Child died while trapped in hospital bed supplied by home care program, report says

One of the deaths disclosed in Manitoba's most recent report on critical incidents in the province's health-care system was a child.

Manitoba Health releases critical incident reports, which note cases where people have suffered "serious and unintended harm" while receiving health care in the province, every three months. 

The latest report, which looked at incidents during the period of July 1 to Sept. 30, 2020, details 48 incidents. Among those are 12 incidents classified as deaths, including the child.  

In that case, the report said "a hospital bed with full side rails supplied through the Home Care Program for a child with an underlying health condition contributed to an event of bed entrapment and loss of life." 

Critical incident reports include short descriptions of each event, but do not provide identifying factors or specific locations.

The latest two-page report also includes a case where a "patient experienced respiratory failure that resulted in death following inhalation of a noxious substance."

It also details an incident where a client fell, resulting in head trauma and their death three days later.

The report also includes three dozen incidents classified as "major."

In one case, a surgical instrument was found to be missing during surgery. The report said while an "X-ray revealed foreign body remained in the patient," the medical team was unable to retrieve it and the surgical site was closed. 

The report described another case where a client was transferred to an emergency department and assessed for stroke-like symptoms.

"Assessment determined client had experienced a stroke and onset of symptoms exceeded timeframe for treatment for reversal of stroke," the report says.

In two other cases detailed in the report, patients came to emergency rooms with stroke symptoms, but stroke protocols were not implemented. 

According to the province's website, clinical experts review each of the incidents reported and make recommendations for improvements to the system. 

Each case is reported publicly in a way that protects the privacy of individuals, families and health-care teams, the province says.

In a statement, the Manitoba Advocate for Children and Youth said it was notified of the child's death and did a review of the services involved, including reports from the Office of the Chief Medical Examiner. 

"Based on the findings of our service review, the advocate determined that a deeper investigation was not warranted," wrote a spokesperson, adding findings from the review can be used to inform future reports.

"In 2020, the Manitoba advocate released a comprehensive special report about disability services for children in the province, Bridging the Gaps: Achieving Substantial Equality for Children with Disabilities in Manitoba, which included recommendations for system improvements. Our office continues to monitor government compliance with those formal recommendations."

The timeline covered in the most recent critical incident report was just months after the first case of COVID-19 was identified in Manitoba.

The report includes a note that "critical incidents related to COVID-19 outbreaks in hospitals or personal care homes are reported as groups."

The report includes an incident classified as a death, but its description says "residents developed a health-care acquired infection associated with a serious outcome," suggesting more than one person was involved.

CBC has asked the Manitoba government to provide more information related to the incident and how many residents were affected.

In an email, a spokesperson said "we do not share additional detail from what is on these reports in order to protect the confidentiality of the [critical incident] process and patient's personal health information."