Failure of system not care givers, says nurses group

Five patients who faced delays in Manitoba’s health-care system were among 16 deaths that were listed in the province’s latest critical-incident reports.

The reports contain brief descriptions of the 16 deaths and 43 major injuries — all deemed critical incidents that required investigations — between April 1 and Sept. 30, 2025.

“Our thoughts are with the patients, families and staff affected by the incidents outlined in these reports,” Health Minister Uzoma Asagwara said in a statement.

“These are not just numbers, they are people, and every incident is taken seriously.”

Government reports listed 91 critical incidents in the first nine months of 2025, down from 98 during the same period in 2024 and 112 in 2023, and comparable to 89 in 2022.

The province cautioned that more analysis and data are needed to draw firm conclusions, because the number of incidents listed per quarter reflect the investigations that have been completed by the time of reporting. Some investigations may be ongoing.

Several incidents involved delays, gaps, missed opportunities for earlier involvement, falls or equipment failures.

One patient died after they were discharged and suffered a “clinical deterioration.” “Opportunities for earlier recognition and intervention were not realized,” one of the reports said.

A different patient died after self-harming. “Opportunities for earlier assessment and treatment were not fully in place,” the report said.

Five patients died after facing delays in either accessing care or treatment, or delays in the response to their medical conditions.

Of the major injuries, a delay in the diagnosis of a patient’s serious medical condition led to harm, while a different patient’s care for an “acute medical event” was delayed due to gaps in reporting and assessment.

Two people were injured by fellow patients in what the reports described only as “interactions.”

Critical-incident reports do not contain details that could identify patients or residents, workers or locations. Investigations are intended to find ways to prevent similar incidents from happening.

Many critical incidents are preventable, said Manitoba Nurses Union president Darlene Jackson.

“What stands out in these reports is not just the number of critical incidents, it’s the pattern,” she said. “Over and over again, we see the same language: missed opportunities, delays in recognition, gaps in monitoring, delayed treatment. Those aren’t random human failures. Those are system signals.”

When the same themes repeat, it points to a system that is stretched too thin to respond in time, she said.

Prevention starts with having enough staff, with the right supports, Jackson said.

“Patient safety is not just about policies or reviews after the fact. It’s about real-time capacity at the bedside,” she said. “Until that is addressed, we will continue to see the same patterns, and that should concern everyone.”

Asagwara said increasing staffing, improving patient flow and reducing wait times are essential to improving patient safety.

“Initiatives like better staffing levels and clearer standards of care are part of that effort, but there is no single solution. This is ongoing work,” the minister said.

Jason Linklater, president of the Manitoba Association of Health Care Professionals, pointed to shortages of respiratory therapists in Winnipeg’s three emergency rooms, and paramedics in rural Manitoba.

“We’re not going to see patient safety, or staff safety, improve until government is willing to make the targeted investments needed to improve staffing levels, bring down wait times and enforce safety legislation,” he said.

“We know from front-line reports that allied health staffing shortages have contributed to critical incidents.”

MAHCP is suing the government for allegedly failing to ensure the safety and health of its members.

The Opposition Tories recently called for a public inquiry after the recent deaths of patients awaiting medical care.

Manitoba legislation defines a critical incident as an unintended event that occurs when health services in hospitals, personal care homes or other settings result in “serious and undesired” consequences, such as death, injury or disability, and do not result from the person’s underlying health condition “or from a risk inherent in providing the health services.”

chris.kitching@freepress.mb.ca