10 patient deaths in Manitoba’s health-care system: latest critical incident report

The wrong antidote dosage being used. The wrong patient receiving a procedure. These are just some of the incidents outlined in the province's latest critical incident report.

The report is for Oct. 1, 2022, to Dec. 31, 2022. During that time there were 10 deaths and 41 incidents recorded in total.

"Critical Incident reports reflect serious and unintended harm experienced by individuals using Manitoba's health-care services. The following posting reflects the initial understanding of the incident. Clinical experts thoroughly review each incident and make recommendations about how the system can improve in order to avoid harm to others," the province has written on its website.

Compared to the previous two reports, this report to the end of 2022 featured more critical incidents and a higher number of incidents ending in someone's death.

Several reasons were listed for why someone died while in care including giving too high of a dosage for a suspected overdose, changes in medical status that may have been missed due to gaps in monitoring, a patient falling from a transfer device, and patient deterioration in the emergency department and a delay in care.

The other incidents that were classified as minor or major included an unintended event during a surgical procedure, a fall while in care resulting in a fracture, a fracture being missed on an X-ray, a minimally invasive procedure being done on the wrong patient, and delays in care resulting in a higher level of care being needed.

Darlene Jackson, the president of the Manitoba Nurses Union, said she was not surprised by the number of incidents that showed up in the report.

"When you have a shortage of nurses, when workloads are unsustainable, when (workloads) are too big for someone to handle, and when you're doing extended hours continuously through overtime, either voluntary or mandated, what happens is you just do not have enough eyes on the patients to monitor their conditions," said Jackson.

She noted COVID-19 played a role during the time frame as it increased the nursing shortage with staff being off sick.

However, she said a lot of the incidents were preventable.

"So when I look at things like the pressure sores and the skin breakdown, those are absolutely preventable and could be prevented with oversight and frequent turns and frequent skincare. But when you don't have the staff to do that, then you would see things like this happening more and more often."

Jason Linklater, the president of the Manitoba Association of Health Care Professionals (MAHCP), agrees with Jackson that these incidents are preventable.

"They are a direct result of a staffing crisis we're seeing across occupations in Manitoba, particularly within Allied Health," said Linklater. "We know when there's not enough people to do the work that the critical incidences certainly are going to increase."

Jackson and Linklater believe this trend will continue when the 2023 reports start to come out and feel nothing will change until long-term fixes are applied to the health-care system.

"I think we all have to remember that this did not happen overnight. This nursing shortage was a long time coming and I believe that we're going to end up seeing changes, but not in the short term," said Jackson.

"I think it's fair to say that to a good degree staffing levels are going to play a great role in terms of the numbers of critical incidents that you see across the system," said Linklater.

To deal with the concerns in the short term, Jackson said staff needs to be bolstered as much as possible to keep the health-care system functioning until the long-term changes can come into effect.

In an emailed statement to CTV News Winnipeg, Uzoma Asagwara, the minister of health, seniors and long-term care, said the government takes these incidents seriously.

"We continue to work on implementing solutions in the short term, that will have lasting impacts in the long term," they said. "These include adding more beds in hospitals, extended hours for discharging patients, hiring more staff and retaining staff by rebuilding the culture and developing a plan to fix health-care together."