HSC hallway death deemed critical incident

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This article was published 09/03/2023 (914 days ago), so information in it may no longer be current.

The death of a patient in a hallway of the Health Sciences Centre ER early Feb. 28 has been officially deemed a critical incident.

HSC management said Thursday a full report will be completed later this spring, as required by provincial legislation.

Recommendations aimed at preventing another ER hallway death are expected to be publicly released within three months as part of the investigation.

Asked what immediate changes have been made to prevent a similar death while the investigation occurs, Health Sciences Centre chief operating officer Dr. Shawn Young, and executive director of acute health services Jennifer Cumpsty, said multiple daily meetings are held with HSC staff, and with staff at other city hospitals, that focus on capacity issues.

Sometimes the meetings are preplanned; sometimes they’re held urgently and managers go to the ER to help move patients, Cumpsty said.

“So that’s some of the work that we’re constantly doing on a daily basis. It’s ongoing work, because we know that there’s ongoing challenges.”

Almost no detail about the patient or the circumstances of his death have been publicly released; that is part of the investigation. Cumpsty said the incident has broadly affected hospital staff, not just those in the ER.

“Overall, people are very much aware of what happened, and nobody ever wants something like this to happen.”

Cumpsty was unable to disclose why the man’s death is considered a critical incident, only that the patient died “in circumstances that we do have some questions about.”

The hospital had implemented its four-level overcapacity protocol on the afternoon of Feb. 28, hours after the patient died, because the ER was backlogged with patients who needed to be admitted to hospital wards.

The protocol allows certain patients, including those “with a reduced need for observation” and those getting ready to be discharged, to be moved to other areas of the hospital. It can mean patients will be moved to a bed in the hallway if there’s no bed available for them in a room, essentially shifting the backlog from the ER to other hospital units.

The protocols are relatively new and not frequently used, Young said, when asked why the overcapacity protocol wasn’t used before the patient died.

“We don’t enact them very often. You really only have one chance at it, so when you do hit a trigger and those movements occur, those patients don’t disappear. They now are throughout the system in hallways, on units,” he said.

The Free Press has reported the man died after being taken to HSC by ambulance during a busy night. Many ER patients were waiting for treatment, in addition to between 30 and 40 admitted patients waiting in the ER to be moved to a hospital bed.

Young and Cumpsty have said the man arrived at HSC around 11 p.m., was triaged and waited about an hour in the hallway before his condition deteriorated and he was pronounced dead. Staff had previously raised concerns that resources were tight and there could be a circumstance such as this.

Young said management has heard concerns from all staff, not just in the ER, for months. The hospital is short-staffed and patients are sicker, he acknowledged.

“Our work is different, our risks are real, and they’re all expressing concern that the work has changed. Our acuity is definitely up and our staffing is not adequate enough to meet that acuity. Any time we stretch our staff as much as we’ve had to, at times like this when acuity is very high, it creates risk,” Young said.

katie.may@winnipegfreepress.com