A client died after becoming entrapped in a bed rail and a patient suffered a fatal injury after leaving a Manitoba hospital emergency department without being seen.
The two deaths were among 37 critical incidents that occurred in health-care settings, such as hospitals and personal-care homes, between July 1 and Sept. 30, 2024, the province’s latest quarterly report said.
In all, 11 people died and 26 suffered a “major” injury. Diagnosis or treatment delays, or missed opportunities for intervention or monitoring were cited in some incidents.
The issues speak to a shortage of front-line staff, Manitoba Nurses Union president Darlene Jackson said.
“The incidents in areas where clearly there’s an inability to monitor and provide oversight seem to be increasing,” she said.
The number of overall incidents and deaths were the highest of any quarter in the 2024 calendar year.
Figures for the final quarter (Oct. 1 to Dec. 31) are expected to be released in a few months.
“That’s very worrying that we’re seeing an increase in deaths,” Jackson said.
Among the non-fatal incidents, a “surgical item” was left inside a patient’s body, a patient underwent an unnecessary surgery and a client suffered serious harm when given the wrong medication.
The impacts on patients, their families and health-care workers can be devastating.
“There’s a lot of moral injury from staff knowing what should be done and how their patient should be cared for and the reality of what they can do within the patient load and the hours that they have to do,” Jackson said.
“Health care is a place where Manitobans should go to get better, so any loss of life or harm done to a patient is a tragedy,” Health Minister Uzoma Asagwara said in a statement.
Some provinces have introduced minimum nurse-to-patient ratios. Manitoba has not yet done so.
Jackson said established ratios would help to prevent critical incidents and retain staff.
A committee with representatives of MNU, the government and regional health authorities is developing ratios for Manitoba.
“At this point, there are no standards that absolutely say a nurse cannot care for more than this number of patients on an acute medical ward or a surgical unit,” Jackson said. “That will provide safe staffing numbers in relation to patient loads and allow for better oversight and monitoring once those are established.”
Minimum nurse-to-patient ratios would vary per unit.
In B.C., for example, the minimums are one nurse to four patients on general medical/surgical inpatient units, 1:1 on intensive-care units and 1:3 for “general” emergencies in emergency rooms, according to that province’s nurses union.
In February, the NDP government said it had hired more than 1,255 net-new health-care workers, including 481 nurses, since April 2024.
“I’m hearing from nurses on the front line that… there’s been negligible change, and they really haven’t seen any impact of having these additional workers,” Jackson said. “Our overtime rates are still more than we’ve ever seen before. The use of agency nurses is still extremely high.”
Asagwara said the government has made progress, but still has “so much work to do to reinforce our staffing levels.”
“Reports like this are an important reminder of why we have to keep going — to keep patients safe,” the minister said, adding “many” critical incidents are a result of “years of cuts to the front lines.”
Progressive Conservative health critic Kathleen Cook said political spin and deflection are not acceptable in this case.
“I think Manitobans will find that response to be particularly troubling and disappointing because critical incidents are presented as learning opportunities,” she said. “I think what Manitobans want to hear is what actions is the minister taking to prevent these kind of deaths and severe outcomes from happening again.”
“Many” employers are not replacing nurses who call in sick, and they’re not posting vacancies, Jackson said.
“There has been some direction from government to save eight per cent in their budgets, and we’re seeing a lot of that saving come right from the front line,” she said. “If you go to work and you are working below baseline — you had a sick call and a vacant rotation — what happens is the number of patients on that unit divided by the number of nurses that are actually there to work becomes your patient load.”
Manitoba legislation defines a critical incident as an unintended event that occurs when health services provided to a person result in a “serious and undesired” consequences, such as death, disability or injury, and does not result from the person’s underlying health condition or “from a risk inherent in providing the health services.”
Incidents lead to reviews that are intended to prevent similar incidents in the future.
Quarterly reports provide brief or vague descriptions of each incident. They do not include details that could identify patients, staff or locations.
chris.kitching@freepress.mb.ca
Chris Kitching
Reporter
Chris Kitching is a general assignment reporter at the Free Press. He began his newspaper career in 2001, with stops in Winnipeg, Toronto and London, England, along the way. After returning to Winnipeg, he joined the Free Press in 2021, and now covers a little bit of everything for the newspaper. Read more about Chris.
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