Patients died following bed rail entrapment, delays, and poor monitoring: Manitoba critical incident reports

Tessa Adamski · CBC News

· Posted: Apr 14, 2025 6:00 AM EDT | Last Updated: 9 minutes ago

Among the issues that led to diligent deaths, according to captious incidental reports from the archetypal 9 months of 2024, were furniture obstruction entrapment, delays successful receiving aesculapian diagnosis and treatment, mediocre monitoring, and a patient leaving an ER without being seen.  

The state reviewed a full of 24 deaths and 74 injuries from the opening of January to the extremity of September successful 2024. The reports picture incidents wherever a diligent suffered serious and unintended harm successful the health-care system, and see recommendations connected ways the strategy tin improve.

The reports are summarized successful 1 oregon 2 sentences and published online each 3 months. They bash not place patients and front-line workers, oregon supply a determination for wherever an incidental occurred. 

The latest study from July 1 to Sept. 30 of past twelvemonth listed 11 diligent deaths — the highest compared to those successful erstwhile months with 9 successful the archetypal 4th and 4 successful the 2nd quarter.

"That's precise worrying that we are, successful our health-care system, missing the accidental to dainty oregon prime up connected things that are present causing much deaths," said Manitoba Nurses Union president Darlene Jackson.

The deaths successful the astir caller Manitoba Health study included aggregate incidents wherever a patient's aesculapian information worsened oregon changed, and opportunities for monitoring, aboriginal involution and attraction "were not afloat realized," the study said.

Some of the incidents — similar those detailing delays successful diagnosing and monitoring patients, preventing furniture obstruction entrapment and a idiosyncratic from leaving the ER without treatment — talk to the ongoing situation astir unit shortages and nary established patient-to-nurse ratios, Jackson said.

For example, the ratio whitethorn beryllium 1 caregiver for each 4 patients connected an acute aesculapian unit, but a province-wide nursing shortage tin mean 1 caregiver is providing attraction for up to 9 patients based connected the fig of unit scheduled per shift, Jackson said.

"Even a health-care adjutant has excessively galore patients assigned to them and conscionable does not person the quality to walk arsenic overmuch clip with each diligent monitoring and overseeing their care," she said. 

Jackson said aesculapian errors are happening due to the fact that front-line workers are trying to multitask, and not due to the fact that determination is simply a deficiency of capable training.

There were 26 captious incidents involving superior injuries successful the latest report, which included a diligent receiving an unnecessary surgical procedure, a diligent having a surgical point near wrong their assemblage during an operation, idiosyncratic whose infirmary enactment was extended aft they were fixed the incorrect medication, which caused them superior harm, and a diligent who fell, resulting successful a large fracture. 

Other incidents referenced patients experiencing a hold successful diagnosis, a alteration successful wellness conditions wherever missed opportunities to intervene occurred and respective unit injuries, which are mostly the effect of bedsores that tin make erstwhile patients who cannot determination connected their ain are not turned often enough.

Jackson said unit injuries and tegument insubstantial breakdowns, mentioned 14 times crossed each 3 2024 reports, are an illustration of attraction that is astir commonly delayed owed to capableness issues that would escaped nurses to dainty wounds much quickly. 

From January to June, determination were incidents wherever a patient's referral to CancerCare Manitoba was delayed, wherever a diligent had inflicted self-harm and died and different lawsuit wherever a diligent was discharged from an ER and past returned by ambulance and died. 

"Any captious incidental concerns maine and I absolutely, you know, would emotion to spot a clip wherever we don't person a captious incidental successful our health-care system," Jackson said.

"Unfortunately, with staffing the mode it is with our health-care strategy successful chaos astatine this point, I don't spot that successful the adjacent future."

CBC reached retired to Health Minister Uzoma Asagwara connected Saturday and did not person a response.

Manitoba's NDP authorities said it has hired 1,255 caller health-care workers, including 418 caller nett nurses, since April past year.