In a fatal case, WRHA review turned up little but the obvious

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This article was published 15/05/2010 (5819 days ago), so information in it may no longer be current.

CRANE RIVER — Nearly four years ago, 19-year-old Brenda McDonald was hit by a truck while riding an ATV near her home on the O-Chi-Chak-Ko-Sipi First Nation, near Dau­phin.

About 24 hours later, she was dead. Her death was what the Winnipeg Regional Health Authority terms a "critical incident," a breakdown in care that worsens a patient’s condition or, as in McDonald’s case, results in a death that could have been prevented.

It was shortly before 6 p.m. on Aug. 14, 2006, and Brenda had just dropped off her three-year-old daughter Shayla with her mother, Marcelline. Then she hopped back on her ATV to pick up another load of children from the beachside day camp she helped organize for area youth.

Brenda was only steps away from home when a truck travelling 70 kilometres per hour struck her ATV, sending her and her younger cousin Carolyn flying into a ditch.

"I looked at her leg and it was pretty bad," said Barry McDonald, Brenda’s father. "There was just a pool of blood there."

Brenda suffered multiple broken bones and a crushed leg, but she was still awake, and was talking and joking before she was airlifted to Health Sciences Centre. Her father rode with her in the ambulance to the airport, and said goodbye, planning to fly to the city the following day with Marcelline.

But early the next morning, the phone rang.

"(Brenda’s boyfriend) phoned us and told us. He said, ‘Brenda’s gone.’ And I said ‘What?’ And he said, ‘She’s gone.’ "

The autopsy report says Brenda died from a massive hemorrhage caused by a tear in her aorta.

It was an injury that was detected by a CT scan of Brenda’s chest at 2:30 a.m.

According to a final medical report written by Brenda’s attending physician, Dr. Jeremy Lipschitz, the tear resembled a flap and was approximately 4.5 centimetres long. A surgery team was in the CT scan room when the aortic tear was identified, and a call was immediately placed to cardiac surgeon Dr. Alan Menkis.

Menkis is the high-profile surgeon who was recruited to lead Manitoba’s beleaguered cardiac heart surgery program six years ago after close to a dozen cardiac patients died while awaiting treatment. He championed the push to consolidate cardiac surgeries at St. Boniface General Hospital and is currently the medical director of WRHA’s cardiac sciences program.

The report states Menkis determined Brenda did not need surgery at that time and that the "CT scan should be reviewed with staff in the morning." Vascular surgeons then assessed Brenda’s condition and recommended a cardiac surgeon assess the injury to her aorta to decide whether it should be repaired surgically or with a stent.

WRHA officials won’t disclose when the vascular surgeons recommended Brenda be assessed by a cardiac surgeon, citing privacy reasons. They also won’t say when this assessment should have been done or whether Brenda’s injury was vascular or cardiac.

"They felt that cardiac surgery should assess the (aortic tear) and decide whether the appropriate management would be surgical intervention or endovascular stenting," Lipschitz’s report states.

Neither was done, and the tear eventually ruptured, flooding her chest with four litres of blood.

Medical staff could not resuscitate her, and Brenda was pronounced dead at 6:11 a.m.

WRHA officials declared her death a critical incident within 24 hours.

Review teams treat each incident as a learning experience, and try to determine what went wrong and how similar incidents can be prevented. In Brenda’s case, there are still more questions than answers.

Although WRHA determined a communication breakdown may have contributed to the death, officials were unable to pinpoint exactly what led to the miscommunication. Doctors gave conflicting statements about what happened in the city’s largest trauma centre that night.

"This was a case of people having different recollections of conversations," said WRHA spokeswoman Heidi Graham. "We were unable to determine what exactly was said, when."

The investigation concluded "it remains unclear how concerns and further questions were acted on and communicated between specialists." It said the attending physician did not directly communicate to the cardiac surgeon that the "patient required surgical treatment," and that "it remains unclear who was clinically responsible" for Brenda during her time in the emergency department.

jen.skerritt@freepress.mb.ca