Patient who died in group home among 7 deaths in Manitoba critical incidents report

A Manitoba mental health patient who died after being improperly monitored while living in a community group home was among seven deaths detailed in a new report on health-care incidents in the province.

Serious health-care incidents include 26 major injuries, 7 deaths from early 2018

One patient with chest pain and a history of meth use left a Manitoba emergency room after only one hour, with no documentation of assessment or treatment, and was found dead an hour later, according to the latest list of critical incidents report from Manitoba Health. (CBC)

A Manitoba mental health patient who died after being improperly monitored while living in a community group home was among seven deaths detailed in a new report on health-care incidents in the province.

The patient had attempted suicide and was found unresponsive, according to the latest critical incidents report released by Manitoba Health.

After the death, it was found the usual process for monitoring clients had not been followed, and the patient was not monitored frequently enough, according to the report.

The list covers a three-month period from Jan. 1 to March 31, 2018, and describes 33 incidents in the province, including the seven deaths.

In one case, a woman was admitted to hospital for treatment of an obstetrical surgical site infection. Two days later, she expressed suicidal ideation, the report says. But although psychiatry was consulted, no one was available to see the patient immediately, the document continues. No reason was provided.

During the night of her third day in hospital, the patient left against medical advice. She was found dead in her home 20 hours later.

2-day-old newborn dies in NICU

The deaths include a newborn baby, who died in a neonatal intensive care unit (NICU) two days after being born. The report says the baby was delivered by caesarean section after signs of bradycardia, or slowed heart rate, were seen during vaginal delivery.

In another incident, a patient was brought by ambulance to a Manitoba emergency room with chest pain and a history of methamphetamine use. The patient left the ER one hour later, with no documentation of assessment or treatment, the report says. The patient was found dead in the community an hour after that.

Another patient died after a central venous access line for medication was mistakenly inserted into an artery, instead of the jugular vein. The mistake wasn't noticed until the following day, and it was determined the patient had suffered a stroke during the placement of the line. The patient died following the removal of the line.

The reports provide only the broad strokes of each situation, and don't include the health-care facility, community or date of the incidents.

24-hour delay in treatment before leg amputated

The major non-fatal incidents ranged from one case where a patient's humerus was fractured after their arm was caught in an MRI machine to a patient who had an unnecessary surgical procedure after diagnostic imaging results were entered into the wrong file by mistake.

In one case, a patient's left leg had to be amputated after the patient was thought to have necrotizing fasciitis, also called flesh-eating bacteria. The patient had a phone consultation with an infectious disease physician, because no on-site consultations are held over the weekend. Then there was a 24-hour delay in transferring the patient to tertiary care for assessment.

Critical incident reports are regularly released by Manitoba Health, covering three-month periods at a time.

Other incidents in the latest report include:

  • A personal care home resident was heard calling for help in their room and was found on the floor with a fractured wrist. Another resident with a history of aggression was found in the room.
  • A personal care home resident was eating supper in the home's dining room when their chair broke and the resident fell to the floor, fracturing their hip.
  • A patient had a 13-hour delay in treatment for congestive heart failure while in an emergency room, including a one-hour delay in treating life-threatening dysrhythmia, or an abnormal heartbeat.

You can read the whole report online.

If you're experiencing suicidal thoughts or having a mental health crisis, there is help out there. Contact the Manitoba Suicide Line toll-free 24/7 at 1-877-435-7170 (1-877-HELP170) or the Kids Help Phone at 1-800-688-6868.