Several relatives who spoke to the South China Morning Post on condition of anonymity said they were angry that outbreak protocols were not immediately implemented when the first staff member fell ill.

But the Vancouver Coastal Health (VCH) authority, that oversees Little Mountain, defended its practice of not declaring an outbreak when only one worker was involved, saying on Wednesday that most of these situations did not result in any further cases being detected.

Two relatives who visited Little Mountain after November 20 said they were disturbed they had not been contacted after the subsequent outbreak declaration; nor were they ever advised to get a Covid-19 test.

According to the memo, the first infected staff member had been put in isolation. “At this time, Public Health has determined that there is minimal exposure risk associated with this case. Because of this, the MHO [Vancouver Coastal Health Medical Health Officer] decided against declaring an outbreak,” wrote Angela Millar, Little Mountain executive director.

The memo continued: “Under the direction of the VCH Medical Health Officer (MHO), there will be no change to admissions, re-admissions or transfers of residents. Visitors may continue to visit at Little Mountain Place and group activities can continue without pause.”

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British Columbia had previously been praised for its handling of the pandemic. In a peer-reviewed analysis in the Canadian Medical Association Journal in November, a “key response was that British Columbia revised its threshold of an outbreak to a single case among LTC [long-term care] residents or staff early on. This definition … was quickly incorporated into provincial guidelines”.

But those rules appear to no longer apply at Little Mountain Place or other care homes overseen by the Vancouver Coastal Health authority. Ironically, co-authors of the CMAJ article include at least one VCH officer involved in the handling of the Little Mountain Place outbreak.

In its current guidelines, VCH says that a single case of Covid-19 among staff that does not involve “high-risk exposure” instead triggers a status of “enhanced surveillance and precautions”.

“An outbreak of Covid-19 is not declared during enhanced surveillance and precautions,” say the guidelines, and “notification of all residents, families, staff and other service providers is not required”.

Under the enhanced surveillance protocols, “asymptomatic screening tests for residents and staff should only be implemented under direction of the MHO”.

Little Mountain residents’ relatives, who said they did not want to be identified, said they were stunned by the ensuing outbreak, and what they saw as failures by the facility and VCH.

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“It boggles my mind how these same processes from BC’s first LTC outbreak failed to be implemented at LMP [Little Mountain Place],” said one, referring to the CMAJ article. Her Hong Kong-born grandmother died of Covid-19 in late December.

Not all relatives received the memo; one who forwarded it to the Post said they were only told about it by another family.

Another relative of a resident said they visited Little Mountain Place after the November 20 declaration of enhanced surveillance. But even after the outbreak was officially declared two days later, no one from the care home, VCH or any other authority suggested they should get a Covid-19 test.

Nor were they ever reached by a contact tracer, they said. Ultimately, the visitor decided of their own volition to get a test the next week, which came back negative.

Soon afterwards, their relative at LMP tested positive for Covid-19, and they too died in December.

“If the outbreak was declared on the weekend [of November 22], and I’m visiting within that 14-day incubation period, shouldn’t I be considered?” said the relative. “Shouldn’t they do contact tracing? But instead, [Little Mountain Place] pushes that onto the health authority, whether to decide to do contact tracing.”

The other relative, whose grandmother died, said the family first heard of the outbreak on the VCH website some time after November 22.

And it was not until December 5 that anyone reached out them to tell them about the outbreak, when Little Mountain Place told them of a Zoom meeting about it that night.

“Why didn’t they tell us beforehand? That’s the big mystery,” she said. “We had to call them about the update.”

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Initially, the family was not too concerned; the facility had had an outbreak in March that was confined to two staff, “so we assumed it would be fine”. “The tone was not to worry, ‘things are under control’,” she said.

But about a week later, the family was told their grandmother, aged in her 90s, had tested positive.

To their surprise, the family was able to visit their ailing relative twice the following week, at the height of the outbreak. They did not receive a rapid test before entering, but instead answered a symptom questionnaire, and wore masks, gloves, gowns and a visor.

The relative said she became worried when she saw another resident wearing no personal protective equipment wandering the hallway, before being ushered back to her room by staff. The facing doors to both rooms were open.

“Clearly there was a problem with the protocols because things got so bad,” she said.

She was grateful that she was able to visit her grandmother before she died in the week before Christmas.

But it is the lack of transparency that most concerned her. Even after the initial Zoom calls, there were no written summaries of the infection or deaths tolls. “We felt like we were really kept in the dark,” she said.

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VCH said in response to questions that the enhanced surveillance protocols (ESP) were initiated at Little Mountain on the same day the first worker tested positive, November 20.

In general, the use of ESP status, instead of declaring an outbreak as soon as one staff member tested positive, allowed VCH to best manage its resources, it said.

“Most ESP declarations have not gone on to become outbreaks – that is, no further cases are diagnosed,” said the statement. “Managing these scenarios under ESP has allowed us to apply a full outbreak response to declared outbreaks, which would not be possible if all of our many one-staff scenarios were declared to be outbreaks.”

The health authority said it had not conducted any rapid testing at Little Mountain Place. “PCR tests remain the gold standard for Covid-19 testing,” it said, referring to more-accurate, but slower, polymerase chain reaction tests.

Little Mountain Place has deferred questions about the outbreak to VCH.

In Zoom town hall meetings with relatives that were previously leaked to the Post, a VCH investigator said that unknowingly infected staff at Little Mountain Place had tried to “push through” their symptoms, going on to infect numerous other staff and residents.

BC’s health authorities have spurned the use of widespread rapid testing among care home staff, even though the federal government has sent 900,000 tests to the province. Some epidemiologists in Canada, and representatives of the long-term care industry in BC, have called for more extensive use of rapid tests in care homes.