Add one more patient to the Grace Hospital emergency-department debacle: my father.
My elderly father suffers from a form of dementia characterized by complete memory loss, but he is able to live by himself with daily help from great home care staff and his many family members. He was sent home from the Grace at 2 a.m. by cab on Aug. 24, 2011. That occurred despite requests from one of his daughters that, because of his dementia, she be called to pick him up when he was discharged.
A clerk wrote that down on a sticky note and put it on his file. Nonetheless he was sent home by cab and none of his family was notified.
He was found lying in a field at 6:10 a.m. in the Moray Industrial Park area by a passerby. His hospital slippers were shredded and his toes cut (and subsequently became infected). He had wandered about one kilometer from his apartment, including crossing Ness Avenue in the dark. Had it been winter he probably would have died.
The hospital and WRHA immediately launched a formal investigation of this "critical incident." We attended three meetings with different hospital and WRHA staff over the seven months it took them to figure out what happened. We were not allowed to have a copy or even read the final report, nor were we told whether anyone was disciplined for this incident. They would not tell us who found our dad, so we could not even thank that person.
All we were told was there were "communication problems" at shift change and the hospital would correct this by ensuring discharge staff would be alerted to "patient characteristics" that would impact on discharge decisions. "Dementia" was prominently recorded at the top of his discharge sheet. I guess that means dementia was not a "patient characteristic" of concern to nurses, physicians and discharge staff in 2011 when he was discharged. And there was also that sticky note that was ignored.
The main activity as a result of this incident was a plan to send three WRHA emergency staff to the U.S. in 2012 to be trained in the "team steps" communication program, which is designed to help everyone in the ER know how to communicate with each other about the status of patients. On returning to Winnipeg, those three would train other staff in the ER. That does not seem to be working out too well.
Manitoba Health should not try to pass along serious diagnostic errors or poor ER staff communication as something correctable by the taxicab industry. Would a cab driver know his passenger has significant dementia? How would a cab driver know when a patient being sent home from an ER is about to have a heart attack when the doctors and nurses obviously don't know? Is it somehow better if the cab driver ensures the passenger has the heart attack behind the door of his home?
I sincerely hope the WRHA is not allowed to investigate the two latest critical incidents internally. There have been far too many ER horror stories over the past few years to continue to leave that to the people who work inside the system making the deadly mistakes. A review by experts from another province is needed.
East St. Paul