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

Among the issues that led to patient deaths, according to critical incident reports from the first nine months of 2024, were bed rail entrapment, delays in receiving medical diagnosis and treatment, poor monitoring, and a patient leaving an ER without being seen.  

The province reviewed a total of 24 deaths and 74 injuries from the beginning of January to the end of September in 2024. The reports describe incidents where a patient suffered serious and unintended harm in the health-care system, and include recommendations on ways the system can improve.

The reports are summarized in one or two sentences and published online every three months. They do not identify patients and front-line workers, or provide a location for where an incident occurred. 

The latest report from July 1 to Sept. 30 of last year listed 11 patient deaths — the highest compared to those in previous months with nine in the first quarter and four in the second quarter.

"That's very worrying that we are, in our health-care system, missing the opportunity to treat or pick up on things that are now causing more deaths," said Manitoba Nurses Union president Darlene Jackson.

The deaths in the most recent Manitoba Health report included multiple incidents where a patient's medical condition worsened or changed, and opportunities for monitoring, early intervention and treatment "were not fully realized," the report said.

Some of the incidents — like those detailing delays in diagnosing and monitoring patients, preventing bed rail entrapment and a person from leaving the ER without treatment — speak to the ongoing crisis around staff shortages and no established patient-to-nurse ratios, Jackson said.

For example, the ratio may be one nurse for every four patients on an acute medical unit, but a province-wide nursing shortage can mean one nurse is providing care for up to nine patients based on the number of staff scheduled per shift, Jackson said.

"Even a health-care aide has too many patients assigned to them and just does not have the ability to spend as much time with each patient monitoring and overseeing their care," she said. 

Jackson said medical errors are happening because front-line workers are trying to multitask, and not because there is a lack of sufficient training.

There were 26 critical incidents involving serious injuries in the latest report, which included a patient receiving an unnecessary surgical procedure, a patient having a surgical item left inside their body during an operation, someone whose hospital stay was extended after they were given the wrong medication, which caused them serious harm, and a patient who fell, resulting in a major fracture. 

Other incidents referenced patients experiencing a delay in diagnosis, a change in health conditions where missed opportunities to intervene occurred and several pressure injuries, which are generally the result of bedsores that can develop when patients who cannot move on their own are not turned often enough.

Jackson said pressure injuries and skin tissue breakdowns, mentioned 14 times across all three 2024 reports, are an example of care that is most commonly delayed due to capacity issues that would free nurses to treat wounds more quickly. 

From January to June, there were incidents where a patient's referral to CancerCare Manitoba was delayed, where a patient had inflicted self-harm and died and another instance where a patient was discharged from an ER and then returned by ambulance and died. 

"Any critical incident concerns me and I absolutely, you know, would love to see a time where we don't have a critical incident in our health-care system," Jackson said.

"Unfortunately, with staffing the way it is with our health-care system in chaos at this point, I don't see that in the near future."

Health Minister Uzoma Asagwara said in a statement Monday many of the critical incidents the province sees each year are a result of "years of cuts to the front lines" the government is working to address.

"We still have so much work to do reinforce our staffing levels," Asagwara said. "Reports like this are an important reminder of why we have to keep going – to keep patients safe."

Manitoba's NDP government said it has hired 1,255 new health-care workers, including 418 new net nurses, since April last year.