Fall from window, miscalculated doses among 12 deaths in Manitoba critical incidents last summer

An inpatient on a mental health unit was given 10 times the ordered dose of methadone and needed more than six doses of an opioid antidote to recover. 

Another patient who urgently needed intravenous medication died after being given too much of the drug and having a heart attack. 

And another patient, after noticed missing from their room, was found dead in the courtyard below the room's window — but staff didn't know whether the fall was accidental or intentional.

These are just a few of the 33 critical incidents reported to Manitoba Health between July 1 and Sept. 30, 2018. The latest quarterly report details healthcare events that resulted in serious harm to a patient. Of these incidents, 12 resulted in death.

The three-page report does not name the hospitals across Manitoba where the incidents happened, or the specific dates the events occurred.

The report notes a jump in the proportion of critical incidents resulting in death between this period and the previous one.

Between April 1 and June 30 of 2018, there were 28 serious incidents, and three of them — or 15 per cent — resulted in a patient's death. That ratio surged between July 1 and Sep. 30, when 12 of 33 critical incidents — or 36 per cent — led to a patient's death.

Missing patients, missed diagnoses

The deaths in the most recent quarterly report are varied.

One post-surgery patient who needed a feeding tube in their stomach died after hospital staff failed to notice the tube was no longer in the right position.

One patient died when hospital staff didn't notice a change in their heart rhythm until they needed to be admitted to critical care.

Another patient was taken to hospital with serious injuries, and died after the severity of those injuries — and the need for them to go to a trauma centre — went unrecognized.

A patient being treated after a suicide attempt took their own life while on the acute mental health unit. Another was found lying on the floor in a pool of their own blood after a fall believed to have been preventable; a CT scan later found they had a blood clot on their brain.

Another was noted to be missing, but procedures to alert staff and security were not initiated; by the time the patient was found, they were dead.

During the same period, another patient fell out of their wheelchair and fractured their hip; their advanced care plan was changed to comfort care and the patient died five days later.

One patient died after symptoms of a serious infection went unnoticed until they needed to be admitted to the intensive care unit. Another died after regular follow-ups for an acute condition didn't happen.

One experienced a traumatic injury, but the diagnosis was missed and the patient's condition deteriorated until they needed critical intervention and died.