Recommendations made following patient death at Winnipeg hospital

A report into a patient’s death in a Winnipeg hospital earlier this year found that a lack of space in the emergency department and patient flow challenges were factors in the incident.

Shared Health released findings from a critical incident report started following the death of a man in a hallway at Health Sciences Centre on Feb. 27.

The man was brought to hospital by ambulance, and was assessed and triaged, but waiting for care in the EMS arrivals hallway. Approximately one hour after he arrived, his condition worsened. Doctors attempted to intervene, but the man was pronounced dead.

The report determined that the patient had not been transferred to a monitored bed due to a lack of space in the emergency department, and that “patient flow challenges” prevented the transfer when he arrived.

“In the 24-hour period leading up to the patient’s arrival, 13 high-acuity patients – more than double the daily average at that time – had required life-saving treatment in the emergency department,” Shared Health said in a news release. “This episodic spike in acute patient presentations exacerbated pre-existing and well-publicized challenges related to emergency department capacity.”

"We acknowledge that events like this can shake the trust of the public and families in our care but we want to reassure everyone that they can have confidence in the healthcare system," said Jennifer Cumpsty, HSC Winnipeg’s executive director of acute care service.

Shared Health said staffing levels were at or near baseline levels that evening at the time of the event, and the median wait time in the emergency department was over two hours.

Dr. Shawn Young, chief operating officer at HSC, says the hospital doesn’t have enough beds to meet all of its needs.

"Every day, we're meeting with the WRHA and some of the other sites within the city and outside of the city to be able to support the flow of patients through the system and we've been doing that for over a year," he said.

The report recommended that Shared Health continue work on addressing patient flow challenges at HSC to help alleviate the backlog, and that HSC review its patient assessment practices and workflow for ordering of tests. HSC is also recommended to update work processes for classifications of staff in the adult emergency department.

“All recommendations have been accepted and work has begun on implementing the necessary changes, including the creation of over-capacity protocols that trigger the rapid movement of stable patients to non-traditional areas of patient care or to alternate locations during a significant surge in patient demand/backlog,” Shared Health said in a news release.