew there was a problem prior to Nov. 2?” asked NDP leader Wab Kinew, referring to ministerial briefing notes obtained by the party through a freedom of information request.

Liberal leader Dougald Lamont said: “This report ignores all the ways this government failed to get ready, failed to put money in.”

Sheryl Lourenco’s mom still lives at Maples. While her mom didn’t end up getting COVID-19 and has received her first dose of the vaccine, Lourenco wants to see improvements.

“I want the recommendations to be fulfilled 100 per cent,” said Lourenco. “It’s very sad. I feel for all the families that have lost a loved one. I’m very fortunate.”

Wendy Gilmour, Revera’s senior vice president of long-term care, called the report fair and thorough. In an emailed statement, Gilmour said the company is looking forward to working with the Manitoba government and WRHA to implement the recommendations at its care homes.

Stefanson said a team has been formed to make sure all 17 recommendations are implemented.

“I think what is important here is we learn from mistakes and make things better for staff and families,” Stefanson said.

Stevenson, meantime, said she can’t say for certain if the recommendations she’s making would’ve prevented deaths.

The NDP is calling for a public inquiry into the Maples outbreak.

Gina Trinidad, the WRHA’s chief health operations officers, said it’s currently conducting critical incident reviews of all COVID-19 deaths in personal care homes, including at Maples. Those findings are confidential and private and will only be shared with families.

“We will certainly be continuing to work with families and reach out to them and share the specific findings related to their loved one’s care,” Trinidad said.  

The full report can be read here.