For more than two weeks last winter, the 14 operating rooms at the province's second-biggest hospital were silent.
There were no doctors and nurses in scrubs, no beeps from monitors and ventilators. Instead, senior hospital staff were scrambling to reschedule surgeries at other city hospitals while cancelling hundreds more.
A programming problem with the new air-handling control system in St. Boniface Hospital's operating room area had caused cold air to enter uncontrolled, freezing heating coils early Jan. 22 and causing them to split.
Nobody died as a result of the crisis, but the situation stressed an already heavily taxed city hospital system. Documents obtained by the Free Press shed new light on what went wrong and why it took so long to fix the problem.
They suggest the vendor of the new air-handling control system being installed at the hospital, Siemens Canada Ltd., was understaffed in Winnipeg. They also show the new air-control system had not been fully tested at the time of the breakdown. And they raise questions about whether corners were cut to install the new system within budget.
More than once during the crisis, Siemens and hospital officials thought they were close to solving the operating-room ventilation problems only to have to go back to the drawing board. It wasn't until nine days into the shutdown that Siemens flew in its top technicians from Calgary to deal with the matter, the documents show.
Under provincial freedom of information legislation, the Free Press obtained copies of emails, meeting minutes and reports on the operating-room shutdown.
In an interview following the release of the documents, St. Boniface Hospital officials mainly defended Siemens' efforts during the crisis. However, the documents reveal a frustration with the vendor.
SSLqI don't think any of us at the time realized that it was going to be a 19-day closure of the operating rooms' -- Stephen Cumpsty
The hospital had wanted to replace its operating-theatre air controls with a new digital system last summer, but wasn't able to get Siemens to do the work at that time. If the job had been done then, frozen coils would not have become an issue.
New digital controls on one of two air-handling units that supply the ORs with clean air were installed without incident in mid-December. Work on the second unit was done in January. Everything seemed to be going fine until a routine backup generator test early on the morning of Jan. 22 exposed several deficiencies with the new controls. When dampers failed to close, cold air -- the outdoor temperature was -27 C -- entered the system, freezing several reheating coils above the operating room area, causing them to split.
Working quickly, the hospital cleaned up the mess, repaired the coils (obtaining new ones immediately would take too long) and prepared the operating rooms for service -- all within five days. Siemens reps were on hand throughout, attempting to deal with the issue, but problems persisted.
While Siemens was addressing the St. B operating room shutdown, it was also installing a new environmental-control system under a strict timeline at Misericordia Health Centre's new Maryland building. At times, both health facilities were competing for the services of the same people.
Late Saturday evening, on Jan. 25, in the fourth day of the OR shutdown, Stephen Cumpsty -- St. B's director of capital planning and property management, and the man in charge of getting the system fixed -- emails his counterpart at Misericordia. He notes a particular Siemens technician is scheduled to be at the Miz on Monday morning and then at St. B. that afternoon. "I'm not sure if there is any flexibility with your project," Cumpsty writes, "but I have stressed to Siemens that our ORs are a high priority to resolve as soon as possible."
In subsequent emails between the two officials, the Misericordia official laments "the lack of vendor resources locally."
Siemens Canada refused repeated requests for an interview for this story.
Another document stated the hospital's concerns with the company in blunt terms.
In a May 8, 2014 email to Siemens officials concerning a billing dispute arising from the vendor's work done during the crisis, Cumpsty writes: "To date (St. Boniface Hospital) has covered the costs of the repairs to the physical plant resulting from the water damage well exceeding the original project cost and subsequent invoices. However, we feel that the responsibility for this failure rests with the quality of the work and investigation conducted prior to installation and the resulting product that was installed by Siemens. The extended delay with completing the project, the lack of a robust local staff in Winnipeg, and the lack of a commissioning plan for the OR Building Automation System contributed to the system failure on Jan. 22 (20)14 and the resulting damage."
Still another document shows hospital officials later realized they should have pressured Siemens earlier in the crisis to get the help they needed. In minutes from a March 4 "final event debrief" on the operating room shutdown, under the heading 'Feedback from WRHA (Winnipeg Regional Health Authority),' the session agreed a "lesson learned" from the event was the need to involve high-ranking officials with the vendor in the process sooner.
Meanwhile, a consulting engineer retained by the hospital's insurance company to look into the cause of the air-handling system failure speculated "there may have been some cost-saving measures incorporated to get the project completed within budget constraints."
In a letter to QA Adjusting stamped 'draft,' SMS Engineering said "the design documents do not match the shop drawings submitted by Siemens."
The letter also noted: "The new (air) control system was put live without proper testing and commissioning of systems, nor was operating staff adequately trained prior to the system going live."
Looking back at the events six months later, senior officials with St. Boniface are grateful for all the help they received from hospitals across the city in helping to deal with the crisis. And they're philosophical about their dealings with Siemens during the shutdown.
"I think the hospital's response and the region's response to the issue was spot on," said Catherine Robbins, executive director of support services, filling in for the vacationing CEO Dr. Michel Tétreault. "There was such an immediate realignment of patient care services so that we could continue providing surgery services to patients (at other institutions)."
Robbins and officials with the Winnipeg Regional Health Authority say nobody awaiting surgery died because of the St. B shutdown.
The hospital is the cardiac surgery centre for Manitoba. However, officials noted many patients awaiting elective (non-emergency and non-urgent) surgeries throughout the Winnipeg hospital system had to wait longer for operations and this, no doubt, caused them stress. The surgery backlog was cleared up by March.
In an interview, Cumpsty refused to lay blame for the OR closures or the length of time it took to get them back in operation.
"I think the important thing to understand is that these (air-handling control) systems are very complex," he said. "There are quite a number of moving pieces to them. So when you're dealing with those complex systems, it's sometimes difficult to anticipate all the ripple effects."
The hospital officials acknowledged the system had yet to be fully tested when the failure occurred, but say that process was about to occur. It's not as though the hospital was going to close its operating theatres to conduct these tests. Surgeries had to proceed, they said.
Should Siemens' most senior technicians have arrived earlier instead of more than a week after the closures? For much of the OR downtime, it was felt the situation was under control. It was only when the system repeatedly failed, St. B officials say, that they realized they needed more help.
"I don't think any of us at the time realized that it was going to be a 19-day closure of the operating rooms," Cumpsty said.
Is Siemens sufficiently staffed in Winnipeg to meet the needs of Manitoba customers?
"I don't think staffing was a problem," said Robbins. "Many of these companies have sufficient staff in our province to deal with 99 per cent of the issues that arise. This was such an unusual occurrence that it required specially trained staff that aren't local."
Cumpsty denied suggestions corners were cut and things done on the cheap to complete the job within budget. "We got the budget that we asked for," he said.
He allowed there were places where the work done did not match the actual design, but he said those anomalies did not result in the system's failure.
"Those things would have come out and should have come out in the commissioning process," he said. "They weren't done out of a shortcut."
The cost of repairs to the hospital was $191,500. Insurance covered the first $25,000 of that, leaving the institution with net costs of $166,500.
Meanwhile, a number of enhancements were made to the air-handling control system as a result of the failure. For example, new operating room door seals, which had not been replaced since the early 1990s, were installed.
"We've put in better (air) pressure monitoring, we have temperature sensors now within the duct work that tells the system when cold air gets into the duct... so basically it goes into a locked-down mode... (when a problem occurs)," Cumpsty said.