‘Blatant disregard for public safety’: nurses censured after baby taken to hospital in handivan

Two Dauphin nurses have been censured by Manitoba’s regulatory college after they ordered a handivan to transport a newborn to Winnipeg instead of waiting for an ambulance.

The College of Registered Nurses of Manitoba entered formal censures into the disciplinary records of Melissa Zepp, a nurse who was working as program services manager at the Dauphin Regional Health Centre on Oct. 5, 2024, and Brittany Gamache, a nurse who agreed to accompany the infant after being contacted at home that day by the mother of the eight-day-old infant.

The college’s complaints investigation committee said the actions were “a blatant disregard for public safety” and “had the potential to seriously harm the patient as well as the profession.”

The committee said the baby was taken to hospital on Oct. 5, 2024, and, after being assessed, an air ambulance was chosen to transport the patient to Winnipeg. Due to poor weather conditions, and because the baby’s condition was stable, it was determined a ground ambulance could be used instead.

After a delay, the baby’s parents decided at 5 p.m. to drive to Winnipeg themselves against medical advice. Zepp arranged a handivan to drive the infant to Winnipeg and the child’s mother called Gamache at home and she agreed to conduct the transport.

When the baby left the hospital nearly four hours later, the child’s doctor was not told about the transport change and, during the drive, the infant “experienced a desaturation and cardiac deceleration during feeding.”

The committee said Gamache never assessed the child herself before the transport and conducted minimal assessments during the drive.

“You were the health-care provider responsible to care for what you felt was an unstable infant,” the committee said in its decision. “It is the committee’s position that you overwhelmingly failed the patient and did not meet the expected standards of a registered nurse.”

The committee also criticized Gamache for failing to exercise “appropriate professional boundaries” when she was called at home.

Zepp admitted she called two handivan crews because the first refused to conduct the transport.

“You were the senior administrator and decision maker at (the hospital) at the time of the allegations… a registered nurse with this level of experience and knowledge ought to have known that this decision was egregious, unsafe and did not correlate with facility policies, procedures or safe patient care.”

Zepp has worked as a nurse for about two decades, while Gamache, who has a background in maternal health, has been a nurse for more than 10 years.

No fines were issued, but Zepp was ordered to pay $2,000 towards costs of the investigation, while Gamache had to pay $1,000.

Neither Zepp nor Gamache, who couldn’t be reached for comment, had been disciplined before the incident.

Noah Schulz, provincial director of the Manitoba Health Coalition, called the case troubling.

“No one should be deciding whether to take their infant out of care against medical advice because they can drive to Winnipeg faster than an ambulance is reasonably expected to arrive,” said Schulz.

“This story speaks to systemic issues in rural health care, caused by under-investment and inadequate staffing, and those are problems with solutions the government must urgently invest in.”

Jason Linklater, president of the Manitoba Association of Allied Health Care Professionals, noted the NDP promised to add 200 paramedics in rural areas during the 2023 election. Not only has that not happened, there are 90 vacancies in Prairie Mountain.

“We’ve seen response times increasing,” he said. “It’s very possible situations like this would never happen if we were staffed properly.”

Linklater, whose union represents rural paramedics, stressed patients and family members should always wait for an ambulance and not take matters into their own hands.

The College of Registered Nurses of Manitoba spokesman Martin Lussier said the nurses’ employer reported the incident to the regulator and both appeared before the committee to be censured on Sept. 12. Censure rules required that both had to accept responsibility for their actions.

“The college is mindful of the fact that the health system is under significant strain, in particular as it respects health human resource challenges,” Lussier said in a statement.

“The college must balance supporting RNs and NPs (nurse practitioners) in maintaining quality nursing practice, while also providing necessary accountability when individual registrants fall short of practice expectations, even in difficult circumstances.”

Health Minister Uzoma Asagwara said situations such as this are the exception.

“In this case, the college determined that established protocols were not followed, and it’s important for the public to know that the regulatory system works to protect patient safety,” Asagwara said in a statement.

The minister said the government has added advanced care paramedic training seats at Red River College Polytechnic as well as in Thompson and The Pas.

“We are committed to listening to front-line workers, addressing vacancies, and building a stronger system so rural families don’t have to worry about transport in an emergency.”

kevin.rollason@freepress.mb.ca