TORONTO - Some employees of a troubled Ontario hospital showed "poor judgment" when they made an elderly woman who broke her hip wait 20 minutes for help after falling in the entrance areas of the facility, a review has concluded.

The Oct. 8 incident made international headlines when Doreen Wallace's family said the distressed 82-year-old woman was told by Greater Niagara General Hospital staff to call an ambulance for help.

"Despite the best of intentions our effort was uncoordinated, resulted in Ms. Wallace receiving less than appropriate initial assessment and institution of treatment," Kevin Smith, the government-appointed supervisor, said in a statement late Monday.

"Our quality of caring missed the mark."

The incident also represents "management's failure" to ensure that hospital procedures for assisting people in distress were clear.

The review confirmed that a housekeeper and security guard responded first, as well as an ICU nurse and an orthopedic surgeon who transported Wallace to the emergency department, he said.

"I would be remiss if I did not also recognize the significant morale and demoralization reported by some staff, who clearly expressed feeling consistently overwhelmed," Smith said.

"This must be a longer-term issue we must address, including a review of ER staffing models."

The hospital has apologized to the family, but Progressive Conservative Leader Tim Hudak -- who grew up in southern Ontario and represents a nearby riding -- said it's not enough.

"I think that's disgraceful and that should not be happening in a province like Ontario in 2011," he said Tuesday.

"If there was an apology -- it was just once -- but it's happened now four times at that hospital. An apology just doesn't cut it."

Health Minister Deb Matthews disagreed, saying Smith's response was "excellent," noting that he not only apologized but also implemented an action plan to make sure a similar accident doesn't happen in the future.

"I'm very pleased that Kevin Smith took this situation seriously, that he has conducted and completed a review of what happened," said Matthews.

"He's very transparent, he's made that public and he's taking steps to ensure it doesn't happen again."

The governing Liberals appointed Smith to the health system -- the largest in Ontario -- after it came under fire for a dangerous outbreak of C. difficile. It comprises six hospital sites and one ambulatory care centre.

"I did not appoint a supervisor lightly, I did it because I know there are serious problems," said Matthews.

"But what I can tell you is that Kevin Smith, through this incident, has demonstrated that he is responsive to concerns of the patients."

New Democrat Leader Andrea Horwath, however, said more needed to be done.

"It's at least good that they've acknowledged that there was a ridiculous, unacceptable, horrifying situation that happened," Horwath said.

"The most important thing, though, is to see the turnaround of the Niagara Health System. People are seeing these massive organizations continue to expand and build, and you're seeing patient care, at the same time, falling apart."

In July, the husband of a Niagara Falls councillor sought help for his barely conscious wife, who was in the hospital parking lot. He said he was told to call an ambulance.

In April, Charlie Poisson, 45, drove his ill girlfriend to the hospital, only to be told when he rushed into the emergency department that paramedics would be dispatched.

When no paramedics came after about three to five minutes, Jennifer James, 39, was taken inside in a wheelchair and received care.

She died five days after being admitted, apparently of a "catastrophic heart event."