Inquiry needed into death of Manitoba woman during failed COVID-19 hospital transfer: physician

This column is an opinion by Dan Roberts, a critical care physician and professor of medicine at the University of Manitoba. For more information about CBC's Opinion section, please see the FAQ.

On May 24, 2021, during the peak of the third COVID-19 wave, Krystal Mousseau, a 31-year-old mother of two, was identified as sufficiently stable to be air evacuated to an ICU in Ottawa.

The young woman had been admitted to the Brandon hospital ICU with COVID pneumonia. Krystal required life support, including a mechanical ventilator and an intravenous drug infusion to maintain a normal blood pressure.

She was not being transported for her own benefit, but rather out of a desperate necessity to make room for less-stable, critically ill patients due to an unprecedented and overwhelming ICU caseload.

Her care was formally transferred to a private carrier's medical transport team. During the ground transport to the airport, Krystal suffered a prolonged cardiac arrest. She was returned to the ICU but died the next day.

No autopsy was ordered and no public inquiry has been launched.

The government has portrayed this catastrophe as an unfortunate but expected consequence of the inherent risks associated with transporting critically ill patients. The medical examiner has declined to initiate an inquiry because he feels that there are no unanswered questions related to the cause or causes of Krystal's death.

I believe that the government's and medical examiner's assertions are incorrect.

Before explaining why that is so, it is important to illustrate that the modern medical air transport service in Manitoba was born out of similar tragedy, and why an inquiry for this case is so vital.

Air ambulance a priority for northern Manitoba

Before the late 1980s, air evacuations of critically ill patients were rarely safe. Occasionally — and always at the desperate request of a northern physician or nursing station — volunteer critical care physicians from Winnipeg would quickly gather supplies, equipment and personnel, and if a ministry jet was available, fly to the patient in what was considered a mission of mercy.

Many patients were less fortunate. The need for a reliable service became a political priority for northern Manitoba.

In 1985, the NDP provincial government announced its intention to establish a provincial air ambulance service, which would include a dedicated jet aircraft and flight crew, as well as trained nurses. 

Some of the volunteer physicians who had experience and knew the stakes insisted that the government use them as an advisory group during the planning of the new service. Despite their recommendations, the government refused to provide qualified physicians to carry out transports of critically ill patients. 

During a meeting of the advisory committee, one of the physicians resigned in protest, warning that disaster would follow, and challenged his colleagues to join him. None did so.

On Oct. 29, 1986, a 70-year-old woman from Grand Rapids went into cardiogenic shock. Her daughter, a medical student, alerted a critical care doctor at Health Sciences Centre in Winnipeg.

He immediately called the air ambulance dispatcher to volunteer to fly to Grand Rapids and attempt to stabilize the patient, but was informed that the transport had already been assigned to a private carrier.

The woman suffered a cardiac arrest on the plane. She was accompanied by a volunteer nurse, who, through no fault of her own, was helpless to attempt to resuscitate her.

Such catastrophes almost invariably involve multiple system failures.- Dr. Dan Roberts

A public inquiry was launched by the medical examiner. The subsequent investigation eventually uncovered multiple communication failures and medical deficiencies. The government was instructed by the court to address these issues and provide qualified physicians to accompany critically ill patients during air transport. 

From these ashes, highly skilled and well-equipped teams of doctors and nurses were quickly formed and a co-ordinated service evolved. During the next 30 years, thousands of critically ill patients were transported to Winnipeg from northern communities to receive intensive care and emergency surgery. 

Warnings about privatization

Some five years ago, the current Progressive Conservative government decided to dismantle and privatize most of the existing Air Ambulance Service. 

Despite warnings by a group of expert physicians that these initiatives would magnify risks of system failures, increase transport times and impair oversight and accountability, the government proceeded with its consultant-recommended cost-cutting agenda. 

In 2019, a five-year contract was signed with the Winnipeg-based Exchange Income Corporation, chaired by former premier Gary Filmon, which operates under a number of small airlines. 

During the 30 years preceding this, we are unaware of any stable patient having died as a consequence of undergoing air transport from a Manitoba ICU to another Canadian facility.

Air transport deaths are rare and usually occur only when unstable patients are being transported from remote communities or nursing stations to an ICU for stabilization. 

This was not the case for Krystal Mousseau. Krystal's death was unexpected and should not have occurred.

Such catastrophes almost invariably involve multiple system failures. These often include communication breakdowns, equipment failures and deficiencies in safety procedures and training.

Forcing hand-offs between care teams that are unfamiliar with each other's capabilities and equipment quickly escalates risk.

If private carriers continue to be involved, then they should be obligated to provide comprehensive medical and flight records for each transport, as well as documentation of their procedures and training standards.  Performance standards for medical transport personnel should be established. Independent auditing procedures should be in place.

Following the unfortunate event in 1986, the medical examiner, the physicians and the court pursued the evidence, uncovered deficiencies and forced those in power to address them. They did their jobs. We should expect no less today.

The events of May 24, 2021, need to be thoroughly and independently investigated and publicly reported. Krystal Mousseau's family and children deserve answers. The medical personnel involved in the case who continue to suffer anguish and guilt deserve closure. 

The public, which should expect safety and competence from their health-care system, needs assurance that such a catastrophe will not be repeated.

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