The importance of critical incident health-care investigations

There is a singular refrain sung by the chorus of those surviving adverse events in health care. 

I’ve heard it hundreds, perhaps thousands of times during the course of my investigations or advocacy work: “I just want to know everything was done so it doesn’t happen again.”

As surviving patients, or the loved ones who survive patients, almost universally they seem to arrive at a point of acceptance. They understand that nothing can really be done to undo their personal tragedy, but as humans they are compelled by compassion for a potential future victim.

They’re really a lot like family members who make a decision to donate the organs of a loved one, hoping that from tragedy, some sense will be made with a better outcome for another unknown, unfortunate soul.

In December of 2010, a woman was admitted to hospital in Winnipeg for psychiatric care. One of the members of the team to which her care was entrusted violated that trust. 

• Former patient sexually assaulted at Winnipeg hospital 

A court has ruled on a matter of sexual interference and civil damages have been awarded.

But no amount of money will undo the harm or truly assuage the hurt. And the future is still a question, the path that will now be travelled most certainly more difficult. 

And she just wants to know, years after, with exceptional courage and fortitude, whether everything has been done that can be done to ensure it doesn’t happen again.

Manitoba has some of, if not the most progressive legislation in the country that sets forth how adverse events in health care are dealt with, and this most certainly was an adverse event, characterized in legislation as a "critical incident."

A critical incident refers to an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that:

(a) is serious and undesired, such as death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay, and

(b) does not result from the individual's underlying health condition or from a risk inherent in providing the health services.

A provincial investigation report from November of 2011 found that the patient was vulnerable at the time of admission to the facility. 

It said: "There is evidence that the patient was subjected to sexual abuse by the respondent who was a staff member during her hospitalization and that this abuse caused the patient harm."

It must be made clear: critical incident investigations are not optional. They are law, a legislated requirement triggered when an event as described occurs. 

Once so declared, there are a number of duties which must be undertaken by the health-care authority. One of the first is disclosure to the victims or surviving families, as soon as possible. This includes:

1. The facts of what actually occurred with respect to the critical incident
2. Its consequences for the individual as they become known, and
3. The actions taken and to be taken to address the consequences of the critical incident, including any health services, care or treatment that are advisable

Critical incident investigations are vested with comprehensive authority, including access to any record or witness deemed necessary. They are extraordinary in that those witnesses are conferred with a legislative privilege that limits use of their testimony to the purpose of the inquiry. What they say cannot be disclosed or used in any other action, legal, disciplinary or otherwise.

The purpose of this exceptional candour is to provide investigators with unique, unfiltered insight, in order that they might create a full narrative of understanding and make a qualitative analysis of events, and then to create recommendations for the actions necessary to keep any similar event from happening again.

The institutional response here was typical of risk management. Human resources were called. We can be almost certain that in-house legal was extensively consulted, and probably the insurer, too. Eventually the staff member in question was removed from his position.

Legal consequences flowed. The victim was told she could make a criminal complaint. The Protection of Persons in Care Office was notified and there were various other administrative reviews and recommendations afterwards.

None of this was wrong or bad. 

The problem was not ignored. But the particular and peculiar process, the critical incident investigation, did not take place, and all that should flow from it, including a final report to the family. 

CBC has reported: “Since the incident the woman says she has had bouts of anxiety and depression, suffered from post-traumatic stress disorder and had suicidal thoughts. She also says she is now afraid of being admitted to hospital.”

In 2007, Manitoba passed The Apology Act, which makes it possible for providers and health care institutions to say they’re sorry, without any admission of legal liability. They don’t have to, but they can. 

I wonder if anyone has or will apologize to this woman and her family. I wonder if everything that can be, and should have been (besides a critical incident investigation) has or will be done. And when or how this family will ever find out.

Darrell Horn is a Winnipeg consultant with Healthcare System Safety & Accountability