Mystery remains around death of woman in failed COVID-19 hospital transfer, Manitoba NDP says
Critical incident report on Krystal Mousseau's death found medication, blood pressure monitoring challenges
There was "no mystery" about how Krystal Mousseau died following a failed attempt to airlift her to an Ottawa hospital last May, Manitoba's chief medical examiner told the province's Opposition party in a letter earlier this month.
But a summary of the critical incident report has the NDP suggesting the circumstances around her death remain unclear.
The NDP renewed its call for an inquest during question period at the legislature on Tuesday, asking if Dr. John Younes, the province's chief medical examiner, knew about the findings of the critical incident report.
Younes said in his March 1 letter to the NDP that he would not call an inquest into the 31-year-old woman's death, writing that "the cause, manner and circumstances" of her death are known, meaning "there are no grounds for the calling of an inquest in this case."
On May 24, 2021, Mousseau, a member of Ebb and Flow First Nation in Manitoba, suffered what the province described as "serious and undesired" unintended consequences as she was being transferred from a ground ambulance to an airplane at the Brandon airport during the height of the third wave of COVID-19.
She died the next day.
Critical incident investigation
The province conducted a critical incident investigation, because Mousseau's death did not arise from an underlying health condition or from a risk inherent in providing health services.
In a written summary of the investigation, which Mousseau's family shared with the NDP, Prairie Mountain Health identified a few issues.
It found the transport team did not have the equipment to connect with the arterial line — a thin, flexible tube placed in an artery — Mousseau was using, which resulted in "difficulties monitoring Krystal's blood pressure," the summary indicated.
The NDP, in its follow-up letter to the chief medical examiner, said it shared Mousseau's blood pressure readings with medical experts, who considered them to be dangerous.
The report summary also said Mousseau was not receiving the right amount of at least one "high-alert" medication she required.
It also states the transport company has undergone additional training and education in the use of IV infusion pump equipment after Mousseau's death — but, as the NDP pointed out, the letter did not indicate the standards at the time of her death.
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NDP Leader Wab Kinew asked Younes to reconsider his decision that an inquiry isn't needed.
"Your letter states 'there is no mystery here' in reference to Ms. Mousseau's death," Kinew wrote in his letter to Younes, dated March 7.
"However, I ask whether it is reasonable to believe that Ms. Mousseau might still be alive had she been transported by a team that had the proper training and proper equipment to care for someone who you rightly point out was very sick at the time."
In his letter, Younes said the purpose of an inquest is to examine the circumstances of someone's death, determine the cause and manner of the death and look for systemic failures that could be addressed to prevent future similar deaths.
He said that "it is certainly not the role of an inquest to second-guess complex medical decisions, particularly those made under horrific circumstances."
Kinew pushed back at that statement, writing "it is the role of an inquest to ascertain the systemic failures at the provincial level."
Discrepancy between reports: NDP
On Tuesday, Kinew said the summary of the critical incident report outlined issues that were not referenced in the chief medical examiner's March 1 letter to the NDP.
"There are still a number of unanswered questions, questions that deserve to be answered to help Ms. Mousseau's family with their healing journey, but also questions that all of us, as Manitobans, should want to know the answers to so that we can avoid ever having a situation like this happen again," Kinew said.
Asked about the discrepancy between the two reports, Premier Heather Stefanson offered her condolences to Mousseau's family. But the premier said she leaves decisions around inquests to the chief medical examiner.
Younes wrote in his March 1 letter that there is an inherent risk anytime an ICU patient is transferred.
"A carefully considered decision was made to move patients out of province to make room for incoming patients who would otherwise not survive," he wrote.
At the time of Mousseau's death, Manitoba's intensive care units were at capacity, he said. At least 10 new COVID patients required intensive care every day, many of whom would die without that level of care.
The province arranged for less-ill patients to be moved to provinces that still had ICU capacity, although even those patients were unstable and likely to deteriorate quickly, he said.
Fifty-seven Manitoba COVID-19 patients were sent out of the province for care when the health-care system was pushed to the brink last spring because of an influx of patients. Twelve of them died.
Mousseau's family has deferred questions related to an inquest call to the NDP.
With files from Karen Pauls