Winnipeg Free Press - PRINT EDITION

Medical reporting is failing

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The bewildering facts of the case of Brian Sinclair, a double amputee who was ignored to death waiting in futility for 34 hours in the HSC emergency room in 2008, could make Manitobans conclude this was an extreme example of medical error in city hospitals. Perhaps. But we can't know that, because Manitobans aren't permitted to know the details of those who die, unnecessarily, due to medical mistakes in hospitals, nursing homes or other facilities here.

That's just one criticism -- lack of transparency -- with a system of reporting critical incidents, the preventable errors in medical facilities that result in real harm, such as death, disability or a prolonged hospital stay to a patient.

The mandatory reporting system, established by provincial law in 2006, resulted from a lengthy, explosive inquest into the deaths of children who underwent heart surgery in 1994 at HSC. It allows staff to disclose in confidence mistakes, prompting a health authority investigation. The report's findings are not released publicly or available to legal proceedings.

The idea was that protecting staff from shame and blame would result in robust reporting of mistakes so they can be fixed and future injury prevented.

However, data compiled by the Winnipeg Regional Health Authority show it isn't working.

Reported critical incidents peaked at 283 in 2009, and have since fallen off. The numbers indicate medical staff are not anxious to comply with the compulsion to report. Further, the hope that such a system would foster a "culture shift" -- from an environment of coverup to one of open disclosure for the sake of prevention -- has not happened.

Estimates of the number of medical errors made every year are still evolving, but based on national and international studies, the WRHA expects as many as 1,800 critical incidents happen annually based on admissions to health centres. In 2011/12, the WRHA reported only 212 critical incidents, for a rate of 2.57 per 1,000 admissions -- a far cry from what's happening inside hospitals.

The HSC is the province's biggest hospital and its ER takes in victims with multiple trauma and those with earaches alike. Yet, at 34 reports in 2011, it has the lowest rate of reported medical errors. It can only mean people on the front lines are loath to admit or to disclose when they see something's gone wrong.

The details of the critical incident review -- leaked to the CBC earlier -- into Mr. Sinclair's death from a simple, but unattended urinary infection found some startling facts. Nurses and security staff were repeatedly alerted by people waiting for care that he didn't look good, that he had vomited and some asked if he had been attended to, but all were largely ignored. Security cameras showed that at points during his 34 hours, the ER was actually quite quiet, with few others waiting, and one nurse actually engaged in banter with the man. It was an ER visitor who noticed the man had died and told a security guard.

By law, critical incident investigations are not made public and an inquest underway into Mr. Sinclair's death will not see the report on him. It will not be released in a redacted form to protect the identities of those interviewed. In this way, the public cannot scrutinize the work, reflect on the quality of the investigation nor the weaknesses in Manitoba's ERs, hospitals or other centres. It must accept that the health authorities, hospitals and administrators are making the right fixes to what's broken.

That is asking a lot, especially in light of the abhorrent lack of attention paid to a man with a simple health problem that was allowed to turn deadly during 34 hours of gross neglect.

At the very least, as Liberal MLA Jon Gerrard demanded in 2007, investigations ought to be done by an external agency or actor. Health authorities are in an apparent conflict of interest conducting investigations of their own facilities and staff. Health Minister Theresa Oswald must move immediately to rectify this conflict to give Manitobans some comfort investigations are meaningful and trustworthy.

Editorials are the consensus view of the Winnipeg Free Press’ editorial board, comprising Catherine Mitchell, David O’Brien, Shannon Sampert, and Paul Samyn.

Republished from the Winnipeg Free Press print edition September 28, 2013 A16

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