No inquest to be called in death after attempted COVID-19 hospital transfer in Manitoba

Manitoba's chief medical examiner won't call an inquest into the death of a 31-year-old woman after a failed attempt to airlift her from Manitoba to an Ottawa hospital during the height of the third wave of COVID-19.

Last May, Krystal Mousseau suffered what the province described as "serious and undesired" unintended consequences as she was being transferred from an ambulance to an airplane at the Brandon airport.

The 31-year-old mother died shortly after.

The province conducted a critical incident investigation, because Mousseau's death did not arise from an underlying health condition or from a risk inherent in providing health services.

In January, Manitoba NDP Leader Wab Kinew asked the chief medical examiner to conduct an inquest into her death.

However, Dr. John Younes wrote in a March 1 letter obtained by CBC News that "there is no mystery" about the circumstances of Mousseau's death.

"A carefully considered decision was made to move patients out of province to make room for incoming patients who would otherwise not survive," Younes wrote.

"The patients who were transferred were determined to be those who had the highest likelihood of tolerating the process without complication, but any transfer of any ICU patient carries risk, even within the same hospital."

At the time of Mousseau's death, Manitoba's intensive care units were at capacity, Younes wrote. At least 10 new COVID patients required ICU care every day, many of whom would die without that care.

The province arranged for less ill patients to be moved to provinces that still had ICU capacity, although even those patients were unstable and likely to deteriorate quickly, he said.

Mousseau was young and relatively healthy, although still critically ill, he said. 

She was not the only Manitoba patient to die during or after a transfer.

"At least a dozen other Manitobans" suffered the same fate, Younes wrote.

In his letter, Younes said the purpose of an inquest is to examine the circumstances of someone's death, determine the cause and manner of the death and look for systemic failures that could be addressed to prevent future similar deaths.

"It is certainly not the role of an inquest to second-guess complex medical decisions, particularly those made under horrific circumstances," he wrote.

"As the cause, manner and circumstances of Miss Mousseau's death are known, there are no grounds for the calling of an inquest in this case."

At the time of her death, Mousseau's family said they were not consulted before the decision was made to transfer her out of the province. 

They have been frustrated and unhappy with the level of information they've received from the hospital and suggested racism may have played a role. Mousseau was a member of Ebb and Flow First Nation.

Her mother and sister have deferred all questions about Younes's letter and this decision to Kinew, thanking him for his help in "bringing this forward for us."

"Krystal Mousseau's life mattered and she is dearly missed by her family and friends. Her death represents a significant moment in the pandemic because it is a clear instance of a Manitoban dying in a situation directly tied to our health-care system running out of capacity," Kinew said in an email statement.

He said the chief medical examiner's decision not to call an inquest is disappointing "because there are still many unanswered questions about the care Ms. Mousseau received and the systemic failures that surround her tragic passing."

A total of 57 Manitoba COVID-19 patients were sent out of the province for care when the health-care system was pushed to the brink last spring. Twelve of them died.