No inquest in case of woman who died in pandemic airlift attempt

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This article was published 15/03/2022 (1275 days ago), so information in it may no longer be current.

Manitoba NDP Leader Wab Kinew is continuing the push for an inquest into the death of a critically ill COVID-19 patient, saying it would shed light on contributing “systemic failures.”

On Tuesday, Kinew asked the Office of the Chief Medical Examiner to reverse its recent decision not to call an inquest into the May 25, 2021, death of Krystal Mousseau, 31. 

The mother of two from Ebb and Flow First Nation needed intensive care, but Manitoba’s ICUs were full during the third wave of the pandemic. She died following a failed attempt to airlift her from Brandon to a hospital in Ontario. 

Systemic mistakes — including a lack of proper training and equipment — may have contributed to her death, Kinew said Tuesday.

“Further investigation is definitely warranted,” the NDP leader told the Free Press, adding it’s a matter of public interest to hold a provincial court inquest. 

“One, we have a grieving family who wants answers, but two, every Manitoban should want us to learn from the mistakes that were made in the care of Krystal Mousseau so that we might be able to avoid them ever happening again.” 

Chief medical examiner Dr. John Younes previously declined to call an inquest — stating in a March 1 letter to the NDP leader “there is no mystery” as to why Mousseau died. 

However, information revealed in the results of a health system critical-incident report may not have been available to inform Younes’s decision, Kinew suggested. 

Those results, shared with the NDP by Mousseau’s family, suggest the team that attempted to transport Mousseau was unable to properly monitor her blood pressure, for example, Kinew wrote in a letter to Younes. 

(Kinew didn’t publicly release the results of the critical-incident investigation, as it contains personal health information.) 

In explaining his decision not to call an inquest, Younes doesn’t mention staff training or equipment, nor any specifics about the circumstances of Mousseau’s death. 

During question period in the legislature Tuesday afternoon, Kinew questioned Premier Heather Stefanson about the discrepancy and asked whether she agreed an inquest was necessary. 

Stefanson responded by taking a “proud parent” moment to congratulate her son on his high school hockey championship win, running out the clock on Kinew’s first question. 

She then offered condolences to Mousseau’s family, and stood by both the chief medical examiner’s decision not to call an inquest and the medical staff decision to attempt the transport. 

“We leave those decisions up to the professionals,” the premier said.

Kinew should have brought his concerns about Mousseau’s case to her, instead of “playing politics” in question period, Stefanson said.

In January, Kinew publicly called for an inquest to examine what led to Mousseau’s death. An inquest typically involves a lengthy court process and results in a judge’s recommendations aimed at preventing future deaths. 

In May 2021, medical staff began sending patients to hospitals out of province on an emergency basis. Mousseau was chosen to be transferred because of her relatively young age, relatively good health prior to getting COVID-19, and because she didn’t have multiple comorbidities which would have put her at higher risk, Younes wrote in his March 1 letter.

“There is no mystery here. A carefully considered medical decision was made to move patients out of province to make room for incoming patients who would otherwise not survive,” Younes wrote. 

Younes described Mousseau’s case as tragic but noted an inquest won’t result in rapid changes to the health-care system. If one was called, it wouldn’t get underway for years and would likely be affected by COVID-19 pandemic delays in court.

It’s not the role of an inquest to “second guess complex medical decisions, particularly those made under horrific circumstances,” Younes wrote.

Internal reviews were conducted after Mousseau’s death. In addition to the critical incident investigation, the contracted flight company was doing its own internal investigation. 

An inquiry, but not necessarily an inquest, is required into Mousseau’s death under provincial law. 

Legislation sets out several types of death that require an inquiry, including when a Manitoban dies as a result of a contagious disease that is a threat to public health, when the death happens within 10 days of an invasive medical procedure, or within 24 hours of the deceased seeking hospital admission. 

In a statement, the Manitoba justice department stood by the medical examiner’s decision, affirming the office’s responsibility to have the final say.

katie.may@freepress.mb.ca