'Missed opportunities' identified in critical incident review of Earl Moberg case

The Winnipeg Regional Health Authority has apologized to Earl Moberg’s family after finding "missed opportunities" in the care of the 81-year-old man with advanced dementia who went missing a year ago.

CTV News has obtained a copy of the summary findings and recommendations made by the Winnipeg Regional Health Authority (WRHA) during a critical incident review into Moberg’s case.

“The review identified missed opportunities for proactive care/safety planning and updates to the care plan to address (Earl Moberg’s) care needs,” the summary of the review reads.

It’s been just over a year since Moberg, who had been living with advanced dementia, was last seen in the River East area. Despite several widespread searches, Moberg has never been found.

While the investigation into his disappearance remains open, his family said Moberg is presumed dead.

“Things could have been done differently that could have, hopefully, prevented my dad's disappearance and presumed death,” Moberg’s daughter Britt told CTV News.

Britt said her father was diagnosed with dementia in 2019 and developed a tendency to wander and get lost. Despite efforts to access resources, long-term care services, and respite care, Britt said her family was waitlisted several times.

Since her father’s disappearance, Britt has been calling for changes.

“What can we do so that what happened to my dad doesn't happen to anybody else, and that was really our concern,” she said.

What did the critical incident review uncover?

The WRHA had confirmed in June that it was conducting a critical incident review to “better understand if there is anything that the system could do differently, and what, if any, improvements can be made to the way health-care providers work.”

That review has now been completed.

It highlights “missed opportunities” in Moberg’s care, in addressing caregiver burnout, and in reviewing Moberg’s care plan to address safety risks.

Moberg had been attending the WRHA’s Adult Day Program, but in late November the WRHA noted "safety risks" were identified during his transportation to the program. Britt said her father’s ride was cancelled because of this, and he was no longer able to attend the program.

“We acknowledge and apologize that your mother requested for your father to attend closer to home and have an additional day and was told these were not possible due to wait lists,” the summary of the WRHA review reads.

It notes professional development sessions offered by the Alzheimer Society of Manitoba are no longer consistently accessed, and referrals to the society’s First Link Program, which connects families to resources, are underutilized.

The summary contains seven recommendations:

Develop a mandatory refresher series for home care case coordinators;

Create clinical pathways in a staged approach for clients along the continuum for progressive dementia;

Review the Adult Day Program to identify opportunities for providing services that are more geographically distributed across the city and that are expanded to address wait lists and additional services based on client needs;

Review respite protocols recognizing the need for caregivers to receive timely and flexible respite support in order to continue to care for their loved one living with dementia;

Review the process for connecting families to the Alzheimer Society First Link Program to actively refer clients and families who have consented;

The Home Care Program will schedule representation from the Alzheimer Society to discuss the First Link Program at new case coordinator orientation; and

The WRHA acknowledges the benefits of having services such as a “Vulnerable Persons Registry” and “Project Life Saver” and will advocate for this by collaborating with other stakeholders to promote community resources for individuals living with dementia.

'It's going to get worse': Alzheimer Society said resources lacking in Manitoba

It also notes the current Home Care Program requires additional resources beyond what’s available to provide in-depth home safety assessments by an occupational therapist.

“There's not adequate resources. There's not adequate education. There's not adequate support for people who have dementia right now,” said Erin Crawford, the CEO of Alzheimer Society Manitoba.

Crawford said the need for these resources will only increase.

“The number of people in Manitoba with dementia is supposed to double in the next 25 years. So it's a problem now. It's going to get worse.”

The WRHA said it is reviewing the recommendations made in the review.

“We are committed to providing them with completion of those recommendations,” said Wendy Singleton, director of WRHA client relations and engagement, quality and patient safety.

CTV News has reached out to Manitoba’s Health Minister for comment.

This comes as the Moberg family continues to call for the federal government to create a national silver alert system. Similar to Amber Alerts for missing or abducted vulnerable children, Britt wants to see geographically targeted alerts sent to phones and broadcast media when a vulnerable adult goes missing.

A petition calling for this change is set for Jan. 20, 2025, and will be tabled in the House of Commons in the new year.