Two infants died after not receiving emergency air transport to Winnipeg's Children's Hospital near the end of 2018, Manitoba Health's latest critical incident report reveals.
One of the infants was taken by ground ambulance to the hospital because air transport was not available, the quarterly report says. The infant, who was in unstable condition, had a heart attack on arrival.
The report, released on Thursday, says intubation was difficult, and the infant was admitted to the pediatric intensive care unit. Treatment was later withdrawn and the infant died.
Another infant, who was premature and in unstable condition, was also taken to the hospital by ground ambulance. The report says transportation by the Lifeflight air ambulance was declined.
The infant had surgery for a bowel obstruction and died the next day.
While the exact circumstances of the deaths are not known, the two incidents happened at a time when tensions were high between Lifeflight staff and the province — which oversaw the air ambulance service for decades before shuffling it over to Shared Health, the organization that co-ordinates health care in Manitoba, last October.
In December 2018, the doctors who work for the air ambulance service threatened to stop working on private medevac planes if the province didn't hire more pilots and fund annually required training for pilots, citing safety concerns.
The move came after the province signalled the possibility of privatizing the service.
30 incidents, including 7 deaths
The critical incident report, released quarterly by the province, details serious health-care events reported to Manitoba Health. It provides short descriptions of each event, but does not provide identifying factors or specific locations.
"While we can provide general information on recommendations that have come from critical incidents, we are unable to provide information about specific incidents (including recommendations)," a provincial spokesperson said.
The two-page Oct. 1 to Dec. 31, 2018, report lists 30 such incidents. Of those, seven resulted in death.
The report also lists a patient who fractured a hip after being pushed onto the floor by another patient as a major incident and not a death — although the patient died two days later.
The report also refers to an incident where a patient died after a STARS air ambulance arrived late and without a doctor.
The patient initially arrived at the emergency room with chest pain and had a heart attack, but was resuscitated. A transfer via a STARS air ambulance was needed, but the ambulance arrived almost two hours late without a physician on board, the report says.
Staff were initially unable to intubate the patient, and later made the decision to transport the person by ground, but the patient was dead on arrival at the destination, the report says.
Choking, misdiagnoses, overdose
The report says another patient, who was supposed to be supervised during mealtimes, choked to death while eating unsupervised. The report says the need to supervise the patient "was not consistently communicated to the entire care team."
The report also details misdiagnoses, including a patient who received an invasive procedure that was not indicated for their condition.
Another didn't get expert consultation for a skin condition that turned out to be misdiagnosed, resulting in a delay in appropriate treatment.
A patient who was assessed for an acute condition and sent home later died after "the opportunity to immediately consult expert medical services to assess the patient's risk was not realized," the report says.
The report also details falls that led to serious injuries, and a miscalculation that led to a medication overdose, requiring the patient to be resuscitated.