A stillborn baby and a patient dying in an emergency room due to an equipment failure were two notable events from the latest critical incident report released by the province.
The report documented major incidents and deaths at Manitoba hospitals between Oct. 1 and Dec. 31 of 2016. There were 26 major incidents and five deaths in the report.
The report did not indicate which hospital each event occurred at, nor did it have any details on the patients involved.
Of note was a baby who was stillborn. The report states a patient in labour was transferred to a higher level of care, but an external fetal heart monitor was not applied after she was handed off. Doctors couldn’t hear a fetal heart rate following an epidural. The baby was stillborn and could not be resuscitated.
The incident was reported with officials believing earlier monitoring could have prevented the death.
In another incident, a patient in the emergency department was having their heart rate monitored, when the monitor was found to not be working. A portable cardiac monitor was hooked up to the patient, but the portable monitor couldn’t communicate with the main monitor. The patient then developed a life threatening cardiac rhythm and no alarms sounded. The patient died.
Another incident saw a patient in the emergency department with a probable heart attack. The report said the patient was not transferred for an urgent cardiac catheterization, as is standard practice. Instead, the patient was transferred to tertiary care the next morning, and died shortly after.
Officials reported the event out of a concern for a delay in the expected standard of care for heart attacks.
The province releases critical incident reports four times a year.
