Report sparks calls for more proactive health system

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This article was published 13/02/2025 (205 days ago), so information in it may no longer be current.

A patient who died after being released from a hospital emergency room was among 31 critical incidents reported in Manitoba health-care settings over a three-month period.

Four deaths and 27 situations involving a “major” degree of injury were declared critical incidents between April 1 and June 30, 2024, as per the provincial government’s latest quarterly report.

The number of deaths was the lowest quarterly total since the first three months of 2019, when four deaths were also reported, a Free Press analysis showed.

The overall number of critical incidents per quarter ranged between 27 and 59 over the five-year period.

Manitoba Nurses Union president Darlene Jackson and Jason Linklater, president of the Manitoba Association of Health Care Professionals, said many incidents can be prevented with adequate staffing levels.

“If you had more staff, you would have smaller patient loads and a better opportunity to oversee and to monitor patients more effectively,” Jackson said.

“(Understaffing) is often identified as an issue in critical incidences, when they’re investigated,” Linklater said. “Short-staffing has all sorts of implications, but certainly safety and risk are right up there in terms of what can happen.”

Health Minister Uzoma Asagwara said hiring more front-line staff is one of the most important steps the government can take to prevent critical incidents.

“We know that when you’re running short of team members, that’s more likely when mistakes or incidents can happen,” they said. “We want to bring the pressures in the health-care system down and improve capacity by adding more people.”

The NDP government said 1,255 net-new health-care workers have been hired since April. Some unions say they have not yet seen an impact.

Provincial legislation defines a critical incident as an unintended event that occurs when health services provided to a person result “in a consequence to him or her that is serious and undesired,” such as death, injury, disability or unplanned hospital admission, and does not result from an underlying health condition or “from a risk inherent in providing the health services.”

The legislation applies to regional health authorities, facilities such as hospitals and personal care homes, and licensed land and air ambulances.

Quarterly reports contain limited descriptions of incidents. They do not contain information that could identify patients, staff or locations.

The province said each incident is reviewed to make recommendations to avoid harm to others.

In the latest report, one death involved a patient who went to a hospital emergency room, was discharged home and later returned via ambulance.

Two patients died after their medical condition changed or deteriorated. “Opportunities for earlier recognition and intervention were not realized” in both cases, the report said.

The fourth death was a patient who had self-harmed. “The opportunity to mitigate the risk was not recognized,” the report said.

While the report did not go into detail, a man died at Health Sciences Centre in May after he self-harmed while recovering from surgery — one day after he self-harmed at the mental-health crisis response centre, sources said at the time. The death was deemed a critical incident.

Of the 27 “major” incidents, three patients or residents had suffered skin tissue breakdown. Four people had pressure injuries (two were related to medical devices).

“When you’re looking at skin breakdown, and I see a lot of them have to do with residents in long-term care, these injuries … are about the inability for staff to turn residents, provide skin care, provide positioning so they’re not getting those injuries,” Jackson said. “A lot of that has to do with patient loads and the inability to actually monitor and oversee patients at all times.”

A delay in diagnosis and treatment was associated with serious harm in one case. Another person needed “emergency intervention” after receiving an unintended medication.

Asagwara and the union leaders said critical incidents have a profound impact on patients, families and health-care workers.

“Any incident, any loss of life is a tragedy,” Asagwara said.

“When an incident happens that results in a critical incident, it is absolutely devastating for staff,” Jackson said.

Asagwara said the health system will never be perfect, but learning from incidents and promising to do better is the only way to make it the best system possible.

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Linklater said the system needs to be more proactive than reactive.

“A lot of times, we see things earmarked as learning opportunities, when we really should have learned from similar incidences a long time ago,” he said.

Linklater said understaffing and heavy workloads increase the risk of incidents being underreported.

A critical incident was declared after a 49-year-old patient died while waiting hours for care in HSC’s adult emergency room Jan. 7. Shared Health’s investigation of Chad Giffin’s death is expected to conclude soon.

chris.kitching@freepress.mb.ca

Critical incident reports April-June 2024

Chris Kitching
Reporter

Chris Kitching is a general assignment reporter at the Free Press. He began his newspaper career in 2001, with stops in Winnipeg, Toronto and London, England, along the way. After returning to Winnipeg, he joined the Free Press in 2021, and now covers a little bit of everything for the newspaper. Read more about Chris.

Every piece of reporting Chris produces is reviewed by an editing team before it is posted online or published in print — part of the Free Press‘s tradition, since 1872, of producing reliable independent journalism. Read more about Free Press’s history and mandate, and learn how our newsroom operates.