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Four serious incidents since 2011

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Winnipeg health officials have reviewed four serious incidents involving patients who were transported home by taxi since 2011.

In three cases, the patients died, sparking considerable public attention.

The fourth incident involved an elderly man sent home in a taxi by the Grace Hospital at 2 a.m. in August 2011. He suffered from dementia, and his family had requested they be informed when he was to be released so they could take him home.

But he was sent home in a cab anyway due to a communication error at the hospital. He was found lying in a field in the Moray Industrial Park, about a kilometre from his home, four hours later by a passerby. His hospital slippers were shredded and his toes cut, his son said later in a letter to the Free Press. Had it been winter, he probably would have died.

The Winnipeg Regional Health Authority commented on this incident for the first time Friday, saying for "a variety of reasons" crucial information about the man's condition and the family's willingness to take him home was not passed on from the evening shift to the overnight shift.

"The safe discharge plan that was established for this man wasn't well-communicated within staff so it was not followed through on," Winnipeg Regional Health Authority vice-president Lori Lamont said Friday.

A review of the incident led to improvements to shift-handover procedures, Lamont said. As well, staff from the Grace and other hospitals were sent for training to North Carolina by experts in "team communication" methods in hierarchical power structures developed for the U.S. military.

The Free Press recently inquired, through freedom of information legislation, a list of all critical-incident reviews involving patients sent home in cabs from city hospitals since 2010.

The response was there were four, including the senior who survived his ordeal.

The three who died were:

-- Wayne Miller, 62, who was discharged from the Grace Dec. 29, 2013 and was found lying on the sidewalk in the 100 block of Arlington Street. He had suffered an aneurysm and died.

-- David Silver, 78, who was sent home from the Grace at about 1:30 a.m., Dec. 31, 2013, while wearing a coat over his pyjamas and bedroom slippers. He had a heart attack moments after the cab pulled away. His housekeeper found him later that day lying a short distance from his front door.

-- Heather Brenan, 68, who was sent home from the emergency room of Seven Oaks hospital Jan. 27, 2012. She collapsed outside her home, lost consciousness and died the next day in hospital.

 

-- Kusch

Republished from the Winnipeg Free Press print edition February 22, 2014 A6

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