Death sparks overhaul of ERs

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This article was published 20/04/2016 (3636 days ago), so information in it may no longer be current.

The Winnipeg Regional Health Authority is overhauling the assessment and review procedures of all emergency-room facilities after identifying “quite troubling” issues in the wake of the death of a woman who suffered an undiagnosed brain aneurysm after spending two hours lying on the floor of a hospital waiting room.

The changes include establishing a four-member review team to conduct regular assessments, both announced and unannounced, of all Winnipeg emergency departments (to begin in May) on a rotating basis, with all performance reviews to be made public.

In addition, a patient advisory council made up of “public interested in or affected by emergency department care,” will focus on feedback and recommendations for emergency patient experiences. The council will begin operating in June.

Meanwhile, a six-week evaluation of conduct at the Seven Oaks General Hospital emergency department will begin immediately. The Seven Oaks review will follow patients “from the moment they arrive at the emergency department to the time they’re discharged” and will include discussions with front-line staff, families and patients, according to a WRHA outline of the changes released Wednesday.

WRHA president and CEO Milton Sussman said implementing the new review and assessment system was critical in light of the death of Mohinder Singh, who was transported to Seven Oaks after experiencing a severe headache Oct. 14 after collapsing in her Maples home.

“I really want to provide the public with the assurance we take this matter seriously,” said Sussman, who described the overhaul as “significant.”

Last October, Singh was told to wait in the emergency room after being assessed by EMS personnel. She was suffering from a severe headache and couldn’t sit upright in a wheelchair provided by staff. Repeated attempts by Singh’s husband, Darshan, to get a doctor to see his wife were unsuccessful.

After two hours on the waiting room floor, Singh lost consciousness. She was later rushed to Health Sciences Centre and died the next day of a brain aneurysm. She was 57.

According to a critical incident review (CIR), which the family finally received Monday, Singh did not receive an independent assessment upon arrival at Seven Oaks, as required by procedure. Neither was she reassessed by staff during her two-hour wait in the emergency room, despite five documented attempts by her husband seeking assistance.

“I really wanted to put in the public record that Mr. Singh did everything he could to get his wife the care she required. We did not,” Sussman told the Free Press. “There’s not anything else he could have done. He wanted to do his part. We didn’t.”

In addition, the WRHA is immediately introducing an “escalation process” at emergency departments whereby resources can be redeployed or additional staff can be added in cases of high patient volume. “They (the Winnipeg emergency departments) did that right away,” Sussman said.

The Singh family, who met with WRHA officials and hospital administrators Monday to discuss the CIR findings and recommendations, said the WRHA’s apology was “good to hear.”

“It was really good that they accepted responsibility for it… and improvements need to be made,” said Mohinder’s son, Braham. “It really went a long way to help the family heal and get over the loss. Hopefully, it will give him (Mohinder’s husband) some peace of mind, at least.”

Braham also called the WRHA changes “a good step.” But he said the family was disappointed neither the hospital nor WRHA would announce or confirm any disciplinary action against front-line staff the day his mother was admitted.

“There needs to be some sort of accountability in place,” he said. “There were numerous people in the emergency room who played a role in my mom’s death. Why are they being left alone? Why is nothing happening to them?

“We need to know something substantial happened to these people. They saw the suffering, and they didn’t do anything. We saw people fail at their job. These are health-care professionals. They need to care about the people.”

When asked about possible disciplinary action if the reviews expose sub-standard care, Sussman replied the results will be made available for the public and the individual hospital board members to respond appropriately.

The WRHA will also undertake an external review of the CIR process, which has been in place for a decade, including communication (or lack thereof) with patients and families. Under current legislation, a CIR must be made available within 88 days.

randy.turner@freepress.mb.caTwitter: @randyturner15