Manitoba·CBC Investigates

Hospitals failed to report 3 drug-related deaths, including 1 that started at Brandon city manager's home

Three overdose deaths linked to opioids went unreported by hospitals this summer, prompting the province’s chief medical examiner to alert doctors that reporting drug overdose deaths is mandatory under the law.

‘If you don't report problems, they don't exist,’ advocate says

No autopsy or toxicology tests were performed on Christine Mitchell. Her body was already at the funeral home when authorities learned of her death from a member of the public. (Christine Mitchell Facebook)

Three drug-related deaths linked to opioids went unreported by hospitals this summer, prompting Manitoba's chief medical examiner to alert doctors that reporting drug overdose deaths is mandatory under the law. 

Physicians at Brandon Regional Health Centre failed to report the death of 30-year-old Christine Mitchell and the death of a 33-year-old woman. Both died of opioid overdoses within a month of each other this summer. 

Mitchell was living at the home of Brandon's city manager at the time of her death in July.

In August, a man in his 50s died at a Winnipeg hospital, 24 hours after being admitted. His death was reported to the medical examiner, but not as a suspected overdose, as it should have been, according to the chief medical examiner.

Advocates for drug treatment say under-counting deaths could result in underfunding the battle against addictions. 

"If you don't report problems they don't exist," said Marion Willis, who runs Morberg House, a support program for men struggling with homelessness and addiction. 

"That whole big picture is really disturbing...If you're not able to provide accurate statistics then it becomes more difficult to actually justify the level of funding or resources that are actually required to try to solve it," Willis said.

Marion Willis, who runs Morberg House, a support program for men struggling with homelessness and addiction, says inaccurate reporting can make it difficult to justify funding or resources. (Tyson Koschik/CBC)

Notifying the medical examiner about overdose deaths is required under the Fatality Inquiries Act to ensure the cause of death is established and to rule out criminal wrongdoing.

And sometimes, overdose notifications can be a matter of life or death. 

"If we detect a spike in deaths due to a particular cause, we were the ones who sound the alarm bell with the respective health agencies," Dr. John Younes, Manitoba's chief medical examiner, said in an interview.

When an investigator from the medical examiner's office told Younes that doctors in Brandon were interpreting the act incorrectly by not counting drug overdoses as poisonings, he knew there was a systemic problem.

"In their minds, the clause 'death due to a suspected poisoning' didn't include drugs and medications. They thought probably they meant things like cyanide and strychnine," he said. 

That prompted Younes to sound the alarm to Winnipeg and Brandon health authorities last month.

"After I became aware that there was a problem here, I sent out a letter to the top levels of the health administration," he said.

Prairie Mountain Health, which oversees Brandon Regional Health Centre, says it "does hold providers accountable for providing notification as required under the Fatality Inquiries Act," but refused to say how.

John Younes said despite the delay in learning of the deaths, his office was able to establish opioids were involved in all three. (Trevor Brine/CBC)

The College of Physicians and Surgeons of Manitoba, which regulates the province's doctors, expects members to comply with all laws that govern them, said college registrar Dr. Anna Ziomek. 

"The college has not received any correspondence from the medical examiner's office regarding this issue. The only information we have is what has been reported by the media," Ziomek said.

Purple heroin warning

Mitchell took a lethal dose of purple heroin before winding up in hospital in July. She died the next day.

Less than two weeks later, Brandon police issued a warning when two other adults were found unresponsive in a home after using methamphetamine and purple heroin. Both survived, but police couldn't confirm if they overdosed on the same batch of purple heroin that killed Mitchell. 

In the case of the 33-year-old woman who overdosed and later died in the Brandon hospital, her body had been cremated by the time the medical examiner's office learned of her death. 

"Neither of the two Brandon cases underwent autopsy or external examination. Neither had samples left at the hospital that could be used for toxicological analysis," said Younes.

Younes said despite the delay in learning of their deaths, his office was able to establish opioids were involved in all three.

"It was due to circumstantial evidence — reports of witnesses or people who were spending time with the deceased prior to them becoming unconscious or unresponsive. And, I believe, reported drug screening done when they came in," he said. 

Brandon police Chief Wayne Balcaen says he contacted the the Brandon Regional Health Centre after learning Michell's death had not been reported to the ME. (Warren Kay/CBC)

Younes said hospitals do urine tests when patients are admitted, which will show if opioids were taken but not the amount. 

He would prefer to err on the side of caution and do an autopsy in all drug-related deaths to see if there were any other contributing factors such as natural disease or injury but admits, in his experience, the likelihood of finding anything surprising is very low.

'It was delayed': Brandon police chief

It's important that overdoses are reported to police, said Younes, especially if there are allegations of drugs being given against someone's will or when something more toxic than usual is mixed into illicit drugs. 

"If someone came into hospital with a drug overdose and the police were never notified and this office wasn't notified, obviously that investigation [will] never occur," said Younes. 

Brandon police Chief Wayne Balcaen said officers learned of Mitchell's death from a member of the public a day after she died. They called the hospital to confirm, then notified the medical examiner's office and started to investigate. By that time, Mitchell's body was at the funeral home.

"We've had some discussions with the hospital because we felt it was delayed," said Balcaen. 

"If we're not alerted, then the true circumstances of someone's death might not be elucidated," said Younes.

Mitchell's death is still under investigation by Brandon police. The other Brandon case, involving the 33-year-old woman, is closed and it was determined no criminality was involved in her death.

It is not known if the death of the Winnipeg man is being investigated by police. 

Arlene Last-Kolb has devoted her life to addictions advocacy after losing her son to fentanyl. (Gary Solilak/CBC)

Overdose Awareness Manitoba member Arlene Last-Kolb lost her 24-year-old son to fentanyl poisoning in 2014. Since then, she has been advocating for improved addictions treatment. 

She says making sure overdose deaths are investigated can help the healing process.

"This is important. It's important to our province. It's important to the families," said Last-Kolb.

"These families need to know how their children or their loved ones passed away so they know how to deal with their grief."

In 2018, there were six hospitalizations for opioid overdoses in Brandon, according to data provided by the Canadian Institute for Health Information. It is not known if they survived.  

And provincewide last year, there were 88 apparent opioid-related deaths according to the Public Health Agency of Canada.


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About the Author

Caroline Barghout

Investigative Reporter, CBC Manitoba I-Team

Caroline began her career co-hosting an internet radio talk show in Toronto and then worked at various stations in Oshawa, Sudbury and Toronto before landing in Winnipeg in 2007. Since joining CBC Manitoba as a reporter in 2013, she has won an award for her work on crowded jails and her investigation into Tina Fontaine's death led to changes in the child welfare system. Email: caroline.barghout@cbc.ca

With files from Riley Laychuk