Deaths of two infants who didn't receive air transport, choking incident summarized in provincial report
Stock image of a doctor
WINNIPEG -- The province’s latest report outlining critical medical incidents includes a case in which an inadequately supervised care home resident died choking during mealtime, a situation where an infant died after being taken to hospital by ground ambulance because air transport wasn’t available, and another in which a premature infant died after surgery for a bowel obstruction, after air transport to Children’s Hospital via Life-flight was declined the day before.
The report covers the period between Oct. 1, 2018 and Dec. 31, 2018. It lists 30 medical mishaps which resulted in patient death or caused major complications.
AIR TRANSPORT NOT AVAILABLE
In this incident, an unstable infant was transported emergently via a ground ambulance to Children's Hospital, the report said, noting a ground ambulance was used because air transport was not available. On arrival to the hospital, the infant had a cardiac arrest. The report said personnel had a difficult time inserting a breathing tube and the infant was admitted to the Pediatric Intensive Care Unit. Treatment was later withdrawn and the infant died.
In this case, an unstable premature infant who needed urgent transport to Children’s Hospital was sent via ground ambulance, because according to the report, “Life-flight declined”. The infant underwent surgery for a bowel obstruction and died the next day. The report did not state details of who declined the Life-flight transport or why it was declined, but in response to a CTV News request for clarification, a
spokesperson for Shared Health told CTV News the term "Life-flight declined" is used for a number of reasons when the services are declined by the requesting facility.
The spokesperson said the reasons it may be declined include a change in patient condition or decisions made following consultation with Life-flight physicians.
The spokesperson could not comment on this specific death.
A personal care home resident choked during meal time, the report said, resulting in the death of the patient. The report indicated the need to supervise the resident during meal times was not consistently communicated to the entire care team.
NO DOCTOR ON BOARD
A decision was made to send a patient -- who’d just suffered a cardiac arrest in an emergency room -- to a location where a higher standard of care would be available. Medical personnel decided transport via the STARS Air Ambulance was needed however, the STARS arrival was delayed almost two hours and when it arrived, a physician was not on board the aircraft. STARS personnel attempted to intubate the patient, unsuccessfully at first, and a decision was made to send the patient to another facility via ground ambulance. The patient died on arrival.
HIP FRACTURE PRECEEDS DEATH
An incident in a personal care home saw a resident who'd been pushed to the floor by a co-resident suffer a fractured hip. The injured resident died two days later.
SURGERY DELAY WORSENED CANCER
A patient’s surgical procedure was delayed by 14 months. A pathology report showed the presence of lung cancer, which had progressed to a level described as “grade 2/3.” The report suggested earlier intervention may have prevented progression of the disease.
NO FOOT PEDALS
In this mishap, a patient was being transported by staff in a wheelchair without foot pedals. While the wheelchair was in motion, the patient’s feet dropped to the floor. The initial diagnosis was that the patient had suffered a sprain. As the pain continued, an X-ray done four days later showed the patient had actually suffered an ankle fracture.
STEM CELL CHANCE MISSED
This case arose when a referral for stem cell therapy was not communicated to the Blood and Bone Marrow Transport Program. As a result, the patient missed the opportunity to be assessed for a stem cell transplant.
Legislation in Manitoba defines a critical incident as “an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that is serious and undesired.”
These incidents can include death, injury or disability, and are not a result from a person’s underlying health condition or the inherent risk that comes from providing a health service. The legislation applies to regional health authorities, hospitals, personal care homes, ground and air ambulances, the Selkirk Mental Health Centre, CancerCare Manitoba and Diagnostic Services Manitoba.
In a statement to CTV News, Health Minister Cameron Friesen said:
"We all regret when there is a negative outcome in the health system and are tremendously saddened for any family that has lost a loved one. We have confidence that the critical incident policy is effective in bringing forward errors in the system, so that learning can take place and the system can be strengthened. We continue to encourage staff to report critical incidents to reduce the chances they reoccur in the future."
The province says critical incidents are reported to look at what can be done differently and to assess what improvements may be made to the way health care providers work. The reports omit details, including regions in which incidents happen to preserve patient and staff privacy and confidentiality and to comply with laws guaranteeing privacy. This level of confidentiality also encourages health care providers to participate fully in investigations.
Incident reviews do not take the place of other investigations such as those by regulatory bodies which might occur after or alongside a critical incident review.